Psychopathy: A new clinical approach offers hope | Hacker News Reader

Psychopathy: A new clinical approach offers hope

theatlantic.com

98 pointskposehn69 comments

The article is kind of all over the place. It's a bit grating to me, because it's a long form piece attempting to grapple with a complex subject, but it's overly sensationalized and doesn't meaningfully differentiate itself from the media representation. Consider that the article insists on using the colloquial, imprecise and emotionally charged term "psychopath" - the clinical diagnosis, antisocial personality disorder, is not mentioned once in the entire article, despite the fact that the author acknowledges the stigma inherent in the disorder. The title itself is clearly sensationalized. Furthermore, it has passages like this one:

Like the guy standing 20 feet away from me in the North Hall of Mendota Juvenile Treatment Center, in Madison, Wisconsin. The tall, lanky teenager has just emerged from his cell. Two staff members cuff his wrists, shackle his feet, and begin to lead him away. Suddenly he swivels to face me and laughs—a menacing laugh that gives me chills. As young men yell expletives, banging on the metal doors of their cells, and others stare silently through their narrow plexiglass windows, I think, This is as close as I get to Lord of the Flies.

That's a laughably sensationalized and stereotypical depiction of someone with antisocial personality disorder, even one given to criminal behavior. On the one hand it's trying to evoke images of children who are wildly remorseless, on the other hand it talks about the "chills" you get from interacting with these people.

It feels like the article decided to play up the angle of, "What if your child was a psychopath?" instead of realistically tackling the subject in a new way. It's just perpetuating the stigma that already exists - "psychopaths" are either remorseless killers with an insatiable thirst for violence, or they're hyper-efficient captains of their fields. I honestly expect much more nuance and integrity in a long form piece approaching this subject.

The article does mention the clinical diagnosis, but the one for children:

"Samantha was diagnosed with conduct disorder with callous and unemotional traits. She had all the characteristics of a budding psychopath."

Antisocial personality disorder is, as far as I know, used for adults.

I think the youngest diagnoses was 12 (I need to double check) but it, generally, begins to manifest at puberty to mid-twenties, barring some jarring event. Even then, that is usually diagnosed as PTSD with Atypical symptoms, displaying in antisocial behavior. It's been a while since I was in school, so categorization may have (and has, since a new DSM has been published) changed, but they rarely make huge changes. It's, generally, language to accord to the societal language.

The point of this article, and one I mention in another comment (https://news.ycombinator.com/item?id=14359033), is that some of the behavior associated with antisocial personality disorder appear to manifest much earlier than puberty. In that case, they use the diagnoses of callous and unemotional traits.

The really broad, overarching point of the article is that a treatment facility was getting good results in children previously considered hopeless. The novel technique is using positive, rather than negative, reinforcement. It seems kind of ironic that the one technique nobody thought to try was being positive.

Funny you should mention PTSD. The treatment they describe in the article is reminiscent of exposure therapy for PTSD, except it seems to have a different theoretical basis. Rather than calming fear by repeated exposure in a safe environment, it looks like they're trying to blunt a reward response from hurting people by not giving them the reaction they're after.

Yes DSM-5 allowed adolescents to be diagnosed with a number of personality disorders previously reserved for adults, but antisocial personality disorder remains adult only.

I agree that this article was too long and overly sensationalized, but I think at the very least I learned a little bit regarding the progress in the field of treating these behaviors.

The concept of coopting the reward system rather than using punishment is a somewhat novel concept to me (with the exception of dog training)

I'm a child and adolescent forensic psychiatrist. The omission of psychopathy from the DSM was a considered decision, but not everyone agreed with it.

People with psychopathy often exhibit antisocial / criminal behavior, but not everyone who exhibits criminal behavior has the deficit of empathy that characterizes psychopathy.

I work in juvenile prisons, and most of the kids have had a very difficult life and have never been able to trust or rely on the adults in their lives who were supposed to take care of them. Almost all of these, with patience and kindness, can learn what it means to trust someone. Others struggle with it, and don't grasp the value of other people beyond what that person can do for them.

What I do think is much sensationalized is the idea that psychopaths enjoy violence. This can be true, but is hardly a hallmark. Most of them are best described as callous, and are not deterred by the effect of their actions on others, but aren't violent for the sake of being violent.

I always make this mental distinction: to psychopaths, emotions are alien, including fear. That's why they _can_ be such remorseless killers, almost not caring about self-preservation. They'd look at a distressed human like we'd look at a twittering bird. Next to this are sociopaths, who actually have emotions, understand them in others, but only care for themselves and thus game the entire system of human interaction.

