Are Psychopaths Born or Made?

There remains intense controversy in both the lay public, criminal justice, and psychiatric realms about how to conceptualize people with the spectrum of antisocial personality traits. In the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), specific criteria for antisocial personality disorder (ASPD) are outlined, particularly in the context of chronicity since adolescence, meeting at least three of a list of seven specified traits, and significant impairment in both self and interpersonal functioning.

The criteria describe a pervasive and persistent disregard for morality, social norms, and the rights of feelings of others, including chronic patterns of exploitation for personal gain, risk taking, and impulsivity in fulfilling one’s needs and gratification. These behaviors often transgress norms of societal behavior, including breaking laws and turning at times to aggression and violence.

However, conceptualizing antisocial personality disorder as a mental illness implies a moral externalization of culpability for an afflicted individual’s actions; can someone with the full-blown personality disorder be truly held accountable for their actions, or are they someone to be treated with compassion for behaviors out of their control? Adding to the complexity of that question are the multitude of factors that contribute to the development of ASPD, which are typically an individualized blend of baseline genetic predisposition with life events and upbringing styles. Are some people with ASPD doomed to become criminals because they are essentially born that way? Or do they have some elements of free will and culpability for the havoc they can create? And what level of severity can be designated as ASPD versus being a mere thoughtless jerk, or conversely, as frightening as a serial killer or genocidal leader?

Adding to the confusion are popular lay terms like psychopath or sociopath, which have varying definitions. In 1941, the psychiatrist Benjamin Karpman theorized there were two subtypes of criminal behavior: a “primary” type who were temperamentally predisposed to such behavior and lacked conscience formation, and a “secondary” type who became violent and impulsive secondary to traumatic life experiences impeding conscience formation. He may have in turn outlined the crude definitions of psychopathy versus sociopathy from a biological versus sociological perspective. (Of note, many others still define and categorize these nonclinical terms very differently, and there is no standardized consensus on either, so please note that accordingly.)

Roughly, psychopath seems to correspond to the most severe subtype of the ASPD spectrum and has its own criteria and research scale developed by the psychologist Robert Hare (Hare Psychopathy Scale). In pop culture, the term gets assigned to serial killers or fictional characters like Hannibal Lecter or the assassin Villanelle from the show Killing Eve. Some have characterized psychopathy as aligning more with a genetically-based neurobiological phenotype resulting in emotional hyporeactivity, which leads to an underlying disposition prone to thrill-seeking/fearlessness, reduced empathy, and internal emptiness. Some genetic heritability studies have noted there may be baseline deviations in emotional processing circuitry (such as in the amygdala or reward centers of the brain) and neurotransmitter profiles (such as serotonin or dopaminergic deficits) in people meeting criteria for psychopathic traits that may eventually lead to callous behaviors and indifference towards social norms (but interestingly not always).

The subtype may cross over into that captured more by the nonclinical term sociopathy, which focuses more on the maladaptive behaviors and attitudes, emotional lability, and poor impulse control seen in ASPD, and may relate more to external sociocultural and environmental factors. Some have thought sociopathy is related more to negative socialization from upbringing or unstable social environments, encompassing parental figures, role models, or peers (or lack thereof), and with contributions of criminality, abuse, and trauma. These factors can lead to a lack of moral and psychological guidance and emotional/identity support and then the development of ASPD-related traits and behaviors.

Obviously, there is still a lot of crossover and mutual contribution between these two subtypes and conceptualizations of ASPD-related traits and behaviors, and the chicken or egg question cannot be easily answered. Most often, people with antisocial traits may stem from a combination of underlying neurobiological temperament with outside socioenvironmental life factors, and to unique degrees for each person afflicted with these traits. Also, some people like the neuroscientist James Fallon may seem to have all the risk factors for the “psychopathic” temperament and still grow up to be law-abiding, socially functional people, as he noted in his research when he scanned his own brain with an fMRI and investigated his family history. In other cases, there are instances where someone may have grown up in a seemingly stable, loving household without major traumas, and still develop marked antisocial criminal behaviors as implied in the recent miniseries Inventing Anna about the con artist Anna Delvey.

The issue of overall social and interpersonal functioning for people exhibiting antisocial traits is also a larger conundrum; on one obvious extreme, you have people who end up imprisoned due to extreme criminal behavior (such as serial killers, murderers, or major fraudsters and con artists). However, some of these traits may actually be “functional” in our society in terms of achieving powerful positions or financial/artistic productivity and more. People often remark and joke that most corporate executives and politicians may have antisocial traits and can be called “sharks in suits.” Can they really be termed as dysfunctional or psychopathic if they are outwardly successful, even if eventual downstream problems surface from their behaviors that cause serious harm and hurt other people’s lives and well-being? This question remains a dilemma when faced with leaders who hold great responsibility and may enact policies that kill or harm people.

There is also great discomfort in appropriating psychiatric diagnoses and terminology when evaluating these larger-scale dilemmas with antisocial traits and behaviors, even though there are important insights and context to be gained as well when targeted in an ethical way. Discussions about the use of the Goldwater Rule have lacked nuance at times regarding recent controversies over problematic behaviors in major leaders or public figures. Should everyone be afforded compassion or the chance for treatment and appropriate assessment, even people who are capable of extreme violence and cruelty due to their underlying conditions? Are there ways to address underlying systemic socio-cultural ills that contribute to the risky formation of future people afflicted with ASPD? Or do we need to be more vocal and honest about the dangers and damage to others that can result from not appropriately confronting behaviors related to antisocial traits?

Sociopathy Essential Reads

Sociopath: A Memoir

6 Reasons It's Hard to Recognize a Sociopathic Parent

The issues remain highly complex surrounding this spectrum of human behavior, and further careful and thoughtful research and discussion remain important as we approach the damaging consequences on every side of this difficult topic.