Psychopathy Without (the Language of) Disorder
- 505 Downloads
Psychopathy is often characterized in terms of what I call “the language of disorder.” I question whether such language is necessary for an accurate and precise characterization of psychopathy, and I consider the practical implications of how we characterize psychopathy—whether as a biological, or merely normative, disorder.
KeywordsPsychopathy Language of disorder Treatment Responsibility
It is no part of biological theory to assume that what is natural is desirable. (Christopher Boorse, 1975)
What is psychopathy? This is a notoriously difficult question with many possible answers. A more tractable question might be: What, if anything, is uncontroversial about psychopathy? Perhaps the answer is as simple as the question: Nothing. However, that psychopathy involves some sort of moral disorder is widely (if not universally1) assumed to be true. In the words of psychopathy pioneer J.C. Prichard , psychopaths suffer from a kind of “moral insanity.” In the words of the more contemporary Linda Mealey , psychopaths suffer from a kind of “ethical pathology.”
The common idea that the psychopath’s problem is largely a moral one, has been expressed in a variety of different, if related, ways. The core idea is typically articulated in what might be called “the language of disorder.” By this I mean nothing especially precise. The language of disorder is nothing more nor less than language that suggests that something has somehow “gone wrong.” So conceived, the language of disorder has been used by countless theorists of psychopathy. It has been used, not only by psychologists and psychiatrists, but also by sociologists, theologians, and philosophers. It has been used by all those who have characterized psychopathy’s distinctively moral component in terms of: “abnormality,” “affliction,” “debility,” “decrepitude,” “deficit,” “deviance,” “disease,” “disorder,” “dysfunction,” “illness,” “impairment,” “incapacity,” “infirmity,” “insanity,” “pathology,” “perversion, " “sickness,” etc. Similar language has been used to characterize the social disorder widely regarded as characteristic of psychopathy. Indeed, the term “sociopath,” once used to label those individuals now labeled “psychopaths,” explicitly attributes a kind of social pathology to the psychopath.2
Might we then say that psychopathy involves moral, and perhaps social, disorder as well? Such a view sounds reasonable enough, perhaps even obvious. However, it might be argued that such “disorder” talk is merely metaphorical and can easily be replaced with literal language that does not invoke the concept(s) of disorder. Indeed, the PCL-R,3 widely used to diagnose psychopathy, might help make the case. To say that psychopaths are morally disordered is to say only that they possess, in sufficient quantity and degree, the affective/interpersonal (Factor 1) traits required for a PCL-R diagnosis of psychopathy. They possess “superficial charm,” they have a “grandiose sense of self-worth,” and so forth. To say that psychopaths are socially disordered is to say only that they possess, in sufficient quantity and degree, the impulsive/antisocial (Factor 2) traits required for a PCL-R diagnosis of psychopathy. They are “impulsive,” they are “irresponsible,” and so forth. Thus, it might be possible to characterize psychopathy, accurately and precisely, without the language of disorder. In that case, that disorder is essential to psychopathy loses much of its initial credibility.
There are at least two problems with this line of reasoning. The first of these is straightforward. Some of the traits specified in the PCL-R are themselves expressed in the language of disorder. For instance, one Factor 1 trait is “pathological lying,” and one Factor 2 trait is “parasitic life-style.” One might try to replace the former with (e.g.) “chronic lying” and the latter with (e.g.) “lives off of others.” However, even these locutions, whether literal or metaphorical, arguably involve the language of disorder. After all, “chronic” conditions are invariably unhealthy, and only parasites, well-known known for their disease-causing properties, “live off of others.” Moreover, even if disorder-free paraphrases of all the PCL-R traits could be found, something essential to psychopathy might nevertheless be lost. “Lies much of the time” doesn’t quite capture the moral pathology associated with “pathological” lying. “Does not assist, financially or otherwise, in the maintenance of the household,” doesn’t quite capture the social pathology associated with a “parasitic” lifestyle.
What do these considerations suggest? Perhaps that psychopathy essentially involves some sort of moral or social pathology, where “pathology” is understood metaphorically. From here on, I will refer to such metaphorical pathology as “normative pathology.” That psychopathy involves normative pathology is perhaps a truism. But what of the idea that psychopathy involves pathology in a more literal sense? What of the idea that psychopathy involves, not only normative pathology, but biological pathology as well? This leads to a second problem with the suggestion that the language of disorder might be “paraphrased out” of characterizations of psychopathy. Over the past several decades, there has been considerable research focusing on the brains of psychopaths.4 A number of researchers claim to have uncovered evidence of neurological impairment. Some of the more recent data (discussed by Blair et al. ) suggest that psychopaths suffer from a trio of connected disorders: emotional, cognitive, and neurological. Here, it is far less plausible to suppose that such “disorder” talk is merely metaphorical. When, for instance, Blair et al.  talk of “dysfunction” in the amygdala of psychopaths, they are emphatically not speaking metaphorically. They say explicitly that the psychopath’s dysfunction is a neurocognitive one. Elsewhere, Blair  characterizes psychopathy’s underlying dysfunction as neurobiological. Thus, that psychopathy involves disorder, metaphorical (normative) as well as literal (biological), is perhaps reasonable after all. In that case, the language of disorder is arguably essential to any accurate and precise characterization of psychopathy.
On any such “selectionist” model, psychopaths are certainly different than the rest of us, biologically speaking. However, they are not, in any biological sense, disordered.6 Perhaps the psychopath’s motives and behaviors reflect a kind of moral or social disorder. Perhaps, in other words, these individuals are disordered (diseased, defective, etc.) in some normative sense. But such is the extent of the psychopath’s disorder on the selectionist model. If such a view is not to be ruled out on factual grounds, it must be possible make sense of recent empirical data that appear to confirm disorder, in the most literal (i.e., biological) sense of that term, among psychopaths.