A psychopath would be able to stab a bystander `because he looked at me funny-like` whereas a sociopath would abhor this violence, but _would_ be okay with gaming his parents out of €50,000, use this to set up a fake investment company, con 20,000 people out of their retirement savings and then just disappear.

Is there any grounds to this distinction?

> On the one hand it's trying to evoke images of children who are wildly remorseless, on the other hand it talks about the "chills" you get from interacting with these people.

You reminded me of one guy who said he lived 20 years believing that knees shaking out of fear is some cheesy bullshit made up by Looney Tunes until he actually experienced it.

Is that what your problem is? Because otherwise I fail to see the WTF here.

You present yourself as having some knowledge in this area. That being the case, what do you think of the treatments presented in the article?

> Indeed, certain psychopathic traits have survived because they’re useful in small doses: the cool dispassion of a surgeon, the tunnel vision of an Olympic athlete, the ambitious narcissism of many a politician. But when these attributes exist in the wrong combination or in extreme forms, they can produce a dangerously antisocial individual, or even a cold-blooded killer.

Certain politicians are responsible for far more suffering than cold-blooded killers... funny what we value.

You were being down voted. By whom? People who love Hitler and Pol Pot? Or just people who are tired of politics on HN?

Because it's a platitude. By the same criteria, the following statement is true: some scientists are responsible for far more suffering than cold-blooded killers.

"It is forbidden to kill; therefore all murderers are punished unless they kill in large numbers and to the sound of trumpets."

Indeed, even if we had a good therapy for psychopaths in general, the ones who don't get in trouble with the law are the ones who are most dangerous. Why would a successful psychopath ever seek help?

The brain is so complicated that circa 2017 A neurologist, let alone a psychiatrist, can't explain why we can look at a cup of coffee, know that it is hot, know how to to pick it up and balance the cup to your lips and swallow the hot fluid without burning yourself while reading a suspenseful book all at the same time.

If science can't fully explain how and why that process can happen, how can psychiatry or psychology be so confident that they can determine how to cure or treat psychopathy at 3-or-4 years old?.

Even take it further, there is no process, procedure, or prescription you can write or execute to immediately mend a broken heart other than time and personal consideration.

If I can't explain where the wind comes from, why there are tides, or what the sun is, I can still sail a ship.

Complete understanding of all the components of a subject or system doesn't typically seem to be a requirement to do work within that system.

The wind, tides, and sun are all real, objective physical phenomenon.

The mind is not so

It can be debated that the wind, tides and sun are not real and only the mind is. This viewpoint usually doesn't result in computers and spaceships being created though.

Very good! This reminds me of an old zen tale:

>Two men were arguing about a flag flapping in the wind. "It's the wind that is really moving," stated the first one. "No, it is the flag that is moving," contended the second. A Zen master, who happened to be walking by, overheard the debate and interrupted them. "Neither the flag nor the wind is moving," he said, "It is MIND that moves."

I'd like to also point out that computers and spaceships are also objectively/scientifically testable and controllable, unlike the mind. There can be no objective control group when it comes testing the subjectivity of mind.

And what it is if not a physical phenomenon?

Then it is metaphysical and subjective, putting it outside the realm of science.

>If science can't fully explain how and why that process can happen, how can psychiatry or psychology be so confident that they can determine how to cure or treat psychopathy at 3-or-4 years old?.

They aren't. Psychiatry is often the least worst option, in a given situation. The tools are primitive, the process is not understood, and the chances of a successful response is not great. But, this has to be balanced against the cost of doing nothing at all.

Additionally, many of the medications in use have been around for 50+ years, consequently have relatively well known outcomes and side effects, even if we aren't really sure how they work, or if they will in a given situation.

>many of the medications in use have been around for 50+ years

Which psychiatric medications are you referring to? It seems to me that most anti-depressants, anti-anxiety, and anti-psychotics have only very recently been invented.

Yes, most. But two counterexamples that readily come to mind are Haloperidol and Chlorpromazine (Thorazine) - still in widespread use.

Along with my strong agreement with maxmcd's post, let me also point out that this isn't science. It's doctoring, which, when you really get down to it, is a form of engineering, not science. We measure success by whether the treatment works, and whether we understand the side effects and such, not whether we understand the mechanisms of the supposed cure or side effects. There is no requirement that we understand something for it to work.

For an engineer to create something that works reliably and that they can't understand would rely heavily on luck. Usually, an engineer will start with proven science and work towards a design.

That is a common myth, but it's complete bunk. There is no clean flow of "science -> knowledge -> engineering". The flow goes every which way, and there's plenty of engineering that we do without a particular knowledge of the "science".

