So what are the outcome predictors for antisocial personalities?

She’s found that most of the children improved as they grow older and did not become adults with antisocial personality disorder.

She concluded that variety and severity of childhood behavior problems are the single best predictors of adult antisocial behavior.

She wrote this, “No patient without moderately severe antisocial behavior is measured by having six or more kinds of antisocial behavior.

So no patient without these moderately severe antisocial behavior.

Let’s regress a bit.

She defined moderately severe antisocial behavior as behavior that has six or more kinds of antisocial behavior, four or more episodes of antisocial behavior, or an episode of such behavior serious enough that it might have led to a court appearance.

She says, “No patient without these was diagnosed with a form of antisocial personality as adult.”

So you need to be really, really bad as a child and even worse as an adolescent. You need to be cruel and sadistic and exploitative and criminalized. And you need to be dysempathic and reckless and defiant and authority rejecting, contumacious. You need to be all these in childhood and adult to become a lifelong psychopath.

Otherwise your chances to not develop antisocial personality disorder is an adult. The chances are pretty good.

Among the few variables predictive of long-term adjustment, Robbins at the time said that greater improvement occurred in people over 40 years at the time of follow-up.

So age is somehow a critical factor, which is a strong indication that antisocial personality disorder, let alone psychopathy, are somehow bodily issues.

They may not be psychological at all. It may not be a psychological problem, but a medical problem.

The same way today we consider depression, psychotic disorders, schizophrenia, bipolar disorder as essentially medical conditions.

I have no idea why they still find their place in the DSM, except for money and insurance.

So there’s other data by Black and others.

It shows that men with ASPD improved with increasing age.

Another variable, by the way, is prison, incarceration.

Fans found that men incarcerated for less than a year had a higher rate of remission than men who were never incarcerated.

And men who were incarcerated, spent time in prison, big time for less than a year, had a higher rate of remission than men who were incarcerated for longer than a year, since the year is a crucial critical factor.

So these findings suggest that a brief incarceration acts as a deterrent to antisocial behavior, but a limited time deterrent. It wears off, memory somehow evaporates, and the deterrence is gone.

But if you spend a longer period of time in prison, this deterrence lasts and could be even lifelong.

Prison does reform.

Even if there’s no rehabilitation, the very act and fact of limiting freedom seems to have a curative effect, seems to have a curing effect, a healing effect, or a remitting effect at least, when it comes to antisocial personality disorder, psychopathy.

Actually prison has adverse outcomes in borderline personality disorder.

And to some extent in narcissistic personality disorder.

But with psychopaths, psychopaths it works, especially as they grow older.

What about relationships?

Marriage is a moderating variable, believe it or not.

Married psychopaths are much less antisocial.

But it’s a chicken and egg situation.

Maybe psychopaths who are less psychopathic simply get married.

Marriage is a social institution. It’s a ritual, it’s a ceremony, it’s a procedure.

And psychopaths hate all these things. They’re nonconformists, they’re rebellious, they’re defiant and contumacious.

So maybe the more psychopathic you are, the less likely you are to get married.

And so it’s not that the marriage affected the antisocial behavior, it’s that if the antisocial behavior is low-level, low-key, you’re more likely to get married.

Possibility, I’m not sure.

Just delineating the possibilities.

But it’s a fact that being married is positively and highly correlated with a reduced incidence and severity of antisocial behavior.

Robinson’s study, over one-half of married people with ASPD improved, but very few unmarried people, spouses, partners, other people close to the ASPD.

They play an important role in regulating the ASPD, urging therapy, and the improvement often comes when one has a source of personal support, motivation.

Sometimes just not wanting to hurt the other is sufficient motivation to not engage in antisocial behavior.

People with ASPD who were admitted, they had stronger family types. They were more involved in their communities and they were more likely to live with their spouses.

These findings are largely consistent with the Glucks findings, which linked job stability and marital attachment with improvement.

Each of these situations, from brief incarceration to relative success with marriage and family life, could easily be the result of improvement rather than the cause of improvement, as I just said.

So we can expect people with ASPD who stay happily married or didn’t face a lengthy period of incarceration to have probably had a milder case of ASPD to start with.

Maybe they were predisposed to getting better somehow.

You see, even psychopaths are embedded in culture and society and maybe their upbringing or their education or a chance opportunity.

It’s very difficult to tell the chicken from the egg.

There is some evidence regarding marriage.

So there was a study of male twins and it followed them from 17 to 29 years.