Perhaps the most often discussed evolutionary explanation of psychopathy is the frequency-dependent selection account. In the most common version of this account, psychopaths have evolved to take advantage of the fact that most people are cooperators by defecting in social interactions. Thus, psychopathy represents an alternative strategy (in the genetic sense) that is successful only at a particular low relative frequency in the population. If there are too many cheaters (or defectors) nonpsychopaths become very vigilant and cheating opportunities disappear. It is not hard to imagine how the constellation of psychopathic characteristics (e.g., manipulative, charming, lack of empathy, failure to learn from punishment, unresponsive to distress cues of others) would facilitate such a strategy. By this account, some individuals are born with a propensity for psychopathy, and the phenotype manifests itself early and perhaps without any environmental cues.
My primary aim in this paper is to do just that. It is not to argue that psychopathy doesn’t involve disorder in any literal (biological) sense. Nor is it to defend the view that psychopathy can be understood on an evolutionary model. It is only to argue that such a view is consistent with recent empirical data with which it might initially appear to conflict. The appearance of inconsistency is due, I will argue, to the theory-laden language used in characterizing the empirical data. Such language effectively rules out any account of psychopathy that does not involve literal (biological) disorder. My secondary aim is to press the idea that psychopathy involves a kind of normative disorder. Indeed, I will argue that the idea that psychopathy involves disorder in a normative sense suggests, naturally though not logically, that it also involves disorder in a biological sense. Normative pathology does not, in others words, logically entail biological pathology. In the conclusion of the paper, I will argue that how one conceptualizes the psychopath’s disorder has important practical implications. In particular, whether psychopathy is conceptualized as a biological or merely normative disorder, is bound to have profound and potentially pervasive effects on how we (whether as lay persons or as theorists) view issues concerning medical treatment and responsibility. For instance, a biologically disordered individual might well be regarded as meriting medical treatment of some sort. He might also be regarded as less culpable for his antisocial (and even criminal) behaviors. In contrast, an individual whose only “disorder” is a moral or a social one, is unlikely to be viewed as meriting medical treatment, or as having reduced responsibility, whether moral or legal, for his antisocial behaviors. By addressing such issues, I hope to forestall the question: So what? What does it matter whether the psychopath’s “disorder” is conceptualized as biological, or as merely normative?
Emotional, Cognitive, and Neurological Disorder
Before commenting on the language used in the foregoing passage, let me briefly comment on the passage’s content. We initially appear to have a theory-neutral description of certain emotional and cognitive impairments characteristic of psychopathy, together with the suggestion that those impairments might be accounted for in terms of neurological impairment: specifically, in terms of dysfunction in the amygdala. In fact, the empirical facts described appear to provide rather telling evidence for the suggested view that psychopathy originates in a specific kind of neurological dysfunction. If the particular emotional/cognitive capacities that the psychopath lacks have their neurological origins in the amygdala, then surely it is reasonable to think that dysfunction in the amygdala might be relevant to an explanation of psychopathy. More generally, the idea that a particular “mental” (or emotional/cognitive) disorder might have its origins in a particular kind of neurological disorder, is quite credible. A number of so-called “mental disorders” (including schizophrenia and autism) are now widely believed to have their origins in neurological dysfunction. It seems reasonable to suppose that other such disorders might someday be revealed as having their origins in neurological (or, more generally, biological) dysfunction. Perhaps psychopathy is one of these.
Two important capacities are necessary for successful socialization. First, the individual must be capable of finding the distress of others aversive. The argument has been made that the expressions of fear and sadness serve as social reinforcers, allowing conspecifics to teach the societal valence of objects and actions to the developing individual…Actions/objects associated with the sadness/fear of others acquire, in healthy children, negative valence. Second, the individual must be capable of performing stimulus-reinforcement learning; they must be capable of learning that a particular stimulus (an object or behavior) is good or bad to do. Individuals with antisocial 8 personality show impairment in both these capacities. Thus, they show reduced autonomic responses to the distress cues of other individuals and impaired fearful facial and vocal expression recognition. In addition, they show impairment in stimulus-reinforcement learning. [For these reasons], individuals with psychopathy are less able to take advantage of this “moral” social reinforcing. They…are more difficult to socialize through standard parenting techniques. They will not learn to avoid using instrumental antisocial behavior to achieve their goals. This is because of a relative indifference to the “punishment” of the victim’s distress and impairment in learning the association between this punishment and the representation of the action that caused the victim’s distress. The abilities to respond to distress cues and to achieve stimulus reinforcement learning are both related to the functioning of the amydala…[This] has prompted the suggestion that psychopathy relates to dysfunction in the amygdala’s role in expression processing and stimulus-reinforcement learning.
However, while Blair’s description of the empirical facts might be accurate, and while the suggested neurological explanation for those facts might be correct, the logical relation between the facts described and the proposed explanation is less than transparent. The described facts might well support a neurological dysfunction account of psychopathy, assuming a disorder conception of psychopathy. However, they arguably do not support a neurological dysfunction account of psychopathy over (e.g.) a non-dysfunctional neurological difference account of psychopathy. Specifically, the facts in question do not rule out, or in any way undercut, a selectionist account of psychopathy that (like Blair’s account) appeals to neurological differences between psychopaths and non-psychopaths. The facts described by Blair are, more precisely, compatible with the view that the particular neurological features that give rise to psychopathy are not, in any literal (vs. merely normative) sense, “dysfunctional.”9 This becomes apparent as soon as we recognize the theory-laden language used by Blair in describing the facts in question.
When I say that Blair’s language is theory-laden, I mean only that it presupposes, or at least suggests, a certain general conception of psychopathy. In this way, it creates a bias against alternative conceptions with which it conflicts.10 With regard to the cited passage, much of the language suggests that psychopathy is a disorder in more than just a normative sense. It suggests that the psychopath, qua biological organism, is somehow malfunctioning.11 Such a view is at odds with the competing view that psychopathy is the result of natural selection, and thus no (literal/biological) disorder at all.
