I interviewed psychiatrist Donald Black, M.D., author of Bad Boys, Bad Men, on May 6, 2013, discussing anti-social personality disorder, sociopaths and psychopaths. This is part one of a tw

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by Oxford University Press

I interviewed psychiatrist Donald Black, M.D., author of Bad Boys, Bad Men, on May 6, 2013, discussing anti-social personality disorder, sociopaths and psychopaths.  This is part one of a two part interview. Here is a link to the audio podcast.

Thanks to Don Caldarazzo   for doing the transcript.

Rob Kall:   And welcome to the Rob Kall Bottom Up Radio Show, WNJC 1360 AM out of Washington Township, New Jersey, reaching metro Philly and South Jersey, sponsored by Opednews.com .  My guest tonight is Donald W. Black, MD.  He's a Professor of Psychiatry at the University of Iowa, and he's the author of a book: Bad Boys, Bad Men: Confronting Anti-social Personality Disorder.  Welcome to the show!  

Donald Black:   Well thanks for having me.

Rob Kall:   This is a fascinating topic, and what is perhaps the most frightening are the statistics about this.  Your book says it's about three percent (3%) of the population?

Donald Black:   Well, it actually might be higher.  There's some surveys that show that about four and a half percent (4.5%) of the general population may meet criteria for this disorder.  In any event, I think all people would agree that it's more common than people think.  When you think about the kind of people who get diagnosed with Anti-social Personality Disorder (or the other more common term people use in the general population is "Sociopathy," or "Sociopath") and where they end up, because a lot of them are in jails and prisons, those people are not counted in the surveys, so the figure could be higher than even 4.5%.

Rob Kall:   So we're talking on a planet with seven billion people, we're talking about a quarter of a billion [250,000,000] people.  Unbelievable.

Donald Black:   Yeah.  Potentially in the United States, over 8 million people.

Rob Kall:   That's very frightening.  I was having a conversation the other day with somebody who is a very positive person, really believes that the world can heal itself.  And then I brought up sociopaths; and his face changed, and all of a sudden it went to, "Yeah.  That's really a problem."  There really aren't solutions -- and your book is very -- again, the book title is Bad Boys, Bad Men, and a revised edition of it just came out in February.  Your book gives suggestions to people who live with sociopaths how to cope, and it gives suggestions to sociopaths and anti-social personality people how the can work on their problem; but there's no real cure, is there?

Donald Black:   No, there isn't.  This is a dirty little secret in the field of Psychiatry and Psychology, that here we have this disorder that I call major; it's widespread, it affects a lot of people, the consequences of it are enormous.  Because just think of all the people who end up in the criminal justice system because of their recurrent criminal behavior, which is one of the main symptoms of this disorder.  You think of how costly it is, and yet we're no better at taking care of these people than we were fifty years ago when most doctors were just writing them off as untreatable. 

Now, I  do make the point in the book that we don't know if it's untreatable, but the government and researchers have put so little effort into looking for treatments, that I could only identify a single randomized, controlled trial in the entire worlds' literature.  Now, if you compare that to schizophrenia, bi-polar disorder, depression, where there are thousands of studies showing that various treatments work - I mean, it's just not a level playing field.  So I maintain that we don't know if it's untreatable, because no one has adequately studied this.

Rob Kall:   So what you're saying is: currently no treatment for it, but there's been only one study that you've been able to find that actually looked at it.

Donald Black:   Absolutely.  I find this very regrettable and disturbing that something as problematic as this doesn't get any/more attention.  And yes, in the book I do provide advice to anti-social men as well as their family members about steps that they can take.  I remember when the book originally came out in 1999 I had a series of letters from people - this is almost pre-email days -- telling me how naïve I was to even suggest these things for anti-socials, since they wouldn't do anything about helping themselves anyway.  In the meantime, I've met with anti-socials, I've discussed the book with anti-social individuals, and they tell me that they like that advice, and in fact that I'm on track.