The researchers discovered that men with less severe faults of antisocial behavior, these men were more likely to marry than the more antisocial twins.

So there was one twin who had ASPD, but it was less severe than the twins ASPD.

And so the one with a less severe form got married.

And so severe antisocial symptoms hinder marriage because they interfere with forming intimate relationships, psychopaths.

Don’t do intimacy. Can’t do intimacy.

Another factor that moderates eventual outcomes is the degree of childhood socialization, the child’s tendency to form relationships, the child’s proclivity to internalize social norms, whether the socialization process was disrupted.

Jenkins and Glickman identified two types of children with conduct disorder, socialized children and the under socialized children.

Glickman said that the ability to develop group loyalty, group loyalty is crucial. It marks fundamental division between the socialized and the under socialized children in the conduct disorder group.

Socialized children, regardless of their wayward behavior, naughty behavior, socialized children form strong ties to a familiar group of friends.

Under socialized children tend to be loners.

In a 10 year follow up, Henn and his colleagues found that socialized delinquents were less likely to have been convicted of crimes or imprisoned as adults.

Under socialized children, under socialized delinquents went on to a life of crime and imprisonment.

There are quite a few studies about psychopaths. It’s a fault-bought topic similar to narcissism.

Three additional studies that I may just mention is the follow up studies of Maddox, Gibbons and the partners and the work done by Tonk. All these were conducted in the United Kingdom in the 1960s.

The subjects of the studies were considered psychopaths, which is today the rough equivalent of ASPD.

Maddox reported a five year follow up study of patients seen in an outpatient department between 1961 and 1963.

The men were considered psychopaths and the inclusion criteria included impassivity, trouble with the law, several spouses of sexual partners, trouble at school and unreliability.

Maddox traced 52 of the 59 men. Ten of them, 19% have settled down, 39, 75% have not settled down and had not settled down and 3% and 3 of them, I’m sorry, 6% died by suicide.

That’s not very far from borderline by the way.

Corresponding number for borderline is 10%, 10 to 11.

But what does it mean to settle down in the 1960s?

Maddox defines settling down as having shown a reduction of impulsiveness, enabling the patient to stay in the same job, stay with the same partner and generally a reduction in symptoms that placed him in the category in the first place.

It’s a good enough definition even today.

Was no clear distinction between the men who had settled and those who had not, but 15 of them, 38% of those who had not settled, drank excessively or were frank on callings.

And his associates reported on an eight year follow up of 72 incarcerated criminal psychopaths whose courses, life development, autobiographies were compared with those of 59 ordinary criminals.

So 72 psychopathic criminals, 59 non psychopathic criminals.

The psychopaths were considered as having severe cases and they were selected with the assistance of experienced prison medical officers.

The psychopaths had a greater number of subsequent convictions than the controlling subjects and yet 24% of them had only one or no conviction.

The psychopaths were more likely than the control subjects to have a normal EEG that is true to this very day.

Americans concluded that psychopathic personality, as he said, I’m quoting, “does not inevitably portend as hopeless prognosis as is usually implied.”

He was malignant optimist.

Psychopaths considered aggressive had a worse prognosis.

Violence externalized aggression, externalization.

This is the extreme form of psychopath.

And it’s compared to what we call the inadequate psychopath.

So aggressive psychopaths externalizing psychopaths had more convictions, were committed for aggressive offenses, willful damage, drunken assault, etc.

Gibbons wrote, “It seems probable that the aggressive psychopath is so crippled in all his social relations that he is only able to live by crime and his record therefore consists very largely of acquisitive offenses.”

Paul reported also on outcomes in criminal psychopaths.

These criminal psychopaths have been legally classified as psychopaths in the United Kingdom and they were incarcerated between 1954 and 1961, the year I was born, at Rampton Hospital.

It’s a special, close security psychiatric hospital that at the time catered to offenders considered dangerous or had violent propensities.

Pong defined psychopathic behavior in a bit of a special way.

I’m quoting.

Psychopathic behavior, he defined it as “criminal behavior characterized by extreme callousness, brutality, disregard for others on the one hand, and/or criminal behavior, which is not necessarily violent or serious, but is repeated over and over again, recidivism.

The men in his study were aged, they had a mean age of 29, had followed up, and they had been incarcerated nearly nine years by that time.

Among the 587 men, 171, 29%, relapsed.

Pong concluded that the prognosis is far from hopeless because only 29 relapsed.

The few that were admitted at much later ages, they did not relapse.

So, late age, at the moment of incarceration, predicts good outcomes.

No relapse and no recidivism.