In some cases, it is obvious that Blair’s language presupposes, or at least suggests, a disorder conception of psychopathy. In other cases, this is not so obvious, but becomes apparent upon reflection. Let’s start by looking at some of the more obvious instances. That the individuals in question are somehow disordered or impaired, is suggested by the use of the term “psychopath” to label them. To call an individual a “psychopath” is to suggest that there is something pathological about their psyche, about their mind. Consistently with this way of thinking, psychopaths are said to lack certain “important capacities”; they are “impaired.” They cannot be “taught”; they cannot “learn.” Those who can be taught, those who can learn, are described as “healthy,” suggesting that so-called “psychopaths” are unhealthy. Differences in the amygdalae of these “unhealthy” individuals that might explain their emotional and cognitive “impairments,” are characterized in terms of “dysfunction” (rather than in terms of mere “difference”).
In other cases, that Blair’s language reflects the disorder conception of psychopathy is somewhat less transparent. For instance, the autonomic responses of psychopaths are measurably “reduced” (as opposed to normal or enhanced); such individuals cannot “recognize” certain expressions of emotion that others can; they are “less able” than others to take advantage of social reinforcing; they are “more difficult” than others to socialize; they are “indifferent” to what others are sensitive to; they are unable to respond to “cues” that others are able to respond to; they are unable to “achieve” what others are able to achieve.
In these more subtle cases, the force of Blair’s language is perhaps more rhetorical than logical. There is, after all, no logical inconsistency between the claim that psychopathy is a product of natural selection and (e.g.) the claim that psychopaths are unable to respond to “cues” that others are able to respond to; or that they are unable to “achieve” what others are able to achieve. Indeed, these latter points are straighforwardly true, as even a selectionist would admit.12 However, Blair’s choice of words in even these more subtle cases, is clearly influenced by his view that psychopaths are disordered in more than just a normative sense. It is unlikely that a selectionist would characterize the emotional, cognitive, or neurological features of psychopathy in terms of Blair’s language of disorder.13 That language is therefore theory-laden, even if it does not rule out, on logical grounds, the idea that psychopathy is a disorder only normatively.
All in all, Blair’s characterization of the facts in question employs language that presupposes, or at least suggests, that psychopathy is a disorder in more than just a normative sense. It thus effectively rules out the idea that psychopathy might be the result of natural selection, and thus no biological disorder at all. It does not, however, rule out other neurological dysfunction theories of psychopathy, including those criticized by Blair et al. . Indeed, Blair’s language does not rule out any conception of psychopathy that views that condition as involving disorder in some literal (non-normative) sense.
None of this is intended as criticism of Blair’s language. Indeed, that he employs the language of “impairment” and “dysfunction” is perfectly appropriate given the plausible, and widely held, assumption that psychopathy involves disorder in the most literal (biological) sense of that expression. Moreover, as philosophers of science have been arguing for half a century, observation itself is intrinsically theory-laden.14 It should be no surprise that such theory-ladenness finds itself reflected in the theorist’s language. However, no selectionist would agree to characterizations that invoke expressions like “impairment” and “dysfunction,” where these are used literally to characterize the non-normative features of psychopathy. Such characterizations, however appropriate with respect to a disorder conception of psychopathy, are highly controversial from the point of view of a selectionist conception of that condition.
It might be objected that Blair’s language is, in fact, inevitable. It would be literally impossible, and not simply difficult, to provide an accurate and precise characterization of the empirical facts of psychopathy without employing the language of disorder. After all, psychopaths do in fact suffer from specific emotional/cognitive impairments, impairments plausibly explained by specific neurological dysfunction. The most appropriate (English) word to characterize impairment is “impairment”; the most appropriate (English) word to characterize dysfunction is “dysfunction.” How, then, is such terminology “theory-laden”? It is simply appropriate, given the uncontestable empirical facts.
This point has undeniable intuitive pull. However, I believe it reflects, not the empirical facts, but only the naturalness of the idea that psychopathy involves literal (biological) disorder. Below, I suggest that the naturalness of this idea is grounded in the misguided assumption that the normative disharmony associated with psychopathy is somehow “contrary to” the intrinsic harmony of nature. In the meantime, a radically different characterization of Blair’s empirical facts will be provided, one that is more in keeping with a selectionist understanding of psychopathy.
Radical Conceptual and Linguistic Shift
That psychopaths might differ neurologically from the rest of us, is something that selectionists would surely concede. How, then, is the selectionist to challenge the disorder conception advocated by Blair? How, specifically, is she to counter the claim that the emotional and cognitive impairments noted by Blair are plausibly explained by neurological dysfunction?
A two-fold approach would perhaps be most effective. First, the selectionist would embrace the empirical facts, while characterizing them differently, in jargon more friendly to her particular approach. She might, for instance, replace the words and phrases italicized in the Blair passage with suitable words and phrases more friendly to the selectionist model. This would include a proposal suggesting that specific neurological differences, not construed as “impairments,” arguably explain the empirical facts in question. Second, the selectionist would provide an explanation for the powerful intuition that psychopathy is indeed a disorder in the most literal sense of that locution. She would explain (in other words) why it is so natural to suppose that psychopaths, qua biological organisms, are not “working” the way nature “designed” them to work; they are “malfunctioning.”15 The challenge, of course, would be to do all this while remaining faithful to the empirical facts.
