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Revisiting the Age-Old Case of Diagnostic Confusion: Sociopath Versus Psychopath

Revisiting the Age-Old Case of Diagnostic Confusion: Sociopath Versus Psychopath 

by Daniel A. Linder, MFT 

Many forensic psychologists and criminologists use the terms sociopathy and psychopathy interchangeably. Leading experts have disagreed on whether there are meaningful differences between them.1 

In an article written in 1996, “Psychopathy and Antisocial Personality Disorder: A Case of Diagnostic Confusion,” Robert Hare explained his concerns regarding the DSM-III when the decision was made to lump sociopathy or antisocial personality disorder 301.7 (ASPD) and psychopathy together. Up to that point, they had been treated as separate entities with contrasting motivational and behavioral profiles, and diagnostic criteria. “In 1980 this tradition was broken with the publication of DSM-III when psychopathy was renamed antisocial personality disorder -- was now defined by persistent violations of social norms, including lying, stealing, truancy, inconsistent work behavior and traffic arrests.” 2 

Hare suggested that a potential consequence of the ambiguity inherent in the DSM-III (as well as IV and V as well) is likely to be a court case in which one clinician says the defendant meets the criteria for ASPD, another clinician say the client does not, and both are right! He added that such confusion, he added, could be a serious impediment for everyone working in the criminal justice system as well as for society.3 

Hare emphasized that psychopath and sociopath (ASPD) are different animals and treating them interchangeably puts a damper on our clinical assessment skills. If we lose track of what a psychopath is and don’t know what to look for -- or if the client’s presentation doesn’t match the criteria for sociopath, we will be unable to make a diagnosis of psychopathic personality disorder, which can put public health and safety at risk.   

Despite Hare’s concerns , efforts to stay apprised of the differences between psychopath and sociopath and that two separate diagnoses have fallen short. Clearly, more fleshed-out descriptions and “psychopath-specific” criteria are needed. It’s essential that diagnosticians be clear that these are in fact two separate diagnoses.   

Let’s begin by looking at the most current DSM-V's description and diagnostic criteria for sociopathy/antisocial personality disorder,   

“The essential feature of anti social personality disorder is a pervasive pattern of disregard for, and violation of the rights of others that begins in childhood or early adolescence and continues into adulthood, as indicated by three or more of the following. . . ” 4 (This pattern has also been previously referred to as psychopathy and sociopathy.)

  1. Failure to conform to social norms with respect to lawful behaviors as 

indicated by repeatedly performing acts that are grounds for arrest--Not Psychopathy

  1. Deceitfulness, as indicated by repeated lying, use of aliases, or conning 

others for personal profit or pleasure

3-   Impulsivity or failure to plan ahead--Not Psychopathy

4-   Irritability and aggressiveness, as indicated by repeated physical fights or  assaults--Not Psychopathy

5-   Reckless disregard for safety of self or others

6-   Consistent irresponsibility, as indicated by repeated failure to sustain 

consistent work behavior or honor financial obligations--Not Psychopathy

7-   Lack of remorse and indifference when causing harm to others 

So far we can see some overlapping description and criteria that fits for 

both psychopathy and sociopathy);

  • fall under the heading of personality or characterological disorders: deep, longstanding and pervasive emotional disturbance; significant family of origin trauma and dysfunction 
  • presume an extremely poor prognosis, considered to be untreatable, or not “therapy material”  
  • display reckless disregard for safety of self or others, implying that both pose a threat to individuals and society; a tendency to display violent behavior 
  • operate deceitfully, stealing, lying, conning 
  • show lack of remorse
  • are unable to empathize
  • cannot form bonds, socially isolated
  • live on the fringes (in different ways) 

However, now I am proposing a whole new set of ‘psychopathic-specific’ criteria and a profile that focuses on specific areas: (a) appearance, (b) socio-economic status, (c) level of Intelligence and Education, (d) modus-operandi, (e) etiology, (f) motivation and (g) criminal history. 

Appearance

Psychopaths and sociopaths tend to look different and come across differently from one another.    

Sociopaths (ASPD) tend to look dangerous. They are most commonly thought of as thugs, social misfits or criminals. Think of Richard Allen Davis could be a poster boy for sociopaths of the world. I saw a TV clip of Richard Allen Davis in a courtroom, as he was being arraigned for the kidnapping, rape and murder of 10-year-old Polly Class. He was unkempt, had a cold, expressionless face and tattoos all over his body, and flashed his middle finger to the court and cameras.

We can also obtain an accurate take on how sociopaths behave by going to some memorable films whose lead characters were sociopaths, most notably, Travis Bickel (Robert de Niro in Taxi Driver), Max Cady – (Robert de Niro in  Cape Fear), Alex Delarge (Malcolm McDowell in A Clockwork Orange (the movie) and Aileen Wuornos (Charlize Theron in Monster). The character of Aileen was a woman who had killed several men throughout Florida claiming they had all tried to rape her while she was working as a prostitute. She was eventually executed by lethal injection.