Rob Kall:   Before we go any further, why don't we do some definitions.  What is an anti-social or a sociopath?  What are the primary characteristic of someone that fits the -

Donald Black:   Well, that's an excellent question, and I think that's a good starting point for the discussion.  To me, in a nutshell, it's "Recurrent bad behavior over time."  So what do I mean by that?  Well, most of these people have an onset of their disorder in early childhood, or at least by late childhood.  So as kids they're regularly getting into trouble: lying to parents and teachers, getting into fights, vandalism, hurting others, hurting animals; in the worst cases, maybe setting fires, that sort of thing.  And then as they transition into adolescence, the kind of misbehaviors depends on opportunities: early sexual misconduct, maybe stealing and thievery, burglary; you know, escalating in terms of crimes.  And then when they hit adulthood, being irresponsible, not paying child support, spousal abuse, criminal behavior.  So again, bad behavior over time. 

People with this condition tend not to benefit from punishments.  They don't tend to learn how to control their behavior the way most non-- anti-social people would.  If you or I do something bad - we get caught, there's a punishment - we learn from that.  We say to ourselves, "I'm not going to do it again, because first of all it's not a good thing to hurt other people, and second of all, I don't want to get punished.  I don't want to go through that."  These people never seem to learn that lesson. 

A subset of these individuals lack a conscience; that is, they can commit all kinds of heinous, criminal acts and not care about it, not care about what the victim goes through.  They lack empathy, and that's what can make some people really dangerous: that they can commit some kind of criminal act and just not care about how it impacts other people.  This is what's frightening about the disorder.

Rob Kall:   So, you know - I have to say, I've got a list of questions here.  Well, let me hold back.  How does this disorder relate to evil?

Donald Black:   That's an interesting question, and I do address that in the book.  I basically sidestep the issue by saying, "Evil is a philosophical or religious concept that, in my view, has no place in medicine or Psychiatry."  Certainly people commit acts that you or I might call evil.  For example: Osama bin Laden and the Twin Tower disaster of 2001.  That was an evil act.  I think most people would say that is the probably about the most evil thing someone could do, and then we saw him on videotape laughing about it.  Thousands of people dead, and then he's laughing about it.  I characterize that as evil.  Or, think of a serial killer like Ted Bundy or John Wayne Gacy, who was torturing or murdering someone essentially for his own twisted pleasure.  That to me is evil.  However, as a psychiatrist, I don't use that term in my daily practice, and I wouldn't encourage my trainees to use it either, because it has religious and/or philosophical connotations that I don't think are appropriate for mental health professionals to be discussing.

Rob Kall:   That's fair enough in terms of talking about Psychiatry; but you're an expert on sociopathy, so I'm kind of asking you also from the perspective of culture, and the perspective of how evil is conceptualized.  It just seems to me that evil is perpetrated by sociopaths.

Donald Black:   Well, a lot of it is, but then you could argue that Osama bin Laden does not meet the definition of a sociopath, because he doesn't have all of the cardinal symptoms that we  would expect for that disorder, including a history of childhood misconduct.  So even non- anti-social people can commit evil acts.  Now, I do make the argument in my book that Saddam Hussein probably was a sociopath and would have met our definition.  We have specific criteria that we use to make the diagnosis, because he has a documented history of misbehavior going back to early childhood, and continuing until the time that he was (essentially) caught and incarcerated.

Rob Kall:   Another thing you say in your book is, "They rebel against every type of regulation and expectation, seemingly oblivious to the value of living within societies boundaries.  Despite all sanctions, parental punishment, ostracism, failure, or jail, they remain stuck in a rut of bad behavior."

Donald Black:  Yes, absolutely.  They don't like rules, they don't like regulations, and they don't seem to learn from the bad consequences of their behavior.  They are stuck in that rut that they can't seem to get out of.  Now, as some of them get older they do seem to climb out of that rut, because anti-social behavior in general tends to subside as people get older.  It's unclear why.  Maybe they're more mature, maybe they're just too tired to act out, who knows; but they do tend to improve over time.