The selectionist might go on to develop her neurological difference account of psychopathy by linking it to the overt normativity of the psychopath’s “disorder.” She might claim that her account of psychopathy:
Two important capacities are necessary for successful individualization. 19 First, the individual must be capable of ignoring (finding non-aversive) the distress of others. The argument has been made that expressions of fear and sadness serve as social reinforcers, allowing conspecifics to inculcate the developing individual with the societal valence of objects and actions. Actions/objects associated with the sadness/fear of others acquire, in susceptible children, negative valence. Second, the individual must be capable of resisting attempts at inculcation through stimulus-reinforcement techniques; they must be capable of resisting the idea that particular stimuli are objectively good or bad. Both these capacities are present in individuals with pro-individual personality. Thus, they show no measurable increase in autonomic response when confronted with potentially distracting expressions of distress or fear. In addition, they show a capacity to resist inculcation through stimulus-reinforcement techniques. For these reasons, individuals with pro-individual personality are better able to resist attempts at “moral” social reinforcing. They are immune to attempts at socialization through standard parenting techniques. They will continue to use instrumental pro-individual behavior to achieve their goals. This is because of a capacity to filter out potentially distracting expressions of distress, as well as a capacity to resist attempts at inculcation through stimulus-reinforcement techniques. Sensitivity to expressions of distress and susceptibility to stimulus-reinforcement techniques, are both related to the functioning of the amygdala. This leads naturally to the suggestion that pro-individualism relates to the amygdala’s devolving role in expression processing and stimulus-reinforcement “learning.”
Here, the language is theory-laden insofar as it presupposes a selectionist conception of psychopathy, according to which that condition involves no non-normative disorder. Of course, the selectionist needn’t be so blatant in exposing her theoretical biases. My point is simply to draw attention to the fact that the language a theorist uses in characterizing the empirical facts, has the potential to create a bias in her theory’s favor. Where such a bias is subtle (as it often is), its influence might go unnoticed. Even the most attentive reader might fail to consider theories that conflict with those reflected in the theorist’s language. Indeed, the attentive reader might fail to consider theories equally well-supported by the empirical facts only because the language used to describe those facts creates a rhetorical bias against any competing theories.
…is consistent with the idea that pro-individualism is the product of natural selection, and thus a “disorder” only normatively. The devolving role of the amygdala enables the pro-individual personality to successfully pursue his goals including and, especially, reproductive ones, without the hindrances imposed by “other regarding” norms of the sort internalized via socialization processes to which the pro-individual personality is immune. In this way, the pro-individual personality is able to insure the dissemination of his (pro-individual) genes in future generations.
Nevertheless, as the above “re-write” makes clear, the selectionist could easily embrace the empirical facts discussed by Blair. She could argue that those facts support an account of psychopathy according to which differences (not properly characterized as “impairments”) in the amygdalae of “pro-individual” personalities explain the invulnerability of those individuals to socialization. Of course, such support is relative to the assumption that psychopathy is not a biological disorder. Thus, the facts described in the selectionist “re-write” of the Blair passage are actually neutral between Blair’s disorder view and the selectionist view. It is the description of those facts, and not the facts themselves, that effectively rules out a disorder conception of psychopathy.20
Here, there is no presumption, logical or rhetorical, in favor of either a disorder or a selectionist account of psychopathy. It is thus a description that either sort of theorist might embrace. How, then, is one to decide between disorder and selectionist conceptions of psychopathy?22 While the facts described above cannot do this, perhaps other facts can.23 However, before considering what such facts might be, another question is in need of addressing, namely: If the facts discussed by Blair are indeed neutral between disorder and selectionist conceptions of psychopathy, why the intuitive sense that psychopathy involves non-normative disorder, just as the disorder theorist maintains? Unless we can provide a satisfactory answer to this question, there is bound to be a natural, though arguably unjustified, bias in favor of a disorder (vs. selectionist) conception of psychopathy.
Because individual personalities21 do not find the distress of conspecifics aversive, socialization does not result when they are exposed to standard stimulus-reinforcement techniques, which are predicated on the assumption that persons, in general, find the distress of conspecifics aversive. Because emotion, including aversion, is regulated by the amygdala, it may be that the amygdalae of individual personalities function differently than do the amygdalae of social personalities.
Pathological Effects/Pathological Causes
The question at hand is straightforward: If it is possible to provide a characterization of the empirical facts that is neutral between disorder and selectionist conceptions of psychopathy, what explains the a priori assumption that the underlying cause(s) of psychopathy is itself pathological? By “a priori assumption” I mean only this. Prior to gathering the relevant empirical data, psychologists hoping to discern the neurological underpinnings of psychopathy, generally assume that what they will find, if they find anything, is evidence of pathology.24 Otherwise, how is one to explain the fact that the neurological findings are almost always characterized in the language of disorder—in terms of concepts like “dysfunction” and “impairment”? It is not, as we have just seen, as though such characterizations are inevitable.
Perhaps the answer lies in the fact, well-known to empirical psychologists, that neurological impairment does sometimes lead to antisocial, and even psychopathic, behavior. The case of Phineas Gage is a case in point. However, there is no empirical evidence suggesting that psychopaths have, at any point in their development, suffered any sort of neurological insult.25
P1 Pathological effects have pathological causes.
P2 Causes resemble their effects.
Suppose for the moment that P1 is true.26 Does that really help the disorder theorist? Only if there is agreement on the very issue disputed: that psychopathy involves some sort of pathology. It might be responded that both disorder and selection theorists agree that psychopathy involves normative pathology. However, as noted above, to talk of normative “pathology” is arguably to use the term metaphorically. It is to say (roughly) that the personality and behavioral traits characteristic of psychopathy deviate from moral and social norms. But there is little intuitive appeal in the idea that normative pathology must have its causal origins in some sort of biological pathology. Were such an idea intuitive, then the commonsense view that the morally disordered psychopath is of “sound mind and body,” would be unintuitive. Such a view might well be mistaken, but it is not for that reason unintuitive. Indeed, how could such a view be unintuitive, given its prevalence among those who do not engage in professional theorizing about psychopathy?