Sociopaths tend to elicit a sense of threat violence and danger. Seeing them makes people want to walk the other way. They tend to give off many clues and exhibit features that proclaim that they are antisocial, hateful, violent, against the establishment or other agency they feel has wronged them and living on the fringes.

Psychopaths, on the contrary, tend to look no different from anyone else; they  do not stand out in any way. They are known as the ultimate masters of deception, wolves in sheep’s clothing, hiding in plain sight. Once people realize they’re in danger, it’s too late. 

The movie Primal Fear is about a psychopath, Aaron Sampler (actor Norton) dupes a hot-shot defense attorney, Martin Vail (actor Gere) into believing he has a multiple personality disorder. The character Vail obtains a verdict of  “not guilty” (by reason of insanity.) It is not until the end of the movie that the truth is revealed and Vail realizes that he had been played. Sampler manipulates Vail into getting him a “not guilty” by reason of insanity’ verdict when he was guilty and acting with conscious intent all along. He knew exactly what he was doing when he was doing it. 

There are also a number of real-life, famous psychopathic serial killers. The list includes Richard Speck who systematically tortured a group of student nurses he kept hostage in a house for hours, leading them one-by-one to separate rooms and stabbing or strangling them to death; John Wayne Gacy, who was nicknamed “The Killer Clown” because of his affinity for dressing as "Pogo" at birthday parties, fundraisers, and even during some of his murders of young boys; Jeffrey Dahmer whose crimes included picking up dozens of teenage boys and younger men on the streets, and drugging, raping and murdering them, is famous for dismembering his victims and storing portions of their bodies in his freezer; and Ted Bundy who killed a string of women after raping them.  

Socio-economic status

Differences in appearance as described above are often tied to socioeconomic status. 

Sociopaths tend to come from poorer, urban, drug-infested, gang and crime-laden, blue collar, uneducated, and disadvantaged backgrounds. 

Psychopaths tend to come from more clean-cut, polished, upper-crust, white-collar backgrounds and reside in middle to upper class suburbia; they are likely working so they do not have to resort to crime to survive, and they operate in mainstream society. A large part of their modus operandi is to not being how they appear. They live secret lives, “with plans for everyone” no one else knows about. Clinicians can often make the mistake of judging them according to their charm wealth or apparent success. 

Level of intelligence and Education

Sociopaths tend to be less educated and are often viewed as less intelligent (as measured by traditional intelligence testing instruments); they are less verbal and have less command of the English language than psychopaths have.

Psychopaths tend to be more educated and show higher intelligence on testing instruments; they are more thoughtful and verbal. They are known to be deliberate and calculated and to have tremendous command over their behavior, which is not surprising given that they sometimes operate under the radar for decades before they get caught. 

The character of Aaron Sampler (Edward Norton in Primal Fear) was brilliant enough to masquerade as having multiple personality disorder (MPD) so convincingly that he was able to trick the prosecutor into defending him and win a “not guilt by reason of insanity verdict. Aaron was so sophisticated that he could mimic emotions and convince the prosecutor that he had MPD

Modus-Operandi

Sociopaths are known to be volatile, prone to rages and emotional meltdowns. They are unsophisticated psychologically, acting overtly, recklessly and mechanically without hesitation or internal control, without ever flinching or registering the gravity of their actions; do not seem to care about exposure; are disorganized, and act impulsively without forethought or planning, which is why they will most likely be caught sooner and faster than will psychopaths.   

In his article, “How to Tell a Sociopath from a Psychopath,“ Dr. Bonn said that what makes psychopaths dangerous is their level of psychological sophistication and intelligence, mastery of disguise and deception, and zeal when inflicting large-scale mayhem. They often carefully plan their attacks and select their prey to kidnap, imprison, torture and murder. “Their crimes, whether violent or non-violent will be highly organized and generally offer few clues for authorities to pursue.

Psychopaths are also known for their uncanny abilities to detect and exploit others’ vulnerabilities. They can figure out ahead of time how to get their victims alone and what they are going to do when that time comes. They are known to lean toward being loners or recluses. 

Etiology: Nature Versus Nurture

Research and expert commentary indicate a consensus on nature versus nurture in regard to sociopathy and psychopathy

Sociopathy is believed to be more nurture rather than nature (innate) – more the result of a “bad upbringing,” a product of families riddled with abuse, absent parents, addictions, crime, guns and violence. “Genetics is not responsible for sociopathy.6 Perhaps it’s where they have lived their whole lives, and that’s all they know -- what they learned to do and how to be to survive.  

