Ideas from psychology catch fire in the public imagination when they offer explanations for disturbing or transgressive behavior. Perhaps no psychology terms are as lurid or fascinating as “psychopath” and “sociopath.” Viral news articles and quizzes promise to answer the question, “Is My Boss a Psychopath?” or even, “Am I a Psychopath?” Crime television shows like Criminal Minds paint vivid pictures of psychopathic “unsubs”: cruel, twisted geniuses with no conscience and elaborate plans for torture and murder.
The problem with these media portrayals is that they present these terms as if they are based on definitive clinical research and diagnostic categories. The truth is, while some psychologists do research these traits, the terms “sociopathy” and “psychopathy” are broad terms that are used differently by different people and are not used in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the primary reference book for diagnosing mental health conditions.
The closest diagnosis in the DSM to these informal popular diagnoses is antisocial personality disorder (APD). This is confusing for people who learn that they or someone they know has been given this diagnosis. This confusion arises because the definition of APD does not quite match the popular idea of a “psychopath.”
One way to think about this difference is to compare someone considered to be a psychopath, like a famous serial killer, to someone who is frequently in and out of jail for a myriad of petty offenses. The latter might be manipulative, aggressive, and a troublemaker, but they are hardly the cold, calculating psychopath of popular myth.
Clinicians try to explain the relationship between the formal diagnosis of APD and pop culture ideas by saying APD more closely resembles descriptions of sociopathy than descriptions of psychopathy. One psychologist explains the difference by saying sociopaths are “hot-headed” while psychopaths are “cold-hearted.” A sociopath has a weak conscience while a psychopath lacks one. Similarly, a person with APD has a weakened, but intact capacity for empathy. To be formally diagnosed with APD, a person must exhibit three of the following traits for a long period of time, starting at age 15:
- Failing to conform to social norms or laws and acting in ways that could lead to arrest
- Being deceitful, using aliases, and conning others for personal profit or pleasure
- Engaging in impulsive behavior and failing to plan ahead
- Exhibiting irritability and aggression, as indicated by repeated physical assaults
- Acting in ways that show disregard for the safety of oneself and others
- Consistently acting irresponsibly, such as failing to uphold work or financial obligations
- Showing a lack of remorse and rationalizing hurtful actions
Someone with APD has poor impulse control. In fact, they have the opposite personality profile from someone described as “calculating.” People with APD learned to survive by manipulating and taking advantage of other people, whether through acts of deceit or physical dominance. They may enjoy the feeling of having power over others or may be indifferent to the effects they are having on others—what matters to them is that they are getting what they want.
What causes a person to be this way? It can help to understand the nature of this kind of disorder. Personality disorders are long-term conditions caused by a combination of biological, environmental, and social factors. For example, a person with APD might have been born with an aggressive or competitive temperament and grown up in a chaotic home where their needs were not met or where they were disproportionately rewarded for aggressive behavior.
Unlike all other psychiatric disorders, personality disorders were originally considered to be life-long conditions which could only be managed, never changed. For example, a person could heal from a depressive episode, but not from a personality disorder. However, since these diagnostic categories were first developed, research has revealed that they can respond to treatment the way other mental health conditions can.
The right approach to treating APD is highly debated. Research does not support any particular medication or therapeutic intervention as the most effective for APD, though psychotherapy is usually the primary treatment method. Psychotherapy is any form of “talk therapy” in which a person talks to a therapist about their mental health problems and works together with that therapist to resolve them.
Most clinicians who treat clients with APD use cognitive behavioral therapy (CBT), which helps people correct cognitive distortions that influence their behavior. In the case of APD, treatment usually includes a social component, as social insight and functioning are the primary deficits for people with APD. This means that group and family therapy can be particularly useful, as they highlight and help people explore social dynamics in real time.
Unfortunately, due to the particular nature of this disorder, most interventions for APD are provided by or in combination with interventions from the criminal justice system. People with APD rarely present to treatment voluntarily, as they typically do not see themselves as having a disorder or even having a problem. They tend to blame others and society for having a problem with them! They are more likely to begin treatment as the result of a mandate from the legal system or another source of social enforcement, such as social services.
This is not all bad news. Due to the deficits in empathy that are characteristic of APD, behavioral interventions that focus on the consequences of behavior are more effective than attempts to provoke guilt or interpersonal insight. Empathy and insight can be increased over time, but this is a long and painstaking process. Mandated treatment can yield results even for clients who originally are resistant to treatment and lack internal motivation to change. Having consequences for noncompliance can help a person stay in treatment long enough to become interested in it and to start responding to it.
It is very common for people with APD and other Cluster B personality disorders to have co-occurring substance use disorders. While there are many key differences among people with these four disorders (borderline, narcissistic, histrionic, and antisocial personality disorders), they all are characterized by having poor impulse control and highly variable moods. The way people with these disorders respond to changes in mood and to social situations leaves them vulnerable to substance abuse.
People with APD have a hard time managing anger. Many of the behaviors associated with the condition arise from direct or channeled aggression. In an effort to tame emotional reactions that make them feel out of control, people with APD often turn to substances. Unfortunately, this increases their likelihood of becoming involved with the criminal justice system.
It’s important not to confuse the temporary behavioral changes triggered by substance abuse with APD traits. Substance dependence can drive people to do things that are out of character, and that is exactly the difference. Someone with APD developed these tendencies during their childhood, while the majority of people who engage in deception or unlawful behavior in the course of addiction do so only under desperate circumstances and stop as soon as they enter recovery. It is not possible for substance abuse or anything else that happens after childhood to cause a personality disorder.
Antisocial personality disorder is a serious condition that is difficult, but not impossible, to treat. Especially when combined with co-occurring substance use disorders, it often leads to frequent involvement with the criminal justice system, which is where people with APD are most likely to be diagnosed and treated.
The consequences of failing to complete mandated treatment are often the most significant motivating factor in keeping people with APD in therapy long enough to start responding to it. People who love someone with APD need to practice self-care and maintain good boundaries in order to avoid protecting their loved one from these consequences. Since this disorder affects the whole family, family therapy can be especially beneficial. Don’t give up if you or a loved one may be affected, and don’t hesitate to seek support.