P3 The biological causes of normative pathologies are themselves pathological.
However, such an assumption is credible only insofar as it is credible to suppose that evolutionary forces are powerless to produce biological features that reinforce normative pathology. But surely the latter supposition is not credible. As Christopher Boorse  observes in his seminal paper on the disease/illness distinction, “it is no part of biological theory to assume that what is natural is desirable.”27 Thus, the hypothesis that psychopathy (an “undesirable” condition) is the result of natural selection, is in perfect keeping with biological theory. The selectionist, of course, rejects the supposition that what is natural is always desirable. For she denies that psychopaths are biologically “designed” for successful socialization. They are instead “designed” to achieve their goals (especially reproductive ones) without the constraints imposed by “other-regarding” norms of the sort generally internalized via socialization.
Psychopathy and Biological Disorder
Suppose that the selectionist is right, and psychopathy turns out to be the product of natural selection. Then, from an evolutionary point of view, psychopathy is emphatically not a “disorder.” Does it follow, given a selectionist model, that the “language of disorder” is appropriate in characterizations of psychopathy only when used in a normative (or metaphorical) sense? I have been assuming that the answer to this question is yes. However, one might challenge this assumption on the grounds that an evolutionary construal of biological disorder is not inevitable. Indeed, any such characterization might appear patently misguided. The victim of a disorder is, after all, the individual, not the genes.28 Thus, even if psychopathy is the product of natural selection, it is not obvious that the psychopath does not suffer from a biological disorder. Indeed, it has recently been argued (by ) that schizophrenia, a paradigm neurocognitive disorder, is a “by-product of adaptive changes during human evolution.” Yet surely no one endorsing such a view would ever conclude that schizophrenia is a disorder only normatively. Why not? Because schizophrenia is a maladaptive condition. It is maladaptive in the strict sense of being associated with decreased life and/or reproductive expectations. It is also maladaptive in the (looser) sense of being associated with considerable suffering. Schizophrenia is typically described as “devastating” for those who suffer from it. Indeed, schizophrenia is widely reported as having the highest suicide rate (anywhere from 5–10%) of any mental illness.
Might psychopathy be associated with considerable suffering as well? If so, might one argue that, even if psychopathy is maintained by frequency-dependent selection, it is nevertheless a biological disorder? For if psychopathy causes considerable suffering to those afflicted with it, then it is arguably more than a merely normative disorder.29
There are compelling reasons for being wary of any such proposal. For there are differences, seemingly important ones, between schizophrenia and psychopathy. These differences mitigate against the idea that both conditions are disorders at least partly because of the suffering they cause their “victims.” First, schizophrenia is associated with genuine neurological impairment: with significant loss of brain (gray matter) volume. (See .) Psychopathy is not associated with any such loss. Second, schizophrenics often seek treatment for their condition, psychopaths rarely, if ever, do. Perhaps this is because psychopaths do not find their “condition” intrinsically unpleasant. Third, schizophrenia, but not psychopathy, appears to fit at least two familiar, if controversial, analyses of disorder/disease. Schizophrenia arguably counts as a “disorder” on Wakefield’s  criterion of “harmful dysfunction,” for it involves clear neurological dysfunction, and is patently harmful to those who suffer from it. Schizophrenia arguably counts as a “disease” on R. E. Kendell’s  “biological disadvantage” criterion, which is defined in terms of reduced life and/or reproductive expectations. It is true that the psychopath’s life expectancy is somewhat reduced, perhaps because of his fearlessness. However, his reproductive expectancy is not reduced, and indeed may be considerably “better than average.”30 For psychopaths are as promiscuous as they are fearless. Although both Wakefield’s and Kendell’s analyses are controversial, both appear to capture, to some degree, our intuitive sense of what makes a condition a (non-normative) “disorder.”
Despite these concerns, I would like to pursue the idea that psychopathy might constitute a non-normative disorder on account of the suffering it causes those who are afflicted with it. For it is certainly possible that disordered individuals might have normal brain volume, might not seek treatment for their condition, and might not satisfy controversial analyses of the concepts of “disorder and “disease.”
The question is: Is it reasonable to suppose that psychopaths experience considerable suffering on account of their psychopathy? One might initially think that the answer is quite obviously no. Psychopaths, after all, don’t experience the (intrinsically unpleasant) moral emotions that the rest of us do. They do not suffer from feelings of guilt, shame, or remorse. Nor, lacking empathy, do they suffer in response to the suffering of others. Nor do they experience anxiety in situations where the rest of us typically would. Rather than suffering from the doubts and insecurities that plague so many of us, psychopaths are known for their “grandiose sense of self-worth.” However, like the rest of us, psychopaths are quite capable of experiencing the emotions of anger and frustration, natural responses to a loss of freedom. Moreover, it seems reasonable to suppose that the psychopath’s “condition” puts him at increased risk for loss of freedom, and therefore for suffering.31 For it is well-known that psychopaths are greatly overrepresented in the prison population,32 and presumably prison is not where anyone wants to be.
I do not think the foregoing considerations provide much support for the idea that psychopathy might, like schizophrenia, be a biological disorder, albeit one that results from frequency-dependent selection. The difficulty is that, in the case of schizophrenia, the associated suffering is not dependent on the contingencies of the individual’s social environment. The delusional, disorienting, and often disturbing thoughts characteristic of schizophrenia follow the schizophrenic from one social environment to the next. He cannot escape them (without appropriate medical treatment); they follow him wherever he goes. They may continue to haunt him even in environments, such as artist colonies or monasteries, where his creativity and originality might be allowed to flourish.