Rob Kall:   Now, that description, somebody "resisting regulations and expectations," it can also apply to protestors, dissidents.  And in other countries, sometimes dissidents have been jailed under psychiatric pretexts.

Donald Black:   Yeah.

Rob Kall:   How do you reconcile that idea, that people who protest, people who engage in civil disobedience and get themselves arrested are -- how do you separate the protestors from the sociopaths?

Donald Black:   Well, again, those sorts of things occur in a cultural context.  They're not acting alone, they're acting within a large group of people - you know, other protestors that share their particular worldview - and that's outside the scope of what sociopathy or anti-social personality disorder is about.  Plus, if you examine these people and took their histories, most of them would not have a history of childhood misbehavior, they wouldn't have a history of adult criminality, they wouldn't be abusing their spouses, they wouldn't be getting into trouble at work, and so forth.  So I think even in countries where these kinds of acts can get you arrested, most people would be able to distinguish between the sociopath who was regularly getting into trouble, and the person who is simply violating laws that he and many other people just don't accept.

Rob Kall:   Can you talk a little bit about this diagnosis and disorder, and DSM-IV and DSM-V, the diagnostic manuals for psychiatrists?

Donald Black:   Yeah, well let me just talk a little bit about the history of this concept.  I remember an interview that I had years ago, I can't remember who was interviewing me, but they said, "Doctor Black, so you are describing a new condition called 'Anti-social Personality Disorder.'"  I said, "I'm doing nothing of the sort."  In fact, if you look at the history of psychiatry over time, this concept has been around at least two hundred years (if not longer), where psychiatrists, or doctors, or others were describing people who were not psychotic (that is, they weren't hearing voices or seeing things), and yet they were regularly getting into trouble and committing criminal acts. 

We've always had a segment of the population who behaves this way, and this has been described in the literature for hundreds of years, and in the late 19^th century, doctors described it in more detail.  In the 20^th century, that tradition continued: there was a man writing in the 40s named Hervey Cleckly, an American Psychologist.  He wrote a book called The Mask of Sanity that really brought these ideas together, and it was very influential book.  By the way, he's also co-author of Three Faces of Eve; everyone has heard of Three Faces of Eve, they haven't heard of Masks of Sanity.  Psychiatrists and psychologists look at the Mask of Sanity as really pulling this concept together. 

The diagnostic and statistical manual of mental disorders, and many listeners may not be familiar with that, but it is essentially the diagnostic bible that psychiatrists and psychologists use.  It's produced and published by the American Psychiatric Association, and has been since 1952 when it first came out.  Anti-social personality disorder, either under that name or other names, has been there from the start.  We have specific criteria to define it that can be used by clinicians in practice, it can be used by researchers, and it is a valid disorder.  It's been shown to be very reliable, that is, various psychiatrists around the world seeing the same patient applying those criteria will diagnose that person anti-social. 

So it's reliable, it's valid, meaning it's a highly useful concept, in that it's predictive of what happens to an individual.  When someone has that diagnosis, we know a lot about that person, and we know what the possible outcome probably is.  Currently, we're using the 4^th edition of the DSM, as it's called, and we're about to go into the 5^th edition, which will be released in late May at the American Psychiatric Association meeting in San Francisco.  I'll be there.  The criteria have not changed; so what's in DSM-IV will be in DSM-V.

Rob Kall:   And what are the basic criteria to diagnose, the bare minimum criteria?

Donald Black:   Well you know, I always have to look it up, because even though I'm an expert in this area, I can never remember exactly how things are worded; and I'll tell you, because I have it right here next to me.  Basically, "A pervasive pattern of disregard for and violation of the rights of others, occurring since age fifteen years."  And the person has to have three of seven different behaviors.  That's how a lot of our diagnoses work: there's a whole list of symptoms, and then we require for diagnosis "x" that the person have a certain number of the criteria.  I'm not going to read them all, but just for example:

1.       Failure to conform to social norms with respect to lawful behaviors.  In other words, criminality. 

2.       Deceitfulness.  In other words, repeated lying. 

3.       Impulsivity, or failure to plan ahead.  So, acting without thinking. 

4.       Irritability and aggressiveness as indicated by repeated physical fights or assaults.

5.       Reckless disregard for the safety of others.

And several others.

