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Book Forum: GOOD AND EVIL   |    
Bad Boys, Bad Men: Confronting Antisocial Personality Disorder
JAMES R. MERIKANGAS, M.D.
Am J Psychiatry 1999;156:2011-a-2012.
View Author and Article Information
New Haven, Conn.

Donald W. Black, M.D., C. Lindon Larson. New York, Oxford University Press, 1999, 231$25.00.

Antisocial personality disorder or sociopathy is the label we give those among us who, apparently from a lack of guilt and an absence of empathy, cause a substantial amount of trouble to society by ignoring laws, rules, and morality. Characterized as having a callous disregard for the rights of others, those we call antisocial seem to cause more suffering to people around them than they themselves experience. This is one way they differ from individuals with the other personality disorders and the major mental diseases, where the biological basis may be more evident or at least more likely to be at the core.

Those who disregard the law and show no remorse and who, despite punishment, continue to offend society are a major problem for the criminal justice system and for psychiatry. Many of the laws and statutes on the books regarding legal insanity specifically exclude the diagnosis of antisocial personality disorder from consideration for a psychiatric defense, despite language such as "a defect of mind or reason which renders one substantially incapable of conforming one’s conduct to the requirements of law" being the standard in some jurisdictions.

This results in a great dilemma, one recognized by Krafft-Ebing in 1866 when he said,

Law and juris prudence have thus far given but little attention to the facts resulting from investigations in psychopathology. Law is, in this, opposed to medicine, and is constantly in danger of passing judgment on individuals who, in the light of science, are not responsible for their acts. Owing to this superficial treatment of acts that deeply concern the interests and welfare of society, it becomes very easy for justice to treat a delinquent, who is as dangerous to society as a murderer or a wild beast, as a criminal, and, after punishment, release him to prey on society again; on the other hand, scientific investigation shows that a man mentally and sexually degenerate ab origine, and therefore irresponsible must be removed from society for life, but not as a punishment. (1)

Further, Krafft-Ebing said, "A judge who considers only the crime, and not its perpetrator, is always in danger of injuring not only important interests of society (general morality and safety), but also those of the individual (honor)" (1).

In Bad Boys, Bad Men, Dr. Black approaches a disorder that afflicts more people and causes more suffering than schizophrenia but that has not received the intense scientific scrutiny that has disclosed the biological basis of many of the other major mental disorders. Drawing on a wealth of clinical material from the University of Iowa Hospitals and Clinics, he builds on and expands the groundbreaking work of Hervey Cleckley in The Mask of Sanity(2) and the classic epidemiologic study Deviant Children Grown Up by Lee Robins (3).

Dr. Black points out that antisocial personality disorder was found to be quite prevalent in the Epidemiologic Catchment Area study: 2%–4% of men and 0.5%–1% of women were diagnosed as antisocial. Only depression was more prevalent, but antisocial personality disorder is forever, whereas depression can remit. When the term "antisocial personality" was introduced in DSM-II in 1968, it was defined by a list of traits, including being selfish, callous, irresponsible, impulsive, and unable to feel guilt or to learn from experience and punishment. It is of interest that there is a word in Japanese, transliterated as boonachimono, which describes people who "lack piety, respect, honesty, trust, justice, courtesy, uprightness and shame resulting in their becoming ruthless outcasts." This condition has certainly been around for a long time. Cicero described an antisocial character by saying,

Oppianicus always remained entirely true to his natural character at other periods of his life as well as those I have been telling you about. For example, the town council at Larinum decided, unanimously, he had falsified the public records of the local censors. No one would dream of entering into any financial arrangement with him or, indeed, would conduct any transactions with him whatsoever. Out of all of his numerous kinsmen and connections not a single one ever appointed him the guardian of any of the children in their wills. To pay him a visit or to have a chat with him, or meet with him on a social occasion, was regarded as exceedingly inadvisable. Everybody shrank away from and detested him, everybody kept clear of his path, just as if he was some nasty and dangerous wild animal, or a contagious disease. (4)

History and literature are replete with examples of people who have no regard for the rights of others, but psychiatry has no answer for either the etiology of this condition or its treatment. Bad Boys, Bad Men brings together a wealth of information and summarizes hundreds of references in a concise and useful way. Dr. Black gives practical guidelines for dealing with antisocial personality disorder, for which, although most experts agree there is no treatment, there is certainly management. The disorder usually begins in childhood and reaches its peak in the 20s and 30s, predominantly in males; job and marital problems and violence are the most common symptoms. There is a strong association with substance abuse. Often the criminal behavior of addicts is a symptom of the personality disorder rather than a consequence of the use of drugs. Although excellent texts exist regarding personality disorders in general, particularly Abnormalities of Personality by Michael H. Stone (5), more specialized books such as Handbook of Antisocial Behavior(6), and popular texts such as Psychopathy and Delinquency(7), are either out of print or not accessible to the general reader.