The case of psychopathy is strikingly different. The psychopath’s suffering (specifically, that associated with a loss of freedom) is not a direct result of his psychopathy. Rather, it depends essentially upon the contingencies of his social environment. His suffering is therefore not intrinsically biological. The point here is a simple one. The psychopath’s (biologically reinforced) antisocial behavior is sometimes criminal. When it is criminal, and when he is caught, he might well “suffer the consequences” of his actions—most notably, a loss of freedom (imprisonment) and in some cases even death.33 In short, while the schizophrenic’s suffering is caused by the symptoms of his condition, the psychopath’s suffering is caused by society’s reaction to the antisocial behaviors that characterize his condition.
The point can perhaps be made more forcefully with the help of a thought-experiment, one in which it is the non-psychopath whose biology puts him at increased risk for considerable suffering. You are stranded on a desert island, along with a companion. There is limited food and water, just enough to last the two of you for a week or so. Your intention is to share these valuable provisions with your companion until help arrives; you assume that your companion’s intentions are similar. However, you are mistaken. Your companion intends to appropriate the provisions for himself and to do so by whatever means necessary. If you attempt to thwart his plans, he will kill you without a second thought. For your companion is a psychopath. In this particular case, we surely do not want to say that you are “biologically disordered,” as your biologically-based pro-social instincts put you at risk for considerable suffering and possible death. Why, then, should we say that the psychopath is “biologically disordered,” as his biologically-based antisocial instincts put him, in certain social environments, at risk for considerable suffering and possible death? We are as “disordered” among psychopaths as they are among us.
In preceding sections, I argued that the “language of disorder” characteristic of most contemporary discussions of psychopathy, is not inevitable. In particular, I claimed that if, as some maintain, psychopathy is the result of frequency-dependent selection, that condition is arguably a “disorder” only normatively. In that case, the language of disorder is an inappropriate medium in which to characterize the non-normative features of psychopathy.
I believe that the answer is clearly yes. In particular, how we characterize psychopathy is bound to influence our views, whether as lay people or as theorists, on issues concerning (inter alia) responsibility and treatment. However, before elaborating, it is important to distinguish between the foregoing question and a similar-sounding, though importantly different, question, namely:
Does how we characterize psychopathy (as involving biological or merely normative disorder) influence how we view individuals with that condition?
This is a far more difficult question, one to which I will return briefly at the close of the paper. My present concern is with the more tractable question that precedes it.
Should how we characterize psychopathy (as involving biological or merely normative disorder) influence how we view individuals with that condition?
Suppose that psychopathy is characterized as a biological, rather than merely normative, disorder. Suppose that it is viewed as similar in kind to other cognitive disorders now thought to be brain-based, including (inter alia) schizophrenia and autism. If we come to believe that psychopathy is similar in kind to these conditions, we will likely see it as at least potentially exculpatory, and as meriting (at least in principle) some form of medical treatment.
Let’s begin with the issue of psychopathy’s potentially exculpatory nature. For decades, criminal defense attorneys have been bringing in “experts” (usually neurologists) to attest to the neurological “impairments” of their clients. In some cases, such strategies are perfectly appropriate. They are appropriate insofar as they serve to confirm the attorney’s independently motivated34 claim that her client is not criminally responsible for the actions for which he is being prosecuted. Certain kinds of neurological impairment are known to precipitate antisocial, and sometimes violent, behavior. In at least some of these cases, it is doubtful that the impaired individual had sufficient control over his behaviors to be held “criminally responsible” in the relevant sense.35
If “experts” come to agree that psychopathy is a biological disorder, defense attorneys are likely to have little difficulty recruiting such persons to assist in their client’s defense. Jurors will be shown brain images documenting “dysfunction” (or “impairment”) in the amygdala, dysfunction that leads to emotional and cognitive “abnormalities” of the sort that reinforce antisocial/criminal behavior. Jurors might well be moved by such rhetoric, and feel some degree of sympathy for the defendant. Psychopaths do terrible things, that much is true, but they do such things only because their brains are “messed up.” Such attitudes might well benefit the psychopathic defendant, especially during the sentencing phase of the trial.
Here is what our brains look like [displaying the brain of a non-psychopath]; here is what a psychopath’s brain looks like [displaying the defendant’s brain]. These images allow you to see, to literally see, the difference between a “good” brain and an “evil” brain. The fact that the defendant’s brain has these unusual features shows, beyond all doubt, that he is a “bad seed.” He was not made bad by a troubled childhood, nor was he made bad by chronic drug abuse. So any sympathy you might feel toward the defendant on account of his difficult childhood or his drug-addled mind, is misguided. For he was born bad, and it is in his nature to be bad.
Here again, jurors might well be swayed by the attorney’s rhetoric, and feel little sympathy for the defendant, a person whose brain is efficiently “designed” for evil-doing, and is therefore “messed up” in only a moral sense. These attitudes might well hurt the psychopathic defendant, especially during the sentencing phase of the trial.
Of course, it is unlikely that there will be a consensus among experts, at least in the near future. However, that only means that both defense and prosecuting attorneys might make use of the relevant brain images. Indeed, they might appeal to the very same images, but characterize them in radically different ways—brains that are “damaged” vs. brains that are “evil.”36
Parallel points apply to the issue of treatment. Suppose experts come to agree that psychopathy is a biological disorder. Then, they will likely push for the development of pharmacological treatments. In contrast, if experts come to agree that psychopathy is a merely normative disorder, the focus might be, not on “helping” psychopaths, but on protecting their potential victims. Educational programs might be implemented—not for the psychopath’s benefit—but for the benefit of the rest of us, the psychopath’s potential victims. Such programs might be aimed at enabling detection, and therefore avoidance, of these human predators.37 Alternatively, programs might be designed, not to change the psychopath’s personality, but to change his behavior by redirecting his adaptive impulses toward more pro-social goals.38
As noted above, it is unlikely that a consensus on the relevant issues will be reached any time soon. In the meantime, it is likely that some will push for medical treatments, others for behavioral modification, and still others for plain old-fashioned vigilance.39
This is an extraordinarily difficult and important question. My intention is not to answer it, but only to draw attention to it, so as to distinguish it from the more tractable question just addressed.