Heck, we can barely get half of Hacker News to agree that programming is a mathematical endeavor, a close equivalent to the idea. How many programmers are out there just bashing away on engineering despite not knowing the science of what they're doing? How many "cloud" developers don't understand the science papers on consensus algorithms? Yeah, their code hurts for that lack, but it still works to some extent. How many programmers are reading papers with any routineness in their field? Non-zero, but nowhere near 100%. Or even 50%.

>How many programmers are reading papers with any routineness in their field? Non-zero, but nowhere near 100%. Or even 50%.

Yea it's gotta be pretty low. I guess that's a sort of engineering by intuition that, if it lead to a working design, could then be explained with scientific theory.

Still, I would expect a licensed engineer not to sign off on a design if they don't understand it theoretically because they are legally liable in a similar way to doctors.

No, that's a feature of software engineering, not of other kinds of engineering.

No one seriously believes that airliners, bridges, and the electrical grid stay up because of luck, hope, and positive thinking.

The last time the flow went "every which way" was during the industrial revolution, when it was still possible to build useful things with a certain amount of guesswork.

Sometimes they didn't even explode.

CS is roughly in that state now - lots of opinion and proselytising, plenty of cut-and-paste cookbook programming, far too little empirical testing of various beliefs and propositions, and even less interest in the continued refinement of formal methods that have proven to be useful.

We did (and engineered) chemistry long before we understood why chemistry works the way it does; we built airplanes long before understanding how a wing actually works (I mean, wing and propeller shapes were derived experimentally in wind tubes, not because of solid reasoning why).

If there is proven science, sure, an engineer should base the design on it. But if there isn't, that shouldn't prevent trying to get a workable solution before you can get proven science - if anything, the practical experience of your working (and non-working) solutions might be required to make the "why" questions answerable.

I mean, right now we have a boom of building things with neural networks despite the lack of proven science on guarantees and reasons why a deep NN (often with much more parameters/degrees of freedom than training samples) must generalize. We have "rules of thumb", algorithms and tricks that tend to result in state of art results, we have practical comparisons between them, but little in the way of proofs stating that this method must be better than the other one and stating why. We'd have some proofs where method A has better guaranteed lower bounds than method B, but the guaranteed bounds are so far from real world results that you'd ignore those proofs and pick method B anyway because it seems to works better in practice for everyone.

And yes, exactly as you say, this means that new systems/NN architectures can't be built reliably, they are designed and tested empirically and some degree of luck is involved; still, that doesn't mean you can't design useful things with it. Making those designs becomes hard engineering work, especially because of the lack of solid rules.

The flow of knowledge is often from practice to science. For instance, it was known that aspirin could alleviate pain for many decades before scientists discovered why.

Engineers can make their work science-based because the sorts of phenomena they are dealing with are well-understood by the scientists. With psychological phenomena, the scientists have a much poorer understanding, and so you have to go by what experiment shows works.

Is it not too ambitious to compare engineering to psychology or doctoring? If it was like engineering or doctoring the success rates would be more consistent and reliable.

I think therapy is important, unfortunately to our severe detriment, as a science it's in the stone age.

Well positive reinforcement works for training animals to modify their behavior so seems likely it will work (and does) for humans.

We don't always have to know precisely how something works to know that it works.

> how can psychiatry or psychology be so confident that they can determine how to cure or treat psychopathy at 3-or-4 years old?.

By correlative study controlling for as many variables as possible, of course. How do you think science works?

> If science can't fully explain how and why that process can happen, how can psychiatry or psychology be so confident that they can determine how to cure or treat psychopathy at 3-or-4 years old?

The answer is right there in TFA: they aren't confident and they can't "cure" them (that's a really weird word to use here, btw). They only found that some things seem to make these kids less aggressive and reduce recidivism in the first few years. They even went as far as openly admitting lack of knowledge about long-term results.

> Even take it further, there is no process, procedure, or prescription you can write or execute to immediately mend a broken heart other than time and personal consideration.

Oh c'mon, you certainly can't explain how the heart works so why are you so confident about time and personal consideration? :p

And, btw, this one wasn't about drugs and simple routine procedures.

I'm not sure how to bring this to the attention of a mod, but is it possible to merge this post with this other one: https://news.ycombinator.com/item?id=14355964

EDIT: maybe if someone flags this commment... don't worry I won't mind :)

I was wondering recently what Dr. Kiehl is up to these days, and the article gives the answer:

Kiehl and the staff at Mendota are now asking some 300 young men to slide into a mobile brain scanner. The scanner records the shape and size of key areas of the boys’ brains, as well as how their brains react to tests of decision-making ability, impulsivity, and other qualities that go to the core of psychopathy. Each boy’s brain will be scanned before, during, and at the end of their time in the program, offering researchers insights into whether his improved behavior reflects better functioning inside his brain.

