Did Their Antisocial Personality Disordered Brains Make Them Do It? Stalkers Who Murder, Serial Killers, Sexual Sadists, and Healthcare Workers Who Kill: An Update on ASPD Diagnosis, Causes, Differentiation of Types, Functional MRIs & Voxel Studies.

There are both lay and professional reasons why it might be advisable for Biomedical & Life Sciences librarians to review recent research on what used to be called sociopaths, particularly those with a propensity for committing violent or sexually based offenses.

It is perhaps a sad commentary on the frequency of these crimes and criminals that even in re-runs, and even when only on cable channels, Law and Order SVU (Special Victims Unit) remains one of the most watched of television series today. 

On a more serious basis, familiarization with evidence-based studies is likely to become more and more important as psychiatrists, hospital-based clinical psychologists and social workers, and psychiatric nurses are being increasingly called upon to  give professional opinions on the “dangerousness” of criminal defendants, or on incarcerated or civilly committed  criminals seeking release.

There is now even a vetted  guide precisely for this purpose: VRAG : Violence Risk Assessment Guide.

Increasingly these health care professionals are also being asked about the degree to which their criminal behaviors are “biologically based.”

The latter consideration is a two-edged sword.

If they testify that there is an overwhelming   “biological basis” (i.e. genetics,  birth defects, or as a result of  prior brain injury or of ongoing neurotransmitter imbalances) a criminal defense attorney might argue that the perpetrator was so incapable of understanding the nature of his crime, or of restraining themselves from committing it, that he is therefore “innocent.”

However, getting criminals off for reasons of “biologically-based mental defect”  nowadays often does not mean that the offenders are set free.

Rather, many of them face enforced hospitalization in what amounts to institutions for what used to be called “the criminally insane,” sometimes for periods of time that would extend beyond their sentence in a penitentiary.

Current Terminology & Standard Means of Diagnosis

Today most of what we used to call sociopaths now are diagnosed as having Antisocial Personality Disorder (ASPD or APD) .

This diagnosis is made on a combination of clinical interviews and on certain standardized psychological tests, which sometimes take the form of a sequence of specific questions posed by the examiner.

The most commonly used test and  severity rating system for this disorder, is, by far,  the Psychopathy Checklist –Revised.

This is followed at quite a distance by the related Psychopathy Checklist-Screening Version, the International Personality Disorder Examination, the Millon Clinical Multiaxial Inventory II, the Personality Assessment Inventory, and the Antioscial Features Scale aka the  ANT.

Traits detected in ASPDers include:

·        A thoroughly consistent disregard for the rights and feelings of others, routinely violating the trust of their family members, the rules of their employers, and the law.

·        It used to be thought that ASPDers simply could not comprehend proper boundaries of acceptable behavior, could not observe where lines of authority are drawn, or especially, could not perceive the hurt feelings of others. But it is now understood that ASPDers are cognitively quite aware of them, but simply find them immaterial to their own modus operandi, since many actually exploit the emotional and physical pain of others for their sadistic delight. You cannot exploit that which you do not know is there.

·        ASPDers are nonetheless, very often successful con artists, who use flattery to win over, (at least temporarily) friends, co-workers, business partners and spouses (Many therapists find them untreatable because even with their professional training, mental health practitioners cannot tell for sure when the ASPD patients are  lying.)

·        ASPDers have an exceptionally high opinion of their own intelligence and abilities. (Some of the very worst, alas, are indeed, very intelligent.)

·        ASPDers   tend to get bored easily and are often on the hunt for novel experiences or thrills, but there are two divergent subtypes among them.

·        One type of ASPDer is explosive in his anger; and discounts the possibility of imminent threats of bodily danger to himself or the risk of being arrested , largely because he   prizes the immediate opportunity to display his special  superiority, or he can publically demand instant redress of some supposed grievance. This type of ASPDer often manifests a “Tony Soprano pattern of dominance through overt intimidation and frequent public humiliation of others.

·        But the risk-avoidant type of ASPDer is more likely to be quietly calculating and operate on the “revenge is a dish best served cold” theory. They tend to have higher scores for sadism, and can be meticulous planners of their crimes. They are the “Hannibal Lecters” who delight in scheming with little chance of getting caught by lesser mortals, as a demonstration of their vast superiority.

·        Through comparisons of police reports of their crimes , with written statements made by convicted explosive ASPDers of the “Tony Soprano” type of the same crimes, it appears that these ASPDers tend to self-report accurately most of the major details of the particular incident and seem to be proud of their power  and dominance. But they rely heavily for their legal defense and justification on blaming the victim.

·        The risk-avoidant ASPDers who were caught by the police, by contrast, constructed more spare, and more skillful accounts, carefully omitting details that were only later discovered by the police.  Their defense is more complex and their prosecution more perplexing.

·        But when risk-avoidant ASPDers are found not guilty, and therefore cannot be prosecuted further, or when they are found guilty and face death or life in prison with no possibility for parole, rather than blaming the victim, the risk-avoidant type often, with rare candor, say “I just did it because I felt like doing  it.”

