Abstract
This book succeeds in two ways. Readers curious about the linked concepts of antisocial personality disorder and psychopathy will have their imaginations fired in the early sections of the book, although there is a danger that they then may be dampened by the density of information in the later sections. Second, the book succeeds in its purpose of underpinning a new portfolio of research in this area. The author comes from the Section of Epidemiology and General Practice at the Institute of Psychiatry in London. The work was commissioned by the High Security Psychiatric Services Commissioning Board in the UK at a time of a resurgence of interest in this topic from health and social service planners and the criminal justice system. The book will also be useful to those interested in the concepts and epidemiology of mental disorders.
The introduction hints at the divide in the field between those who take the personality-based approach of Checkley and Hare, criticised as ‘uncomfortably close to a moral concept, and for some critics representing a disguised attempt to study the concept of evil scientifically’, and the approach of Cloninger and Robins based on behaviour. The latter is ascendant in the DSM and ICD classifications, where the relevant criteria are derived from Robins' famous 30-years follow-up study of children referred to a child guidance clinic. Since this approach focuses on antisocial behavioural deficits, the epidemiological literature on antisocial personality disorder is criticised as circular, with findings of high prevalence rates in populations of prisoners, the homeless and drug users. The author notes that the Checkley–Hare model also produces tautological findings, since the validating criteria are the same as those used to define psychopathy, such as poor behaviourial control and irresponsibility. He comments that although the medical profession has largely abandoned the term psychopathy on the grounds that that it is pejorative, refers to a heterogeneous group of individuals and is confusingly also a legal term, literature on the subject continues to proliferate and the Checkley– Hare model of psychopathy remains a popular one, particularly in the USA.
The chapters on descriptive studies and natural history studies are thorough and carefully argued, while remaining succinct and readable. Explanations of relevant epidemiological concepts are effectively and relatively painlessly woven into the text. Changes in lifetime prevalence rates are often assumed to mean a rising incidence of antisocial personality disorder. Early mortality and impaired recall will make such an interpretation risky. Avoiding misinterpretation in this area is critical and underlines the need for careful analysis as in this book.
The remainder of the book concentrates on studies of associated conditions, risk factors, social and health-care burden and needs assessment. This detailed material is not as clearly illuminated by the accompanying analysis as were the earlier chapters. The author notes that he has had to limit the scope of the work and exclude detailed discussion of the overlap with borderline personality disorders and crime. He has also limited the discussion of the overlap with drug- and alcohol-related disorders. This is a pity because the behavioural consequences of continuing or ceasing to abuse alcohol or opiates remain unclear, may be different, and require more discussion. I missed any mention of the work of George Vaillant.
The author quotes Aubrey Lewis' renowned critique of 25 years ago and notes that the concepts remain as elusive as they were then. Comparatively little is known about the incidence of the disorder, its prevalence in the community, general practice settings and prisons, protective factors and the natural history of the disorder. He concludes that the most important priority should be the accurate determination of natural history through the long-term follow-up of large cohorts of individuals at high risk of developing antisocial personality disorder as defined by the review: those with a family history of antisocial behaviour, children with mixed conduct disorder and hyperactivity symptoms, juvenile delinquents, children with an ‘undercontrolled’ temperament and abused children. Further studies of this type should include repeated follow-up measures and the use of psychosocial outcome variables in preference to conviction data which has been the main outcome assessed in previous work. The book does not address treatment outcomes in any detail as this was the subject of a previous review [1] which concluded that ‘… there is still no convincing evidence that psychopaths can or cannot be treated’ (cited on p.98).
Overall this book highlights the importance of the area to our community, as well as to the profession, and highlights the gaps in our knowledge. The way forward is indicated, although it is difficult, the difficulties being practical as well as conceptual. The question of taxonomy for personality disorders is highlighted as a concern, with a plea for a dimensional as well as a categorical approach. I recommend this book to clinicians and epidemiological researchers.