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OF mental health care and mentally ill

Psychopathy: a special case

The much bandied-around, indeed, maligned label of psychopathy has little to do with real individuals with such a complex disorder of personality. It is usually that which accompanies individuals with challenging behaviours and reflects not a state of psychopathy but a felt sense of professional inadequacy in caring for those who refute help offered and take far more than they give. The emergence of psychopathy as a clinical construct over the last century belies its early existence. Indeed, individuals through the ages have demonstrated evidence of this devastating disorder, defined by Pinel  as insanity without delirium, a status which he regarded as morally neutral. Prichard  on the other hand defined the construct as moral insanity, ‘a madness consisting of morbid perversion of natural feeling, affection, inclinations, temper, habits, moral dispositions and natural impulses … without insane illusion or hallucination’. The debate as to whether the psychopath is mad or bad, or simply diabolical has continued across the generations. Indeed there are those that simply deny its existence, which is at best unhelpful. Within modern mental health care we have the benefit of the research by those such as Hare  not only in shedding light on the existence of the clinical construct of psychopathy but allowing the operationalization of the construct using psychometric procedures with established validity and reliability. He describes psychopathy as socially devastating, encompassed by a complex plethora of interpersonal, behavioural and affective characteristics. These are underpinned by a callousness and lack of empathy, together with a repetitive and all pervasive violation of expectations and social norms. Hare  uses a factor model to distinguish between these aspects of psychopathy. Research demonstrates that the key elements of psychopathy, including the broad content of personality style and criminal versatility, are stable over time and are associated with deceitfulness and criminality. Despite the correlation of crime and psychopathy, some psychopaths invariably manage to remain outside the criminal justice system, though those that deviate from society’s rules run the gamut of possible offending.

However, it is the ease with which the psychopath engages in dispassionate violence that makes society reel. The flippant use of the term psychopathy that trips off the tongues of not only the day’s society but clinicians diagnosing the disorder treads a difficult path. The ease with which clinicians use DSM-IV criteria for antisocial personality disorder to apply a diagnosis of psychopathy is alarming and can only lead to unfortunate consequences. Psychopathy is not synonymous with, yet is often confused with the diagnostic category of antisocial personality disorder. This distinction is often lost on clinicians. The majority of individuals with anti-social personality disorder are not psychopaths. Those individuals diagnosed as psychopathic may well demonstrate all or some of the features of the anti-social, but are also likely to show evidence of criteria for narcissistic and/or histrionic personality disorder, earning their place as a special case.


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