The Demographics & Social Circumstances Presumed To Be Contributing Causes

While both women and men can be diagnosed with ASPD, men are about four to five times as often considered to fit the criteria, particularly in cases where the ASPD seems to be a factor in violence, and especially homicide.

Females with ASPD who commit serial murders are, however, much more likely than male serial killers, to involve partners, virtually always female partners. This is in rather stark contrast to men who almost always commit their crimes alone.

While persons of any race, and seemingly from any culture, can have ASPD, in the US it seems to be more common among whites.

As adults, most ASPDers smoke, many drink to excess, and a high proportion use street drugs as well.

Co-morbidities may sometimes include depression, anxiety, bipolar disorder, and even schizophrenia, but Axis B concurrent diagnoses of  extreme histrionic and narcissistic personality disorders in men, and especially in women,  borderline personality disorder, seem to fit the pattern  better.

As children, ASPDers are most likely to come from homes with incompetent mothers with whom they could form no attachment. Many Freudians, and developmental psychologists in general, suggest that this is overwhelmingly the key single causative factor.

When fathers were present, it appears that a higher than statistically expected percentage of them had done time in prison. This is a factor frequently cited  by those who suggest a genetic basis for the disorder.

One or more of the parents may well have been verbally or physically abusive. This is often the basis on which social workers or school guidance counselor premise their interventions on behalf of the student.

Many ASPDers were childhood bedwetters, schoolyard bullies, engaged in petty thievery, smashed windows, cut up furniture, slashed   car tires, and at any early age, often began setting fires.

Not uncommonly, they move up to torturing animals for pleasure.

As adolescents, they engage in gang violence, street mugging, and burglary or home invasions.

The very best single predictor of which kids are the very most likely to develop into adult ASPDers is a firm diagnosis in childhood of pervasive Conduct Disorder.

Parents with children for whom a Conduct Disorder diagnosis persists for several years, and particularly throughout adolescence, should be very afraid, if not for themselves, then for the rest of us.

Stalkers Who Kill vs. Serial Killers

Not all killers can be diagnosed with confidence as ASPD psychopaths.

Contract killers are a case in point.

While it is possible to hire a person with ASPD to kill someone for the hiring party’s own pleasure, it seems more likely that the person doing the hiring has something akin to the disorder themselves. Many execution style killings are done for financial gain, or to end an unhappy marriage, by complete strangers who quickly exit the scene.

When interviewed, despite the villain in the Academy Award winning movie, “No Country for Old Men,” contract killers often report that indeed, the killing was “just business and nothing personal.” Most importantly, most such killings are done expeditiously with efficiency rather than with prolonged pain inflected for sadistic pleasure. Judging from the literature, factors involving the length and depth of suffering play a great deal of importance in killings by some ASPDers.

Stalkers are another case where ASPD is not an automatic diagnosis. Stalkers who are known to have committed a single murder (and stalkers in general) tend collectively to have only a 15% probability of a diagnosis of ASPD. 

The central issue with stalkers is their need for control of,  or a return of, unrequited love or recognition, from  their victims with whom they often have, or seek to have, or imagine that they have, a close personal relationship.

Their goal is to have, or to have the attention, of that particular woman or that particular man.

They do not always have to have a generalized pattern of seeing themselves as superior, dismissive or  domineering  of over everyone else, if they can have whatever it is that want on demand from this particular person on a recurring basis.

Establishing the motivation for these crimes is often rather easy, and readily believable by juries -----jealousy and extreme fan worship being not uncommon emotions or phenomena.

This differs from the risk-avoidant ASPD serial killers, who may favor a general type of victim, and zero in for a time on a victim of their favored type, but who do not really want a recurring, close relationship with the victim.

A risk avoidant ASPD serial killer will often switch target victims if another is more convenient to him, and generally fits the bill.

Establishing the motives for a risk avoidant ASPD killer’s crimes is more difficult, precisely because there is often no obvious link between the victim and the perpetrator. Furthermore deeply ingrained and heartless sadism is harder for many juries to conceptualize, or to imagine being possible in a sane person who can be  held responsible for their actions and found guilty.

The goal of the risk avoidant ASPD serial killer is to have a singular experience that gives them intense pleasure. Their trophy taking is not so much to remind them of that particular person, so much as to allow them to relive the experience.

By contrast, the stalker turned killer is likely to want a picture of his real (or imagined) lover to remember her by; not a body part.

The differentiation of mass killers (and stalkers) as opposed to serial killers (and serial rapists, btw), also has to do with the length of time they take to commit their crimes.

Stalkers who murder usually kill their victims  as quickly as possible in what might be called the heat of passion, and often at whatever site the victim is to be found at the time. It is often all over in a matter of minutes. If these killers have ASPD, it is likely to be of the explosive type.

Likewise mass killers (people who kill multiple people at one time in a particular location) tend to methodically and rather expeditiously, kill not only the original person against which they may have a real or imagined grievance (an ex-boss, an  unfaithful spouse who works there, the people in a section of a plant who made the particular product that the killer found defective or annoying) but others whom they do not know, but who just happened to be there. 