And the person has to be at least 18 years old, and there's evidence of a conduct disorder before age 15.  So as I was saying, these people have an early onset with misbehavior of their conduct prior to age 15.  I've certainly talked to mothers of anti-social men, who say, "Even by age two (2) my child was misbehaving."  And you think, what would that be at age two?  How would a 2 year old misbehave?  But these mothers say, "You know, there was something different about that kid."  And certainly when they're a little older and capable of lying, they're doing that, or getting into fights with their friends, or something of this nature. 

So you get the idea that this is, as I said,  "Recurrent misbehavior over time."  I've also used the phrase "Recurrent serial misbehavior."  Because if you watch these people, if you follow them around, for example let's say if you had a mini-cam watching them, most of the time their behavior is just fine -- probably no different from yours or mine.  But on a regular basis they're going to be getting into trouble with someone, being irresponsible, committing a crime, lying about that crime, or something else.  So there's this misbehavior over time.

Rob Kall:   OK.  Now, you've mentioned that this is a Men's disease.  That it's like 8-1 men to women?

Donald Black:   It depends on the study. but that's a figure that I use.  Interestingly, I did a study of anti-social personalty disorder in a local prison.  I'm a consultant for the correctional system here in Iowa, and I found that the prevalence, that is the percent of men and women having this condition, was about equal.  So in certain populations it may be about equal; in the general population, it's really a man's disorder. 

This was interesting, because I said that in the first edition when it came out in 1999; and I had letters, and later, emails, from people who essentially said I was sexist, and I need to talk about the female anti-social.  So I made certain in the 2^nd edition to talk about the female sociopath (or anti-social), and to point out that they are there -- there are fewer of them, and we don't know exactly why.  It could be genetic, it could be partly cultural, it could be partly definitional, we don't really know.  But there are women anti-socials out there, and I discuss some of the differences that they have with male anti-socials, and I mention a few popular cases in the news.

Rob Kall:   OK.  What about related diagnoses?  I noted that in your book you mention that a lot of women who might not be diagnosed as anti-social might be diagnosed as "borderline." 

Donald Black:   Yes.

Rob Kall:   You also mentioned in your book that there is a lot of co-morbidity for anti-social personalities with depression and alcoholism.

Donald Black:   Yeah, that's true.

Rob Kall:   So I'm curious about, particularly, borderline disorder and narcissism.  Where do they tie in with this?

Donald Black:   That's an excellent question.  It gets at the larger question of what you mentioned as "co-morbidity."  Listeners may not know that term; it just means, "other conditions or disorders that a person has in addition to the anti-social personality disorder."  Now, as a psychologist I can tell you: most people I see because of one disorder - let's say obsessive compulsive disorder - also meets criteria for other disorders as well.  Maybe substance abuse, or depression, or a gambling problem; and this is true with anti-socials. 

They often have a whole host of problems, and I know speaking as a Psychiatrist, they don't come to our clinic specifically for the anti-social personality disorder.  They don't come in and say, "Doc, I've got ASPD, I've got Sociopathy.  I need help for this."  They don't come in for that reason.  They'll say, "I'm depressed," or "I'm suicidal," or "I'm drug-addicted, and I need help for that."  And then as we evaluate them we see what their personality pattern has been long-term, and then we make that other diagnosis.  But anti-socials as a group have a high level of co-morbidity with substance use disorders, alcoholism, drug addiction, they're often addicted to gambling, they often suffer depression or other anxiety disorders; so those are all fairly common. 