And as Pong said, both age of discharge and length of stay in hospital correlated positively with success.

But findings are similar to blacks in their follow-up study.

So we have no reason to doubt them.

Okay, that’s the overview.

What are my conclusions?

What am I trying to tell you?

Antisocial personality disorder is a childhood disorder.

It’s behavioral.

It’s defined by society and for society.

It’s very well studied.

Possibly it’s the most well studied disorder.

It started 150 years ago, at least.

Definitely in the past 80 years or even 100 years, it was a linchpin of mainstream psychological research and we have a lot of data on psychopathy, or people with antisocial personality disorder.

It’s a chronic disorder.

It begins in early childhood, continues through adulthood.

It’s associated with other mental health and addictive disorders.

Mortality rates are very high.

People with ASPD improve with age.

The problems continue, even though they improve.

But they continue on a lesser scale and they are more benign and the target group is much smaller.

So poor job performance, domestic problems, abuse.

The improvement can occur at any age, but most likely between the mid-30s and the mid-40s.

People with more severe symptoms at onset appear to be the ones with the most severe antisocial personality disorder at follow-up.

There’s no way to predict outcomes in ASPD, but people with earlier onset tend to have a worse outcome and moderating factors include marriage, family and community types, early incarceration, adjudication in childhood, the length of incarceration, degree of socialization.

There’s a lot of work to be done first and foremost to determine whether we should establish a whole class of social relational mental disorders.

Narcissism, for example, is a relational disorder.

Psychopathy and antisocial personality disorder, these are societal disorders.

It’s not shameful to say it’s a group of disorders which have to do with brain abnormalities, for example, bipolar, psychosis, schizophrenia.

There’s a group of disorders which are innate and reflect mental illness.

And there is a group of disorders which erupt and occur only when other people are present, only in interpersonal and societal settings. These group of mental illnesses should be separated, even in the DSM, under the heading of societal, cultural and interpersonal relational mental health disorders.

Until about 100 years ago, this was the case.

Many mental health disorders were described as character disorders.

We need to determine the full extent of this alleged disorder in various subpopulations, for example. We need to determine the clinical picture in women, for example. Of course, outcome, we don’t know any of this.

There’s a small percentage of people with ASPD that have no precursor, have no history of conduct disorder.

How come?

We need to characterize this subset. We need to use much bigger samples.

We say that the disorder is chronic, but why? Why do some people improve while others do not, even though we know the predictors, we don’t know the process. We don’t know if therapeutic interventions, for example, incarceration, how do they change the course of ASPD, if at all? Outcome predictors are important, of course. Clinical illness variables, potential biomarkers, everything, yeah, sure.

But if this is a disorder of childhood, we must focus on troubled children. They are at the greatest risk of developing ASPD.

And children go through the process of socialization. They are in the throes of becoming.

So these are disorders of becoming. Something goes awry in transitioning from tabula rasa to individual. Everything again is not as it should be in the process of individuation.

We need to focus on this. We don’t need to pay so much attention to criminals in prison populations. There was a wrong orientation. It led us astray. We wasted decades.

Of course, some people got rich in the process. Names withheld. But it led us astray.

We need to realize that disorders like ASPD reflect a child’s inability to internalize socialization. And a child is unable to internalize society and its signals and messages and values and core and conventions and mores.

Child is unable to internalize all these.

Because there’s something wrong with the socialization agents. His parents, his peers, his teachers, his role models. Something’s wrong with them. Something goes awry.

The acculturation and socialization processes in these children, they just don’t learn how to be social beings.

It’s not so much as antisocial personality disorder. It’s like non-social personality disorder. These children become adults who go through life doing whatever the hell they want.

Because they don’t realize the interplay between society and individual.

This is what we need to focus on.

Not on measuring all kinds of nonsense in prison populations or people hospitalized in mental asthma. We won’t get anywhere with this.

Because these people are finished. They’re ready made. They’re made.

They’re not going to reverse. They’re not going to regress. They’re not going to change.

So why study the unfortunate outcomes and not the process that leads to the outcomes and give us hope of treatment?

And yes, of course there is hope of treatment if we care to find out what causes this disorder.

Including the possibility that there are brain abnormalities and so on.

Again, it‘s a chicken and egg.

Was the brain abnormality caused by the disruptive, disrupted process of socialization? Or did it cause the disrupted process?

I opt for the first.

I think the brain abnormality is a secondary, not primary.

But this also needs to be proved, or at least investigated.

We have a lot of work to do. Eight years later. Shame on us.