PERSPECTIVES ON PSYCHOPATHY- CONCEPT OF PERMANENT DEBATES
Psihopatia (Tulburarea de personalitate antisocial) este prima tulburare de personalitate descrisă în psihiatrie, conceptul fiind controversat este subiectul unor dezbateri aprinse în practica clinică a psihiatriei, dar, de asemenea și la nivelul altor categorii profesionale care vin în contact, mai mult sau mai puțin, cu persoanele care prezintă această tulburare. Acest studiu își propune să sintetizeze, prin intermediul unui chestionar structurat format din 17 întrebări, cunoștințele și metodele de raportare a câtorva categorii profesionale, pentru persoanele care corespund acestui tip de tulburare de personalitate.
Antisocial Personality Disorder is the first Personality Disorder recognized and described in psychiatry. From a historical point of view, the concept found itself since the beginning on a controversial ground, either because it was about the adequate name that this personality disorder should have, the most suitable attitude as to the persons fitting this type of personality disorder, existing contradictions even with reference to its existence, as well as regarding its semiological and nosographical delimitation and definition (1).
Historically speaking the concept has a long and tumultuous tradition beginning with the description made by Theophrastus, continuing with Pinel and his “Manie sans delire”(Insanity without delirium) (2), Rush (3), Koch with “psychopathic inferiority” (4), Kraepelin (5), Schneider (6), Cleckley (7) and more recently Eysenck (8), Cloninger (9) and Hare (10).
From the point of view of the diagnosis criteria, in this study we shall limit ourselves to lay out just some of the defining elements of this disorder, namely: pathological pride, lack of empathy, manipulation tendency, lack of scruples, lacking feeling of loyalty, lack of capacity to take responsibility, impulsiveness, superficiality, superficial charm. All these elements concur at building the psychopathologic picture specific to the antisocial, and generate a perpetual adaptive deficit with major social-family-professional implications. Deviant psycho-behavioral manifestations are early and maintained by the rejection and the tolerance or the imitative attitudes of the surrounding people – first of all of their peers. They allow the diagnosis of Antisocial
Personality Disorder since the age of 15. The behaviour of the antisocial, corresponding to its very own dominant attribute is one that confers to the homonymous personologic diagnosis a specific moral dimension. (1). To this end we conclude our introduction in the approached field, outlining the concept of “moral imbecility”, introduced by J.C Prichard in 1835 and quoted by E. Simonsen in his work referring to psychopathy (11).
PURPOSE OF RESEARCH
Through his behavioral disorders that generate a trailing adaptive deficit, mentioned previously, the antisocial comes often into contact not only with the psychiatry clinic specialists, but also with persons from other professional categories, belonging to the community, being known the prejudices and the mentality assigned to the subject.
Due to these contingences, we considered useful and even necessary to approach, and to the extent possible to assess, the attitude but also the knowledge of certain professional categories, with reference to persons who have this personality disorder. We assume of course, from the very beginning, the limits of this research, limits deriving from the short number of respondents, corresponding to each professional categories, and from the fact that due to the time factor, there have been included in the study only three professional categories, which we considered due to our clinical experience to have more contingence with this category of persons.
MATERIAL AND METHOD
In this study there have been included three professional categories, which as we emphasized previously, enter frequently enough into contact with the persons with antisocial personality disorder. By the nature of the behavioral disorders, which lead to a severe adaptive deficit, the antisocial intercrosses first of all with law enforcement persons, in this case with policemen. This intercrossing derives especially from the adaptive deficit mentioned, generated by a clastic type of behavior, destructions, arsons, physical and verbal hetero- aggressiveness of which, characteristically, the antisocial tries to exonerate himself inclusively by its capacity to manipulate the entourage. The other two professional categories taken into discussion are the registered nurses from the psychiatry clinic and those from internal medicine clinic. We have chosen that the number of respondents to be equal, 20 of each professional category taken into account. From the total of 60 respondents, 45 were of female and 15 males, and 50 persons were from the urban environment and 10 from the rural environment.
From the point of view of the method applied, we used a questionnaire composed of 17 questions. At 16 of them, we used as method of answer, the Likert Scale to cut short the time necessary to fill in the questionnaire. The mentioned questionnaire has been elaborated by the group of authors, and we intend by it to assess, as mentioned before, the attitude and knowledge of various professional category regarding the antisocialness and the antisocials. We have also taken into discussion within the questionnaire a few data concerning the environment of origin of the respondents, age, sex, seniority in work as well as epidemiologic, economic data, and cultural and religious references.
Regarding the self-assessment of the level of knowledge on antisocialness, most of the psychiatric nurses, respectively 50% have circled value 8 on the Likert Scale, most of the internal medicine nurses respectively 35% have circled value 9 and among policemen most of them, respectively 30% have opted for value 8. Those most sure of their knowledge on antisocialness were the psychiatric nurses (average=8.2) and those most uncertain were the internal medicine nurses (average=7.4). In the case of the internal medicine nurses the variation of answers was much higher having a dispersion degree of 4.56 in comparison to the psychiatric nurses whose dispersion degree was only 0.48.
