Bad to the Bone

By Harriet Barovick

To their victims they seemed pretty normal at first, even admirable. Reinaldo Silvestre, a charming Miami con man with no medical training, is alleged to have operated on his plastic-surgery patients by shoving implants into their chests with a spatula; several were permanently mutilated. A drifter named Luis Garavito confessed in October to kidnapping, torturing and killing 140 children over five years in Colombia. Dylan Klebold went to the prom (and Eric Harris wanted to) before shooting up Columbine High in April. Predators with such little regard for morality and human life defy rational explanation, right?

Wrong, say an increasingly vocal group of psychiatrists and criminologists. Many of the most depraved, coldhearted criminals, they suggest, suffer from a definable but little studied psychiatric disorder known as antisocial personality. "We blame crime on everything from bad parenting to violent video games," says University of Iowa psychiatrist Donald Black, whose book Bad Boys, Bad Men: Confronting Antisocial Personality Disorder was published early this year. "But medical journals don't cover ASP, and no one wants to look at it. It's baffling."

Not to be confused with occasional periods of bad behavior or crimes of passion, ASP (also referred to as sociopathy) is defined in the latest Diagnostic and Statistical Manual as a lifelong "pervasive pattern" of rule breaking and violating the rights of others that begins before age 15. ASPs are chronic troublemakers whose symptoms vary greatly in severity: they can be constant money borrowers, black sheep, pathological liars, white-collar criminals or, at the most severe end of the continuum, murderous felons. They are impulsive and grandiose, don't learn from punishment, are poor self-observers, blame others for their problems and see themselves as victims. Their primary hallmark is a striking inability to feel empathy or guilt. According to a national study of psychiatric disorders, an estimated 7 million people in the U.S. have antisocial personality disorder, eight times as many men as women.

The shocking videotapes that Harris and Klebold made before the Columbine massacre provide a unique glimpse into the antisocial mind, say those who have studied ASP. "What's frightening is how cold and calculated all this was, with no regard for the consequences," says Black. "They view it through their perverse world view, not seeing it as others would, which is a characteristic of antisocials." Though the two boys expressed remorse for the hurt they were about to cause their parents, their ability to shut off such pangs of guilt is also characteristic of ASP. "There was some remorseful thinking, but not enough to compensate for the enormous excitement of the enterprise they were contemplating," says Stanton Samenow, a psychologist and author of several books on criminal personality.

Sociopathy has been recognized as a social menace since the mid-1800s (when it was called "moral insanity"), and antisocial personality disorder has been listed in the DSM since 1968. Yet surprisingly little research has been done on it. According to the National Institute of Mental Health, only $3 million was spent last year for research on ASP, and $31 million was spent on its childhood predecessor, conduct disorder. Yet $132 million was devoted to schizophrenia.

One reason for the resistance is that ASP is still not universally accepted by psychologists as a diagnosis. Some critics dismiss it as a category so broad as to be useless. "It's used for everyone from the person who cheats on his income taxes to Attila the Hun," says Fred Berlin, associate professor of psychiatry at Johns Hopkins medical school. "It's a label masquerading as an explanation." Others wonder whether the term is simply a catchall psychological description for people who are habitual criminals. Yet proponents argue that the disorder's core ingredients--a lifelong pattern of behavior, a willingness to break rules and hurt others, a lack of empathy or guilt--set certain criminals apart. "Empathy is what stops you and me from doing horrible things," says Black. "Every disorder has been criticized for being too broad. But the description of ASP hasn't fundamentally changed since 1968."

Kathleen (not her real name), a suburban mom from Iowa, wishes she'd known about it 27 years ago. She says there was something chilling about the way her only son coaxed her for a cookie at age two. "It was way beyond manipulative. He was very adept at reading me, at figuring out what it took to get him what he wanted." By adolescence, the handsome, popular high school athlete had taken to stealing from her purse, torturing animals, driving drunk and making violent threats against classmates. Typical boyish rebellion? "There was a difference," Kathleen says. "I didn't sense any real remorse. He would use his charm to overcome my anger." Now she has accepted that her son--a lawyer with diagnosed ASP who changes jobs regularly, terrorizes former girlfriends and accrues credit-card debt--probably won't change.

The search for causes of antisocial personality disorder gives rise to the usual debate between nature and nurture. Studies have found that insufficient bonding between infants and mothers is a strong indicator for ASP and that people with ASP often come from abusive or impoverished home environments. But increasingly, research is focusing on biological factors. Studies have shown that identical twins have a dramatically higher chance of sharing ASP than do fraternal twins. Adrian Raine, a neuroscientist at the University of Southern California, has found that the brains of people with ASP look different from those of the rest of the population, with less gray matter in the prefrontal cortex, the part of the brain that regulates behavior and social judgment. Just last month University of Iowa neurobiologist Antonio Damasio reported findings from a study showing that early brain injuries affect the long-term ability to distinguish between right and wrong.

Thomas Thompson, a New Mexico forensic psychologist, insists that ASPs are "hardwired to act out," and that "they lack free will." His evaluations recently helped convert the sentences of two death-row inmates to life in prison. Yet Thompson's brand of biological determinism sets off alarms for many. "The idea that you're simply born bad is an evil misconception," says Peter Fonagy, director of the Child and Family Center at the Menninger Clinic, who has done a review of conduct-disorder studies for the British government. "We have to look at intervening early and how that can help change antisocials."

How can the disorder be treated? Though certain medications, like Depakote, curb individual symptoms like aggression and impulsiveness, there have been no drug trials specifically for ASP. Fonagy claims intensive psychotherapy and parent training can help. But researchers say that signs of ASP often show up by age four or five, and that if the behavior is not caught and dealt with before adolescence, there's little hope of making significant change. New York City psychoanalyst Leon Hoffman points out another problem: people suffering from ASP are difficult to get into therapy because they typically don't think anything is wrong with them. "They can be a psychiatrist's worst nightmare," he says. And society's as well.

--Reported by Debbie Seaman

With reporting by Debbie Seaman