Should how we characterize psychopathy (as involving biological or merely normative disorder) influence how we view individuals with that condition?
Our attitudes (and their associated behaviors) are undoubtedly influenced by how we characterize psychopathy, and in ways that are not difficult to predict. I tried to predict some such influences in the preceding paragraphs. Biologically disordered individuals are naturally thought of as not fully responsible for their motives and behaviors; they are naturally thought of as meriting medical treatment. Individuals who are merely normatively disordered are naturally thought of as fully responsible for their behaviors (and perhaps even for their motives). Their “ethical pathology” is a condition for which medical treatment is likely to be regarded as inappropriate on roughly Szaszian  grounds: To attempt to treat a moral condition by medical means is to “medicalize morals.” It is to fail to respect the important distinction between genuine medical problems and “problems of living.”
However, it is not clear (pace Szasz) whether our attitudes toward psychopaths should be influenced by whether we conceptualize psychopathy as a biological, or merely normative, disorder. Suppose, for instance, that psychopathy turns out to be a biological disorder. Does that mean that research should be devoted primarily to the development of pharmaco- logical treatments? Does it mean educational programs, designed to protect the general public from their predatory fellow humans, should be taken less seriously, or funded less heavily? Does it mean that psychopaths should be treated as having diminished criminal (or moral) responsibility for their antisocial behaviors? Suppose, on the other hand, that psychopathy turns out to be a merely normative disorder. Does that mean that pharmacological treatments should not be pursued? Does it mean that research funding should go primarily toward educational programs aimed at protecting the psychopath’s potential victims? Does it mean that psychopathic criminals should be treated as no less culpable than non-psychopathic criminals—even if their neurology, however “well-ordered,” predisposes them toward criminal behavior?
It might initially be thought that these seemingly difficult questions could be answered straightaway by an application of Szasz’s famous dictum against the medicalization of morals. If psychopathy is a disorder only normatively, then psychopaths are not amenable to—let alone deserving of—medical treatment. Nor are they any less responsible for their antisocial actions than we are for ours. The problem with Szasz’s catchy dictum is that it is only that: catchy. It leaves important questions unanswered: What exactly is wrong the “medicalization of morals”? If morality is ultimately a biological phenomenon,40 then mightn’t the medical treatment of psychopathy be perfectly appropriate? In treating psychopathy with medication, might we be medicating an emotional, rather than a moral, deficit? If a moral condition is in fact brain-based, is there perhaps a sense, and an important one, in which that condition cannot be purely normative?41
The question thus remains: Should how we conceptualize psychopathy (as a biological or merely normative disorder) influence our attitudes toward practical issues, such as those concerning treatment and responsibility? Again, this is a difficult and important question that really needs to be addressed before policies regarding responsibility and treatment can be implemented with complete confidence. In the meantime, what is to be done? How, in particular, are we to approach the question of psychopathy’s status as a disorder, without being influenced—perhaps in the wrong direction—by the language in which the relevant data are formulated?
Should theorists of psychopathy be cautioned against employing language that is heavily biased in favor of a particular conception of that condition? Unfortunately, any such advice would be virtually impossible to heed. After all, to have a theory of some phenomenon just is to conceptualize that phenomenon in certain ways, in ways that effectively exclude other conceptions. The disorder theorist, just because he is a disorder theorist, sees the thoughts and behaviors of the psychopath as involving impairment and dysfunction. The selectionist, just because she is a selectionist, sees the same phenomena differently. She sees the thoughts and behaviors of the psychopath as involving capacity and evolved function.
Perhaps, then, it is the would-be-theorist, the individual trying to come to an understanding of psychopathy, who should take it upon herself to attend carefully to the influences of language, influences that can be as distorting as they are profound.
No one challenges the idea that psychopaths are lacking in the moral emotions, such as empathy, guilt, remorse, and shame. However, not everyone agrees that such deficits invariably conflict with social norms. See, e.g., Hare .
Because contemporary theorists tend to focus on the personality (vs. behavioral) features of psychopathy, there is less of a tendency to conceptualize psychopathy primarily in terms of social pathology. Such pathology is, however, what effectively defines “Antisocial Personality Disorder,” as that condition is characterized in the DSM-IV.
Gathered from forensic populations, and diagnosed in accordance with Hare’s PCL-R.
Grant Harris has indicated (personal correspondence) that when he denies that psychopathy is a “disorder,” disorder is to be understood in roughly Wakefield’s  sense: as involving “harmful dysfunction,” where “dysfunction” is understood in evolutionary terms.
From here on, I will use quotation marks around “disorder” only when I intend the expression to be interpreted metaphorically, as indicative of some sort of normative disorder.
Although the expression “antisocial” suggests merely normative disorder, I have highlighted it because it is coupled with the assumption, rejected by selectionists, that all “healthy” human beings are genetically programmed for successful socialization. Thus, Blair’s use of “antisocial” indirectly suggests biological dysfunction, and is therefore theory-laden in the sense with which I am concerned.
One might argue that while a selectionist account specifies the “ultimate” cause of psychopathy, a neurological difference (not dysfunction) account specifies the “proximate” cause of that condition. Thanks to Grant Harris for drawing my attention to this possibility. Murphy et al.  make a similar observation.
As I suggest below, this bias is sometimes logical and sometimes merely rhetorical.
Qua person (a social construct), it is relatively uncontroversial that the psychopath is, in some metaphorical sense, “malfunctioning.”
Thanks to both Neil Levy and Shaun Nichols for drawing my attention to these points.
See Radical Conceptual and Linguistic Shift below for a detailed defense of this claim.