As for the concrete assessment of the knowledge on antisocialness, respectively recognition of real characteristics of an antisocial, most of the psychiatric nurses, 60% (in equal proportions of 30%) have opted for values 8 and 10 on the Likert Scale, the internal medicine nurses, most of them, that is 60%, have chosen values 7, 8,
9 in equal proportions of 20%, and most of the policemen, respectively 70%, have chosen values 8 and 9, with a 40% higher weight at value 9.
In the case of assessing the antisocialness as a mental disorder, psychiatric nurses have been reserved in stating it, with an overwhelming majority of 90%, circling in a proportion of 50% value 6 and in a proportion of 40% value 5. In the case of the internal medicine nurses the dispersion degree was one rather high, but the majority in a proportion of 45% being in a quite strong agreement with this statement. With reference to policemen the overwhelming majority respectively 80% placed themselves at value 10, being in a very strong agreement with this statement.
In the case of assessing the gravity of the antisocial personality disorder, and the most suitable place where the persons with this type of disorder should be assisted, the dispersion degree of the answers was a noticeable one, underlining the uncertainty and their own opinions in the assessment of an optimum management of this field.
Going further, in assessing the fact that the majority of the crimes are committed by antisocials, 45% of the psychiatric nurses have circled value 2, being in a strong disagreement with this statement, the internal medicine nurses and the policemen situating themselves in a proportion of 80 respectively 100% in the half of the strong agreement regarding this statement.
At the statement that the antisocials represent a permanent danger, the majority of the psychiatric nurses, respectively 70% were in a strong disagreement with it, circling in a proportion of 55% value 2 and in a proportion of 15% value 3, underlining a higher tolerance and a more honest appreciation of the real danger, as a resultant of the daily experience in the psychiatry clinic. In the case of the internal medicine nurses the opinions were divided, but concentrated enough towards the two poles of the scale,
50% being concentrated towards the strong agreement pole and 55% towards the strong disagreement pole. In the case of the policemen the dispersion degree of the answers was a noticeable one, underlining probably the great variability of crime types encountered and the specific manner of approach of the law enforcement forces in specific situations.
Another important aspect approached in our research, was with reference to an issue that has received great media coverage and it is discussed especially in the western space. The issue approached and which raises questions, is if the antisocials should or shouldn’t benefit of the same care in the health system as the rest of the population. To this dilemma, the opinions of the psychiatric nurses were in proportion of 60% that these should not benefit of the same medical care as the rest of the population. This percentage underlines probably, a lower tolerance, resulted from the clinical practice, regarding the perpetual reported cases of the antisocial and the medical services, for issues that don’t always have necessarily a medical character. In the case of policemen things are reversed, 90% being situated towards the disagreement pole regarding the limitation of the types of medical care, for the antisocials. The percentage indicates in fact in our opinion, formed in the current practice, especially in the emergency psychiatric service, the desire and the tendency of policemen to leave exclusively up to the psychiatrist the ordeal of the management of such a person.
DISCUSSIONS AND CONCLUSIONS
•ASP remains also at present a challenge even for the specialists who come into permanent contact with this type of persons
•There is still a permanent dispute regarding ASP even within the same professional category
•It is obvious the difficulty to come to an agreement concerning the optimum management of ASP
•It is taking shape the necessity of certain joint debates concerning ASP for a better collaboration between the various professional categories involved
1.Lăzărescu M, Nireştean A. Tulburările de Personalitate. București: Editura Polirom, 2007.
2.Pinel P. A treatise of insanity (Davis D, Trans.). New York: Hafner, 1962. (Original work published in 1801).
3.Rush B. Medical inquiries and observations upon the diseases of the mind. Philadelphia: Kimber and Richardson, 1812.
4.Koch JL. Die psihopatischen Minderwertigkeiten. Ravensburg, Germany: Maier, 1891.
5.Kraepelin E. Psychiatrie: Ein Lehrbuch (7-th ed.). Leipzig: Barth, 1903-1904.
6.Schneider K. Psychopathic personalities (9-th ed., M. Hamilton, Trans.). London: Cassell, 1958. (Original work published 1950).
7.Cleckley H. The mask of sanity. St.Louis, MO: C.V.Mosby, 1941.
8.Eysenck HJ. The dynamics of anxiety and hysteria. New York: Praeger, 1957.
9.Cloninger CR. A systematic method for clinical description and classification of personality variants. Archives of General Psychiatry 1987;44: 573-588.
10.Hare RD. The Hare Psychopathy Checklist. Toronto: Multi-Health Systems, 1986.
11.Simonsen E, Millon T, Birket-Smith M, Davis R. Psychopathy – Antisocial, Criminal and Violent Behavior. New York, London: The Guilford Press, 1998.