Also, "while adult psychopaths constitute only a tiny fraction of the general population, studies suggest that they commit half of all violent crimes.". This is beyond scary. I wonder how we, as a civilization, can get psychopathy under control? We have 1 percent of the population that places enormous burden on the society, and we still act as if they are normal people. Why there's no requirement for psychopathy assessment for jobs like police officers or civil servants? Should we apply mandatory psychopathy testing to all convicted criminals and divert the positives into a specially-designed life track - and what would that life track even look like?

Quite a lot of psychopaths are well-adjusted and trained themselves to fake empathy and other social traits they don't innately have. You probably have a psychopath among your friends, it is not that rare.

Unfortunately, this mental adaptation might never happen or happen too late.

According to most sources 1 in hundred people are psychopaths. Most people don't have that many friends. I for example have just one.

This made me shiver. As a parent that's more or less my worst nightmare, to raise kids who are like that.

+1, I couldn't even finish reading. The scary part is the consistent fear of "raising" that behavior; that somehow it's your fault. It would be very hard to live with that idea.

They made it clear that parenting doesn't matter for these cases as far as they can tell, they focused on a juvenile treatment facility in the main part, not the family in the introductory paragraphs, and the facility tries to mold behavior with high reward/low punishment system ( with the juveniles behind bars to protect everyone else )

A professional could tell me it wasn't my fault over and over again; but it'd honestly take years (at least) to get over that fact. That's just something I'd be hard to un-program from myself.

So, a configured abstract reward system can make psychopaths look like regular narcissists. And then?

Did they find a cure or become mutual accomplices? They learned that if they maintain without showing emotion long enough that they can earn a form of respect by playing the patient's own game. Not surprisingly, the respect sustains when nourished with rewards. The doctors and patients are now comrads. The patient shows improvement during the state of success, diplomatic accomplishment, overcoming their peers, winning, etc. and while it is nice they can reproduce the system, they are still misunderstanding it.

By their logic, we would elect the patients into office, process their confidence as wellness, and maybe one day they can become so cured they will be president!

Maybe there is some valuable stuff being researched here but this essay doesn't confirm that. There is a comparison opportunity in the two origins discussed that might offer actual insight but I guess that was just a narrative decoration?

I find myself stuck on a single data point from this article, the one that reports 16 people lost their lives due to the release of just 248 incarcerated kids. Now my rational mind is able to grasp that this is only 6.5% of the group they were tracking, but I can't help but feel like we owe those 16 people a greater standard of care than to release these deeply disturbed individuals. The recidivism rate for that same group was 97%...so a virtual certainty. They don't break that down into violent crimes vs property crimes, but seat of the pants wisdom suggests that even if it is property crime initially, that it is similarly likely to progress to more sinister deeds later on. If that's not enough to justify a life sentence in perhaps a minimum security facility, I don't know what is.

Yikes. This was a horrifying read. Mostly because my five year old daughter displays some of these characteristics. Like not seeming bothered by others' distress. Or like sometimes maybe enjoying terrorizing her siblings. I think sometimes when she acts concerned it's just because she wants to get her sister to stop crying, not because she cares about her sister, but because the sound annoys her. Does this mean she's wired for psychopathy? That we need to sleep with one eye open? Man, I hope not! Or is this fairly typical of children of this age?

Diagnosing a child as a psychopath is pretty questionable. In addition, diagnoses of psychopathy in adults is difficult and expert psychiatrists have admitted even they are fooled.

I was not surprised then when the article admitted that the parents diagnosed the disorder themselves, and then shopped around for therapists until they found one in another state willing to agree with their diagnosis. I bet it made them feel good when they finally found a doctor willing to support their amateur diagnostic efforts.

Exactly. Psychology is not totally exact... think of the false positive rate (it's going to be big!) and the toll a false positive would take on a child's life. Think of a mentally ill parent doing exactly what you say. That is terrifying to me.

Imagine the toll on a parent if the child remains undiagnosed and untreated. Imagine constantly viewing yourself as a failure for 18+ years because you are unable to control your child's behavior - as they go from hurting pets for fun to hurting siblings and school peers...

Not to mention the toll on their victims.

All children have empathy problems. It's a capacity you develop as you get older (some kids develop it faster or slower). If you diagnose your child with that kind of mental illness in the early stages of development you are completely insane and probably need to have your custody taken away.