Now there's a group of them that also seem to have this Borderline Personality Disorder, which is a disorder that tends to be more common in women.  Basically, in a nutshell, for those who are not familiar with it, it's a disorder of emotional intensity.   People get overly emotional reactions when things happen to them, and what that produces is rapidly shifting moods, difficult relationships, suicidal behaviors, self-harm by cutting or burning or other methods.  I think one way you could look at it is, these women (because it's mostly women) are in distress, and they're taking it out on themselves, where[as] the men with anti-social personality disorder, they're kind of taking it out on the world around them.  So they're externalizing their problem; the women are internalizing their problem. 

But there are a lot of women with borderline personality who also have anti-social traits or features, as you might refer to it.  For example, shoplifting, minor crimes, lying, some domestic abuse, neglect of their children.  And we see that in male anti-socials, that they may have some borderline features, maybe they hurt themselves repeatedly by cutting, or they have fears of being abandoned by some girlfriend or other person they're in a relationship with.  So there's this overlap in some people.  I certainly see that in the prison system. 

Rob Kall:   Now I've had a lot of contact with psychologists over the years - by running conferences, presenting at meetings, and what have you - and I've met a number of psychologists who say that they refuse to see borderline patients, because they tend to let you get close to them, and then bite your face off.

Donald Black:   Well, there all also a group of psychiatrists and psychologists who say they're not going to treat anti-socials.  They don't want anything to do with them.  But in terms of the borderline patients, I think that's unfortunate.  I see and treat a lot of borderlines.  I write about it, we've developed a treatment program for borderline patients called "The Steps Program," and I can tell you: most of them tend to improve, and if we follow them up years later after we first see them, many of them no longer even fit the definition of borderline personality because they've improved so much.

Rob Kall:   That's very hopeful.

Donald Black:   It is.  So I think it's unfair, and in fact wrong, for a group of mental health professionals to just write off a group of patients.  Now, I see this far more commonly with anti-social personality disorder patients, where the doctor or therapist says, "I'm not going to have anything to do with these people because they're dangerous.  Maybe they'll become stalkers or they'll hurt me in some way.  And besides, we have no treatments anyway!" 

But as I point out in my book, we just haven't studied the treatments well enough, so we don't know that it's untreatable.  In fact, the same phenomenon of improvement occurs in anti-socials as it does in borderline patients.  If you follow anti-socials long enough, many of them will improve and no longer meet the definition for anti-social personality disorder.

Rob Kall:   All right.  We're going to come back to that.  This is the Rob Kall Bottom Up Radio Show, WNJC 1360 AM out of Washington Township, reaching metro Philly and South Jersey, sponsored by Opednews.com .  I'm speaking with Donald W. Black, MD.  He's a Professor of Psychiatry at the University of Iowa, and he's the author of Bad Boys, Bad men: Confronting Anti-social Personality Disorder, also known as Sociopathy.  Now, where does Psychopathy come in - and psychopaths - to this conversation?

Donald Black:   Well I'm glad you asked that question because there is overlap between psychopathy and sociopathy or anti-social personality.  Sociopathy and anti-social personality are really synonymous, and both terms are commonly used, although "Anti-social Personality Disorder" is the official term.  Psychopathy is a variation, and I look at it as "The severe end of the anti-social spectrum."  Now what do I mean by that?  Any disorder that Psychiatrists treat lies along a continuum of severity from very mild to very severe.  That's just how it is. 

That's true with anti-social personality disorder too.  At one end are those who we might call sociopaths; these are the ones who have a callous disregard for others, lack a conscience, and so forth.  It's a popular concept among many mental health professionals to write about that and to study psychopathy; so it's worth saying that, while most all psychopaths are anti-social, maybe a third of anti-socials meet the definition of psychopathy.  But psychopathy is not an official diagnosis.

Rob Kall:   OK.  Next: you mention in your books on a couple occasions use of marijuana as a sign, potentially, of anti-social personality; yet several states have now made it legal, and it's available for use as a medicine in a growing number of states.  Where does marijuana fit in with this?

Part two of the transcript will be up tomorrow.

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