Bad Boys, Bad Men traces the history of the diagnostic criteria for antisocial personality disorder and outlines the symptoms and the process of diagnosis with a scholarly summary of a huge body of literature. After a discussion of the course and outcome of the disorder, various possible causes are discussed, including a discussion of the interplay of genes and environment. Of great interest is the summary of current treatment methods. A fascinating chapter is an in-depth study of the serial killer John Wayne Gacy. There are throughout the book vignettes of actual cases that illustrate the complexity of this disorder. Particularly useful is the final chapter of the book, which provides advice for families coping with the disorder.

My only criticism of the book is also one of its chief virtues, that is, it lacks statistical tables, charts, diagrams and numbers drawn from the author’s vast experience. However, such recapitulation of what is already documented in other sources is unnecessary to the mission of this book, which is to provide a useful and readable source for the profession and the public to deal with this enormous social problem. Left unexplained, although fully described, is the biological defect or perhaps adaptive flaw that produces personalities who can lie, cheat, and steal without feeling guilt. In The Inferno of Dante, Ulysses is in the eighth circle of hell, which is a place reserved for con men, where he has been placed for deceiving his crew on his self-serving search for adventure or what Cloninger would describe as sensation-seeking behavior. Ulysses illustrates the paradox of antisocial personality disorder by his speech to his men, who were misused for his own purposes, with the deceit, "You are not born to live as a mere brute does, but for the pursuit of the knowledge and the good" (8, Canto 227). Thus, the paradox of human nature is that knowing what is right and good and claiming to have been reformed, mankind continues to lie, cheat, steal, and make war to its own detriment and to the consternation and misery of others.

Donald Black has made a major contribution to the understanding of this condition with Bad Boys, Bad Men. This volume deserves wide circulation, both to psychiatric training programs and the public at large. It would constitute a great service to education if it were required reading in high school. Perhaps by teaching young people how to recognize personality disorders they may be spared the misery of being exploited by those who have antisocial and borderline disorders.

von Krafft-Ebing R: Psychopathia Sexualis. Translated by Wedeck HE. New York, GP Putnam’s Sons, 1965, pp 519–520
 
Cleckley H: The Mask of Sanity, 2nd ed. St Louis, CV Mosby, 1950
 
Robins LN: Deviant Children Grown Up. Baltimore, Williams & Wilkins, 1966
 
Cicero MT: Murder Trials. Translated by Grant M. New York, Dorset Press, 1986, pp 144–145
 
Stone MH: Abnormalities of Personality. New York, WW Norton, 1993
 
Stoff DM, Maser JD, Breiling J (eds): Handbook of Antisocial Behavior. New York, John Wiley & Sons, 1997
 
McCord WJ, McCord J: Psychopathy and Delinquency. New York, Grune & Stratton, 1956
 
The Inferno of Dante. Translated by Robert Pinsky. New York, Farrar Straus & Giroux, 1994
 
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References

von Krafft-Ebing R: Psychopathia Sexualis. Translated by Wedeck HE. New York, GP Putnam’s Sons, 1965, pp 519–520
 
Cleckley H: The Mask of Sanity, 2nd ed. St Louis, CV Mosby, 1950
 
Robins LN: Deviant Children Grown Up. Baltimore, Williams & Wilkins, 1966
 
Cicero MT: Murder Trials. Translated by Grant M. New York, Dorset Press, 1986, pp 144–145
 
Stone MH: Abnormalities of Personality. New York, WW Norton, 1993
 
Stoff DM, Maser JD, Breiling J (eds): Handbook of Antisocial Behavior. New York, John Wiley & Sons, 1997
 
McCord WJ, McCord J: Psychopathy and Delinquency. New York, Grune & Stratton, 1956
 
The Inferno of Dante. Translated by Robert Pinsky. New York, Farrar Straus & Giroux, 1994
 
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