It definitely can't be left to the parents, but of course a determined parent is going to shop around for a diagnosis, and of course some people are really hungry for a diagnosis. On the other hand it can be tragic when parents deny a problem and prevent their kid from getting treatment.

It sucks that so many parents let their own wishes interfere with their kids' medical needs, from inventing food allergies to denying mental illness. Some people just looooove a diagnosis (for themselves or their kid) because they love using it to give a certain context to their lives, and some people will live in denial for years because they don't trust doctors or fear stigma.

>Imagine constantly viewing yourself as a failure for 18+ years because you are unable to control your child's behavior

I understand this sentiment, but looking at it from another angle, this sentiment suggests control/blame issues on the part of the parent. Which itself can be classified as a "mental illness".

This highlights how often the macro social environment is ignored in the production of mental issues, and how the blunt of the blame is placed on the individual.

I'm not sure I understand what you're trying to say... that if a parent tends to blame issues with their children on themselves, that parent has a mental illness? I don't think you understand a parent's position in society. It may not be a beneficial reaction, but it's presently a fairly normal one.

Indeed it is "normal" in the sense that it is common, but allow me to elaborate.

>>Imagine constantly viewing yourself as a failure for 18+ years because you are unable to control your child's behavior

This sentiment implies the impossible and horrid belief that a parent has and should exercise absolute control over their child's mind.

Incessantly blaming yourself for 18+ years for something you were never in control of in the first place is self-destructive and masochistic. Furthermore having such an attitude is toxic to those around you, like that of a infectious disease, and would only serve to reinforce the mental issues of the child.

To be fair, this is often not a tractable situation for parents. The child behaves in a manner that the parents don't know how to address (which doesn't surprise me with the kind of materials available out there). Most parents can't deal with a kid that expresses violent intent toward other kids, regardless of what's the accurate diagnosis in that situation. Various attempts to address the situation didn't work. What then?

I was reading the other day about a situation that was far simpler. The child just screamed constantly nonstop for a year and neither a therapist nor a pediatrician was able to provide anything useful.

When the system doesn't work, people are going to take matters in their own hands, however problematic that may be. This is not a bad thing.

I think the article could have been clearer but it sounds like they described the recommended treatments in the previous paragraphs. None of them worked and the child did not "outgrow" her condition as predicted by everyone that they saw. Considering they have seven other children that are not particularly troublesome, the most common diagnosis that it was the parenting to blame might drive the most reasonable parent to seek other options, especially after the horror movie-esque “I want to kill all of you.” and "Four months later, Samantha tried to strangle her baby brother, who was just two months old." Someone might consider it reasonable for the safety of the other children to give up at that point but they continued to seek treatment options.

There's another factor at play in Samantha's case - she was adopted. The article mentions that no evidence of abuse was ever uncovered by previous parents (both biological and foster), but who knows?

You're right, they did adopt a half sister who may have not shared any family home with Samantha at all or was cohabiting a home, could have used some more info on that.

This NYT article from 2012 addresses this point: "Can You Call a 9-Year-Old a Psychopath?", http://www.nytimes.com/2012/05/13/magazine/can-you-call-a-9-...

The article's answer is basically yes, but it is not easy. Yes, many of the typical criteria used to diagnose psychopathy are normal traits in children at certain ages. But one of the counterpoints is that what are the chances that people suddenly become psychopaths in adulthood? It's likely they exhibit some diagnosable traits in childhood.

Funny. I can't believe it feels "good" for any parent to conclude that their child has an incurable predilection for callousness and violence that could lead to a life in and out of jail.

Maybe you have some problems with empathy yourself, if your understanding of feelings is that faulty?

Think of it as if you were raising a zombie, all deep in the uncanny valley. This is how some people feel when facing a psychopath.

They don't quite act within human parameters.

To overcome this you have to be quite callous yourself. It is a reaction and emotion.

> “What fits with the behaviors I’m seeing?” Eventually she found one condition that did seem to fit—but it was a diagnosis that all the mental-health professionals had dismissed, because it’s considered both rare and untreatable.

They dismissed it because it's rare and untreatable, not because it didn't fit the symptoms.

> I bet it made them feel good when they finally found a doctor willing to support their amateur diagnostic efforts.

I doubt I'll see a more ironic statement this week. Congrats.

What's scary is that these people are actually released into the world. 36% of them do violent crimes again. And that's considered a GOOD stat.

That's insane. I don't know what the answer is, but this article makes me more aware (and maybe scared) of how many violent people are out there.

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