Psychopathy is believed to be the result of nature (genetics, faulty “brain wiring”). The dysfunction and abuse in their family systems were of a more subtle nature. It’s not at all unusual for family members of psychopaths to have no idea how deeply disturbed the person is or what horrific acts they are planning or have already committed. Psychopaths were cut off from and invisible to their parents. Their lack of remorse and inability to empathize are attributed to genetics and neurobiology. Their penchants for ritualistically torturing and humiliating their victims, and exploiting their vulnerabilities point to a deeper disturbance of biological origins.

Motivation

Sociopaths’ anti-social behaviors are fueled by their alienation, rage, and hatred as well as being in environments where crime and violence are the norm. If they want to rape, hurt or kill someone, they’ll do so without a second thought. It doesn’t matter to them whether they are going after children or innocent people; they are unaffected when inflicting pain or harming others, nor do they care whether anyone knows what they did or if anyone saw them. They learned their behaviors to survive in the world where they grew up.

Psychopaths’ motivations appear to be power-driven and sadistic. Psychopaths get off on control, manipulation, humiliation, and exploiting their victims’ vulnerabilities.   

Criminal History

Sociopaths generally have extensive criminal histories filled with assaults, robberies, rapes and murders. The overwhelming majority have contributing drug/alcohol problems, whether they are using, dealing or both. Our prisons are filled with sociopaths, those with antisocial personality disorders.

In contrast, psychopaths tend to have shorter criminal records because they operate incognito and covertly. No one is around when they are terrorizing their victims, which makes identifying and apprehending psychopaths more complicated, and which is why there are many fewer psychopaths in our prisons than there are sociopaths.

Closing Thoughts

Neither sociopaths nor psychopaths should be considered not guilty by reason of insanity. They should never be exonerated from responsibility for their actions and the harm and suffering they cause to others. The harm they cause cannot be attributed to extenuating circumstances or a biologically based psychotic disorder  (i.e. schizophrenia or bi-polar, or issues related to being on or off their medication as they are not typically treated by psychotropic medications). Their crimes usually are not were not isolated incidents, and they have extensive histories of criminal behavior.  

If we have to choose between psychopaths and sociopaths as far as whether one has a more favorable prognosis or is more treatable, it would have to be sociopath. Going back to the nature versus nurture issue, sociopathy is often sourced from a history of trauma, abuse, violence, addiction and emotional deprivation. Wounded souls needing healing have a better chance of somehow being reached, touched, or spiritually inspired or, at some point, discovering the wonder of human connection. They are slightly more likely to be ego-dystonic – to have some awareness of the problematic nature of the harm they inflict -- and may exhibit some anxiety about what they’ve done.  

The same is not true for psychoptaths whom I consider to be soulless and completely ego-syntonic all their lives. They cannot and never will change, in spite of their punishment or time in prison. They are not going to have any anxiety related to their plans or actions of torturing, raping, murdering, or humiliating their victims. They will bring their psychopathy with them wherever they go, and they are smart enough to continue manipulating other prisoners and the system. 

We have to assume that we’re not going to find ourselves treating sociopaths or psychopaths unless they are court mandated or in prison because neither are considered to be “therapy material.” 

However, our responsibility doesn’t end there. We will be called upon to assess, diagnose, develop treatment, intervention or containment plans, but will have our hands tied unless and until there are diagnoses-specific criteria in the DSM VI for each one separately. Sociopaths are to psychopaths as lions are to tigers. Both are cats, but they require different handling.  

References

1. How to tell a sociopath from a psychopath, Understanding important distinctions between criminal sociopaths and psychopaths; Dr. Bonn

2, 3. Psychopathy and antisocial personality disorder: A case of diagnostic confusion; Robert Hare, PhD; Psychiatric Times; 1996

4. Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association; Library of Congress; Washington DC; 2013 (DSM-III, 1980; DSM-IV, 2000)

5. How to tell a sociopath from a psychopath, Understanding important distinctions between criminal sociopaths and psychopaths; Dr Bonn

6. Psychopath vs. sociopath: What’s the difference? Blog post from the Masterminds series produced by the Huffington Post in partnership with NBC’s The Blacklist.

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About Daniel Linder, MFT

Daniel Linder

Relationships. I was born with a keen sense about relationships, was always assessing how close and intimate people are with each other. I had a knack for relationships. The importance of relationships cuts to the core of who I am. The combination of clinical training, 25 years of professional experience treating dysfunctional, non-intimate couples and families, as well as rigorous self analysis has given me a lot to work with. I put what seemed to come naturally to me under a microscope in an effort to break the process of building healthy relationships down to concrete essentials: Understanding of Basic Principles, Communication Skills, Self-realization and Intimacy.


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