See, for instance, Kuhn .
Such an explanation is provided in Pathological Effects/Pathological Causes below.
The resultant conceptual shift might approximate a Kuhnian  “paradigm shift.”
Crucially, the psychopath will not be seen/characterized as a disordered duck whose disorder causes him to think and act like a rabbit. He will be seen/characterized as a “well-ordered” rabbit who thinks and acts just like a rabbit is supposed to think and act.
As above, theory-laden expressions are italicized.
Roughly, the achievement of reproductive goals without the “hindrances” imposed by norms of the sort ordinarily internalized through socialization.
The same point applies to the original passage. It is Blair’s language, and not the facts he describes, that effectively rules out a selectionist conception of psychopathy. I say “effectively rules out” only because, as noted above, the ruling out might, in some cases, be more rhetorical than logical.
Here, I am trying to avoid the value-ladenness of locutions like “antisocial” and “pro-individual.”
I do not mean to suggest that one or the other of these two conceptions must be correct. There are many other ways in which psychopathy might be conceptualized. Perhaps most obviously, one might think of psychopathy, not as a biologically-based condition, but as an environmentally-based one. Mealey  argues that psychopathy can be biologically, or environmentally, based. See her (1995) discussion of the distinction between primary and secondary sociopathy.
See Harris et al.  for empirical data that support a selectionist account of psychopathy.
This assumption is not universal, as it is not made by selectionists.
The principle is clearly not true in general. If X is a pathology, it does not follow that its cause must be pathological, if this means that the cause is not well-designed. HIV is an example of a paradigm pathology which is well-designed for replication. Thanks to Neil Levy for drawing my attention to this point.
This reinforces the point made in note 26 above.
Thanks to Neil Levy for this point.
This way of thinking is in line with the DSM-IV definition of “mental disorder,” which makes explicit reference to the “distress,” “disability,” and “loss of freedom” that such disorders tend to cause.
See Harris et al. .
It is not only the psychopath’s amorality, but also his imprudence, that puts him at increased risk for loss of freedom. See Mailbom  for a discussion of the psychopath’s impaired practical reasoning.
A frequently cited statistic is that, while psychopaths make up at least 20% of the prison population, they make up only about 1% of the general population.
I have in mind cases where the death penalty is applied. However, it seems likely that the psychopath’s fearlessness would lead to reduced life expectancy, independently of any criminal behaviors. Might not reduced life expectancy then constitute grounds for regarding psychopathy as a biological disorder? Not clearly. After all, being male is associated with reduced life expectancy, but we do not therefore conclude that being male is a biological disorder. Clearly, more needs to be said about the relationship between reduced life expectancy and biological disorder.
For more on the importance of independent motivation, see Morse .
See Morse  for a clear characterization of the notion of “criminal responsibility.”
Given the current lack of consensus, one might well wonder whether such images should even be admissible in criminal trials.
See Wong and Hare’s  “Guidelines for a Psychopathy Treatment Program,” for an example of such a program.
It seems that cognitive behavioral treatments have proven counter-productive. See Harris et al. .
See, for instance, the papers in Sinnott-Armstrong’s  The Psychology and Biology of Morality.
Szasz himself  suggests that if conditions regarded as “mental” illnesses are subsequently discovered to have their origins in structural/functional brain “abnormalities,” then those conditions are, in fact, genuine (rather than mental) illnesses, and so amenable to medical treatment. The question, of course, is whether the psychopath’s neurology is rightly conceptualized as “abnormal” (or as merely “unusual”).
- 1.American Psychiatric Association. 1994. The diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Association.Google Scholar
- 4.Blair, J., et al. 2005. The psychopath: Emotion and the brain. Malden, MA: Blackwell Publishing.Google Scholar
- 5.Boorse, C. 1975. On the distinction between disease and illness. Philosophy and Public Affairs 5: 49–68.Google Scholar
- 7.Hare, R.D. 1991. The Hare psychopathy checklist—revised (PCL-R). Ontario: Multi-Health Systems.Google Scholar
- 8.Hare, R. 1993. Without conscience: The disturbing world of psychopaths among us. New York: Guilford Press.Google Scholar
- 9.Harris, G., et al. 2001. The construct of psychopathy. Crime and Justice 28: 197–264.Google Scholar
- 10.Harris, G. (forthcoming) In In cold blood: The evolution of psychopathy. Oxford: Oxford University Press.Google Scholar
- 12.Kinner, S. 2003. Psychopathy as an adaptation: Implications for society and social policy. In Evolutionary psychology and violence, eds. R. Bloom and N. Dess, 57–81. Westport, CT: Praeger Publishers.Google Scholar
- 13.Kuhn, T. 1962. The structure of scientific revolutions. Chicago: University of Chicago Press.Google Scholar
- 16.Morse, S. 2006. Brain overclaim syndrome and criminal responsibility: A diagnostic note. Public Law and Legal Theory Research Paper Series No. #06–35: 397–417.Google Scholar
- 17.Murphy, D., et al. 2000. Darwin in the Madhouse: Evolutionary psychology and the classification of mental disorders. In Evolution and the human mind: Modularity, language and meta-cognition, eds. P. Carruthers, and A. Chamberlain, 62–92. Cambridge: Cambridge University Press.Google Scholar
- 18.Prichard, J.C. 1835. A treatise on insanity. London: Sherwood, Gilbert, and Piper.Google Scholar
- 19.Sinnott-Armstrong, W. (ed.) 2007. The psychology and biology of morality. Cambridge, MA: MIT Press.Google Scholar
- 20.Stout, M. 2005. The sociopath next door. New York, NY: Broadway Books.Google Scholar
- 24.Wong, S., and R. Hare. 2005. Guidelines for a psychopathy treatment program. Toronto, Ontario: Multi-Health Systems.Google Scholar