Bad Men Do What Good Men Dream

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FORENSIC PSYCHIATRY SPECIAL REPORT: PART I

We are pleased to offer a broad sampling of fascinating subjects by experts in forensic psychiatry. This 2-part Special Report focuses on pyromania, court testimony, avoiding malpractice, and psychopathy. Psychopathy is a particularly interesting subject in that it has been heavily researched, yet it remains something of a puzzle, and most certainly a huge burden on society.¹ In forensic psychiatry, psychopathy is generally thought of as a more aggressive, narcissistic, predatory form of antisocial personality. French physician Philippe Pinel introduced the concept of the psychopathic personality at the turn of the 19th century.² He described characteristics such as impulsive violence in the absence of appreciable deficits in intellect or cognition. In 1941, the classic text by Hervey Cleckley, MD, The Mask of Sanity, provided more detailed clinical descriptions. Building upon the work of Cleckley, Robert D. Hare, PhD, has approached the clinical construct by developing a research tool—the Psychopathy Checklist (PCL-R).³

Nevertheless, there remain multiple conceptualizations of psychopathy, as well as problems with reliability.⁴ While a large body of research has been generated on the subject, the heterogeneous nature of psychopathy renders many conclusions speculative.⁵ In fact, the epidemiology of what I would like to call “antisocial spectrum” disorders is complicated by their heterogeneity. While it appears that antisocial behavior is heritable, its expression varies by age, definition, and adverse life circumstances—among other factors.^6,7 Psychopathy research, conducted primarily on caught or “unsuccessful” psychopaths, continues to seek clarity via grouping characteristics into various facets or models.

For example, the triarchic model of psychopathy is a more recently developed model identifying 3 primary domains: they include boldness, meanness, and disinhibition (Table).⁸ Boldness relates to fearlessness, toleration of danger, and high self-confidence. Meanness encompasses lack of empathy, disregard for close attachments, and exploitative tendencies. Disinhibition refers to poor impulse control, inability to delay gratification, and possibly frontal executive dysfunction.⁹

Throughout the centuries, we have continued to puzzle over our capacity for antisocial behavior. All the while, it may be helpful to keep in mind the aphorism, “Bad men do what good men dream.”¹⁰ Or as the great psychoanalyst, Mick Jagger, aptly noted, “Just as every cop is a criminal, and all the sinners saints . . .”

Dr Knoll is director of forensic psychiatry and professor of psychiatry at SUNY Upstate Medical University in Syracuse, NY. He is editor in chief emeritus of Psychiatric Times® (2010 to 2014).

References

1. DeLisi M, Reidy DE, Heirigs MH, et al. Psychopathic costs: a monetization study of the fiscal toll of psychopathy features among institutionalized delinquents. J Crim Psychol. 2018;8(2):112-124.

2. Pinel P. Traite, Medico – Philosophique Sur L’Alienation Mental. Paris: Richard, Caille et Ravier; 1801.

3. Hare R. Psychopathy: A clinical and forensic overview. Psychiatr Clin North Am. 2006;29(3):709-724.

4. DeMatteo D, Hart SD, Heilbrun K, et al. Statement of concerned experts on the use of the Hare Psychopathy Checklist—Revised in capital sentencing to assess risk for institutional violence. Psychology, Public Policy, and Law. 2020;26(2):133-144.

5. Woody RH. Incidence of Psychopathy. In: Risks of Harm from Psychopathic Individuals. Cham, Switzerland: Springer; 2019: 29-31.

6. Goldstein RB, Chou SP, Saha TD, et al. The Epidemiology of Antisocial Behavioral Syndromes in Adulthood: Results From the National Epidemiologic Survey on Alcohol and Related Conditions-III. J Clin Psychiatry. 2017;78(1):90-98.

7. Gard A, et al. Genetic influences on antisocial behavior: Recent advances and future directions. Curr Opin Psychol. 2019;27:46-55.

8. Hyatt CS, Crowe ML, Lynam DR, Miller JD. Components of the Triarchic Model of Psychopathy and the Five-Factor Model domains share largely overlapping nomological networks. Assessment. 2020;27(1):72-88.

9. Skeem JL, Polaschek DL, Patrick CJ, Lilienfeld SO. Psychopathic personality: Bridging the gap between scientific evidence and public policy. Psychol Sci Public Interest. 2011;12(3):95-162.

10. Simon RI. Bad Men Do What Good Men Dream: A Forensic Psychiatrist Illuminates the Darker Side of Human Behavior. Arlington, VA: American Psychiatric Publishing; 2009.