Richard Zhang
Farmington, Connecticut, United States

 

Man in a Hat. Painting by Josef Capek, 1915–16. Via Wikimedia. Public domain.

A frequently overlooked topic in psychiatry is “antisocial personality disorder” (ASPD) or “sociopathy,” specifically as it manifests in higher socioeconomic backgrounds and thus evades recognition.

I once cared for a well-spoken, charming patient who practiced for years in a prestigious profession. While in his professional capacity, he embezzled thousands of dollars from clients and his own family. Yet, per documentation and history provided by others, he did not appear financially lacking. He exemplifies a small minority of people who repeatedly commit callous acts and believe they can escape consequences. They represent a historically perpetual trend.^1,2 From serial graffiti vandals who damage public property to extremists who justify causing harm by distortedly citing ideology or scripture, many of these figures have become literal tropes. The misleadingly-named psychiatric term “antisocial personality disorder,” which refers not to one’s level of sociability but rather to their antipathy towards societally accepted norms and ethics, may be used to define such people.³ Unfortunately, many physicians focus on the most eye-catching, violent manifestations of ASPD to the exclusion of more discreet patterns of transgression: “repeatedly performing acts that are grounds for arrest”; “aggressiveness, as indicated by repeated physical fights or assaults”; or “reckless disregard for safety of self or others,” according to the DSM-5.⁴

One’s socioeconomic status often influences how these traits manifest and enables a charming facade. “Irritability and aggressiveness” can manifest verbally in corporate and parliamentary meetings.^5,6,7 “Deceitfulness” can involve serious misrepresentations of one’s background and motives towards others, sometimes enabled by one’s access to social capital. “Failure to conform to social norms,” “lack of remorse,” and “rationalizing having hurt” can occur tacitly and around the gray fringes of legality, depending on the perpetrator’s savviness and educational level. They may manifest in a candidate for public office who greatly inflates his own prowess and lies to friends and foes alike, a former computer science intern who maliciously manipulates online search engine results about chosen targets, or an affable medical student who performs egregious deeds under the noses of his professors and attendings. These outwardly trustworthy people can construct multiple personae or even different names for themselves.⁸

The label of antisocial is frequently applied to poor and socially under-resourced persons with unrepentant histories of violence. But it is less often recognized in people of power and privilege. How could someone so well-dressed and financially secure have a temperamental urge to abuse or cheat others? Popular public misconceptions of “sociopaths” overwhelmingly skew towards the severely physically violent, including serial killers and mob bosses. Television thrillers such as Dexter and The Sopranos and documentaries about Ted Bundy may bias fascinated viewers’ perceptions of ASPD towards characters who carry out homicides.^9,10

Standardized diagnostic criteria for ASPD in today’s DSM-5 only capture certain outwardly observed—and not inherently necessary—manifestations of this personality.¹² These criteria were often based on studies of incarcerated populations and people with histories of aggression or crimes while blurring out noncriminal behavior and persistent cruelty.^13-15 Yet people of higher socioeconomic backgrounds with the same fundamental drive to provoke and injure others, or to elicit grossly misled sympathy and reverence, can manage to escape attention, disguise their culpability, and malign those who expose them. They may minimize their wrongdoings, feign victimhood, and project their own negative qualities onto others. For these things, they often escape accountability.

It may unsettle those in healthcare, law, politics, technology, and other white-collar professions to acknowledge the minority presence of ASPD within their ranks. ASPD does not preclude the ability to entertain at parties, flatter at wine bars, or appear socially popular. By overlooking occasional, mild misdeeds, we may unknowingly enable perpetrators’ greatest transgressions. Any enabling of acts of malevolence, no matter if the enabling is intentional or inadvertent, inevitably damages our society. To assume that ASPD exists only in under-resourced, traumatized people with arrest histories is too biased a mental shortcut and contributes to escapes from justice and to societal harm.

 

References

1. Coolidge, Frederick, and Daniel Segal. “Evolution of Personality Disorder Diagnosis in the Diagnostic and Statistical Manual of Mental Disorders.” Clinical Psychology Review 18, no. 5 (1998): 585–99.
2. Moran, Paul. “The Epidemiology of Antisocial Personality Disorder.” Social Psychiatry and Psychiatric Epidemiology 34 (1999): 231–42.
3. Frick, Paul. “The Nature of Antisocial Behaviors and Conduct Disorders.” In Conduct Disorders and Severe Antisocial Behavior, New York: Springer US, 1998, 9–19.
4. American Psychiatric Association. “Personality Disorders.” In Desk Reference to the Diagnostic Criteria from DSM-5-TR, Washington, D.C.: American Psychiatric Association Publishing, 2022, 269–78.
5. Sheehy, Benedict, Clive Boddy, and Brendon Murphy. “Corporate Law and Corporate Psychopaths.” Psychiatry, Psychology, and Law 28, no. 4 (2020): 479–507.
6. Wellons, Sophia. “The Devil in the Boardroom: Corporate Psychopaths and Their Impact on Business.” PURE Insights 1, no. 1 (2012): 42–45.
7. Warren, Gemma, and Jane Clarbour. “Relationship Between Psychopathy and Indirect Aggression Use in a Noncriminal Population.” Aggressive Behavior 35 (2009): 408–21.
8. American Psychiatric Association, “Personality Disorders.”
9. Keesler, Michael, and David DeMatteo. “How Media Exposure Relates to Laypersons’ Understanding of Psychopathy.” Journal of Forensic Sciences 62, no. 6 (2017): 1522–33.
10. Lopera-Marmol, Marta, Manel Jimenez-Morales, and Monika Jimenez-Morales. “Aesthetic Representation of Antisocial Personality Disorder in British Coming-of-Age TV Series.” Social Sciences 11, no. 3 (2022): 133.
11. Pickersgill, Martyn. “Standardising Antisocial Personality Disorder: The Social Shaping of a Psychiatric Technology.” Sociology of Health & Illness 34, no. 4 (2012): 544–59.
12. Milligan, Meg. “Classification of Psychopathy in Diagnostic and Statistical Manual of Mental Disorders.” In The SAGE Encyclopedia of Criminal Psychology. Thousand Oaks, CA: SAGE Publications, 2019, 375–77.
13. Black, Donald. “The Natural History of Antisocial Personality Disorder.” The Canadian Journal of Psychiatry 60, no. 7 (2015): 309–14.
14. Gibbens, Trevor, Desmond Pond, and David Stafford-Clark. “A Follow-Up Study of Criminal Psychopaths.” The Journal of Mental Science 105, no. 438 (1959): 108–15.
15. Milligan, “Classification of Psychopathy in Diagnostic and Statistical Manual of Mental Disorders.”

 

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RICHARD ZHANG, MD, MA, is a second-year psychiatry resident at the University of Connecticut. Concurrently with residency, he serves as an affiliated faculty at the UConn Asian and Asian American Studies Institute, and as the American Psychiatric Association Resident-Fellow Member Deputy Representative for APA Area 1 (New England and Eastern Canada). He intends to continue pursuing clinical, academic, and advocacy work as a future attending psychiatrist.

 

Submitted for the 2022–23 Medical Student Essay Contest

Winter 2023  |  Sections  |  Psychiatry & Psychology