Antisocial Personality Disorder (APD) and Its Relationship to Socioeconomic Status

Antisocial Personality Disorder has been linked with psychopathy since its conception and can be traced backed to the mid 19th century. Its predecessors include “Manie sans Delire” (insanity without confusion), a disorder described in an 1835 essay by the physiologist Philippe Pinel, and “Moral Insanity,” a term coined by the psychologist James Prichard in the 1850s. At this time, it was conceptualized as behavior so far outside of legal and moral boundaries that it seemed to be a form of lunacy, although intellectual skills remain completely functional. More recently, Hare’s psychopathy checklist (1988) described the disorder as a combination of two factors: emotional detachment, and impulsive-antisocial lifestyle. Hare’s psychopathy checklist is very important because it is the basis for the diagnostic criterion of Antisocial Personality Disorder that appear in the DSM-5, which is currently the only manual that psychiatrists in the United States can use to assess and diagnose mental disorders. 

However, the DSM-5’s adaptation of Hare’s Psychopathy Checklist is very problematic. In Hare’s checklist, there are eight items under the emotional detachment factor, and nine items under the impulsive-antisocial lifestyle factor, so the two factors are evenly balanced. The emotional detachment section’s items focus on the selfish, callous, and remorseless exploitation of others, and include things like pathological lying, grandiose sense of self-worth, and shallow affect (disingenuous expression of emotion). The impulsive-antisocial lifestyle section describes chronically unstable and antisocial lifestyle and includes juvenile delinquency, problems with parole, and lack of realistic long-term goals. The two sections make sense and accurately characterize psychopathy when balanced evenly, but the DSM-5 focuses disproportionately on the impulsive-antisocial lifestyle factor. It includes seven items (with a minimum of three needed to diagnose the disorder), and five of them relate to the lifestyle factor while only two relate to the emotional detachment factor.

The way that the DSM-5 has adapted Hare’s checklist means that if someone is frequently unemployed, does illegal things, and gets into fights, they can be given a diagnosis that is primarily meant for psychopaths. The really detrimental part of this is that the diagnosis can now be applied to a large portion of the urban poor in America, who cannot attain the level of education necessary to get a job that pays a living wage and who have grown up in neighborhoods dominated by violence and illegal activities. Not only does this have the potential to further stigmatize the poor and add the label of “psychopath” to the already extensive list of labels that Americans place on people of low socioeconomic status, but it is reflective of issues in other areas of our society. First, it illustrates that poor people in America do not have adequate access to mental health services. If people of lower socioeconomic status were attending therapy and addressing psychological problems at the rate that middle and upper class people are, there would be an overdiagnosis of Antisocial Personality Disorder, and the criterion for diagnosing it would probably be revised as a result. However, the vast majority of people who currently have this diagnosis are incarcerated, and have only received the diagnosis in a psych evaluation that was part of criminal court proceedings (Hare, 2006). In addition, only 10-15% of incarcerated individuals with an APD diagnosis match the criterion presented in Hare’s Psychopathy Checklist (Newman, 1987). Mental health services in our country are designed for the upper class, probably because of our lack of affordable healthcare. The diagnostic criterion for APD demonstrate the profound disconnect between mental health professionals and the urban poor.

Neumann, C. S., Kosson, D. S., Forth, A. E., & Hare, R. D. (2006). Factor structure of the Hare Psychopathy Checklist: Youth Version in incarcerated adolescents. Psychological Assessment, 18(2), 142-154. doi: 10.1037/1040-3590.18.2.142

Newman, Joseph P., Mark Patterson, and David S. Kosson. Response Perseveration in Psychopaths. Psych.wisc.edu. University of Wisconsin- Madison, 1987. Web.