Many mass killers tend to just keep shooting until they run out of ammunition, the police kill them, or they kill themselves with the last few bullets. While these are often rage killings based on the need for people to pay attention to the killer, they are not generally pleasure seeking events that last several hours. Once again, if these killers do have ASPD, it is likely to be of the explosive type, although depression and even schizophrenia are actually more often diagnosed in mass killers.

Serial killers (and serial rapists) tend commit their crimes in an elaborate , ritualized manner, often in a prepared location, and they often take hours doing it, because it seems to heighten their pleasure.

One related controversy in forensic psychiatry and criminology today is whether the current model of rape as overwhelmingly an explosive crime of violence and power instead of being a crime of sexual gratification, is in fact correct, or whether the sadistic pleasure factor ought to give more weight.

There seems to be unanimity among the authors found below that serial rapist, particularly serial rapists who subsequently kill their victims, do so primarily for the repeated sadistic sexual gratification it affords them.

Indeed, there is an intriguing study that serial killers who strangle their victims, themselves engage in autoerotic asphyxiation as one of their principal forms of sexual release.

Healthcare Workers as Serial Killers

There is clearly awareness that many physicians covertly participate in the euthanasia of their patients with the consent of those patients and their families on a limited basis.

In countries where euthanasia is legal, the doctors must also satisfy medical ethics committees who oversee the decision making process.

In either case, there is some sense that the doctors are trying to follow social norms of compassion, certainly an instinct not typical among ASPDers.

However, it appears that there may be a growing number of nurses (86% of those prosecuted) and to a lesser degree physicians  (12%) , who clearly display what one analyst called a “God-complex,” which, when they finally are forced to explain themselves, show all the usual ASPD assertion of superiority, made in grandiose style.

One disturbing trend is that those physician criminals who came from countries where genocide has occurred or where torture is common,   may have brought this sort of indifference to life covertly into their practice, when they immigrated.

In any case, the numbers are startling. One study reviewed the cases of 54 convicted caregivers from 20 different countries, and found 2113 suspicious deaths attributed to them. 

What Do the Brain Studies Have to Say?

There is, in fact , a growing consensus that ASPDers have less gray matter, particularly the frontal lobes, and other areas where decision making is most commonly thought to occur.

In addition, there is a relative left side reduction in volume in the amygdala, an area  of the brain that is important in both the  detection of danger, and in the person’s own facial expression of fear, as well as  in the  hippocampus, where short term memory and spatial navigation abilities are  handled.

Several studies have determined this using Voxel software that processes MRI or other imaging data.  A “voxel” is a neologism that combines the word “volume” with the word “pixel”, yielding a unit of volume measure that can be digitized, calculated and represented on a 3-D basis more readily.

The use of functional MRIs, which are otherwise best at detecting levels of metabolic activity in certain areas of the brain, has also shown reduced activity in areas of the brain responsible for emotional processing and recognition of social cues in some studies of ASPD adults and Conduct Disorder adolescents, but the results are inconsistent from study to study.

One notable study shows that when pictures of sad and neutral pictures are shown to children with Conduct Disorder, they register the same level of brain activity, whereas in healthy normal children, the sad pictures register a heightened level of activity. Nonetheless, the point is that the image does register. It is not as if they cannot see the image, it just doesn’t register empathy.

Other conflicting studies of childhood onset Conduct Disorder male adolescents actually show enhanced sensitivity and levels of awareness in the same areas, which is a pattern that is also seen in ADHD children and children with difficulty in reading.

At this time, it would seem that the biological or brain defect determinists have the upper hand, but they cannot prove that anatomy is destiny, and in particular, they cannot prove that a propensity equals a certainty. In other words, just because one has an aberrant brain structure, it does not mean that they are going to commit crimes.

This is particularly the case since most studies show that some normally behaving, law abiding  subjects in these studies do have abnormal brain anatomy or activity  as well.

Psychotherapists are also caught in a quandary because saying that the person with brain abnormalities must be excused because they cannot help themselves, and cannot change their behavior, leaves the therapeutic community  with nothing to do, and no hope for developing successful therapies, something that clearly  has not yet happened, despite their often dismal level of success.

A propensity to blame the biology of the brain also relies on an old  neurological doctrine that clearly has been shown to be not the case: the brain is much more malleable than was previously thought.  Different areas of the brain grow and show  greater activity when reinforced by education and training.

A famous case is London cabbies who must pass a particularly rigorous exam that tests their navigational abilities. After study and with experience, it can be demonstratyed that their hippocampus has actually grown.

Areas of the brain that seem to govern depression actually can be seen by functional MRI to change structurally and functionally for the better, not only through drug therapy, and talk therapy  plus drug therapy, but also through talk therapy alone.

There remains the possibility that, as an evolutionary strategy, the brain grows and trains itself to function with the tactics that work the best for the brain owner’s survival. The problem of course, is that their particular survival strategy seems to turn a significant number of these ASPDers into predators.

And as mentioned earlier, this mis-evolution into predators is likely to get them caged.

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Tony Stankus, tstankus@uark.edu Life Sciences Librarian & Professor

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