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Labeling Mental Disorders Doesn't Answer the Real Question:
Does a "Diagnosis" Mean There's a Cure?

by Andrew Vachss

Also available in Russian (

The Diagnostic and Statistical Manual of Mental Disorders (DSM), periodically issued by the American Psychiatric Association, is not a guide to treatment, but merely a nosology—a system of classification. So what is it used for? (1) To code for billing, to ensure reimbursement from health plans, whether private or Medicaid, and (2) to reflect politics—for example, to placate the "false accusations" crowd, Multiple Personality Disorder in the DSM-III gave way to Dissociative Identity Disorder in the DSM–IV. In contrast, the same group's attempt to insert "false memory syndrome" was unsuccessful. And despite fervent advocacy, defense attorneys' dreams such as "rapism" and "parental alienation syndrome" have never made the cut.

Various personality disorders may cause distress to an individual, but, generally, such distress occurs only when the individual's delusion is not accepted or acknowledged by the rest of the world. For example: a narcissist will keep moving from therapist to therapist, as each in turn proves incapable of explaining why society does not recognize the narcissist's unique superiority and personal perfection.

When a personality disorder goes red–zone, there are only three possible results: (1) criminal conduct, (2) psychosis, and/or (3) suicide. Attempts to fake psychosis are not uncommon when there is irrefutable proof of criminal conduct, or when seeking a Disability diagnosis, which will entitle the applicant to financial support. And these attempts occur so frequently that the DSM even has a term for it: malingering.

The "paraphilias" are diagnosed only when they are dystonic (i.e., cause significant stress to the individual), or when the individual engages in a paraphilia that violates the law ... and actually is caught doing so. Therefore an individual diagnosed with "pedophilia" could fantasize at will and never come to our attention. Only the predatory pedophile has turned his feelings into behavior. In such a case, so-called "pedophilia" would not succeed as an insanity defense—because we are finally learning to separate "sick" from "sickening."

The DSM is full of disorders for which there is no treatment, including Anti–Social Personality Disorder, which is the DSM's latest label for what it used to call "sociopathy." Television, whether in fictional soft–porn or in repulsive "true–crime reenactments," would have us believe that all sociopaths are handsome, charming, and intelligent, and capture only young, attractive women to play with. And the media has far more impact on juries than any diagnostic manual. Since the only truly distinguishing characteristic of any sociopath is a total lack of empathy combined with a profound sense of entitlement, how exactly does calling a serial rapist a "sociopath" help us?

The DSM's definition of mental disorders may be useful for making notes on charts and sending out reimbursement requests, but it does not reflect real–world understanding. Worse, it plays directly into the fascist paradigm: the power to interpret the meaning of "The Word" constitutes the power to rule all those who follow it. Ask Joe McCarthy. Or Jerry Falwell. Or any ayatollah who came to power by force.

Those who want their theocracy to control the world will always claim to be standing against the abuses of an allegedly opposing theocracy, but it is an inherent characteristic of theocracies to demand that all accept domination or suffer a fate worse than death ... again and again. What is the difference between "Christian" and "Muslim" pretexts for executing "disobedient" children? Neither of those religions actually condones such grotesque interpretations. But the power to force such interpretations on others is the single greatest threat to democracy, justice, and freedom anywhere on earth.

What's the difference when a combat veteran who is clearly suffering from Post'Traumatic Stress Disorder (PTSD) is kicked out of the military, supposedly because he has some "personality disorder" that wasn't picked up by the recruiters? Oh, not much: a correct diagnosis of PTSD would have entitled the vet to a full panoply of (costly) services that the government affords to the returning war hero, whereas the "pre–existing personality disorder" label results in a dishonorable discharge for the "liar who hid his condition."

Whenever those with the power to interpret (in this case, diagnose) clearly benefit from one particular decision, what result would you expect? Remember, when the government makes a "diagnosis," there is no second opinion.

Why is this important? Imagine the power to decide a person is "insane." And the consequences of such a decision. The DSM is a swell party game. What fun to sit around and diagnose others, or to spew terms like "sociopath" or "malignant narcissist" on the oh–so–reliable Internet. But it's a very dangerous game when played for keeps.

In America, we respect titles more than knowledge. But despite intellectualized attempts to merge the "psychopath" and the "sociopath," there are significant differences between them. They share some characteristics—a total absence of empathy, a profound sense of entitlement, and a complete lack of conscience. The last explains why they never bounce the needles on a polygraph, a machine which does not detect lies, but only measures "guilty knowledge." Neither ever feels guilt for their conduct, because they do not experience—or even conceptualize—guilt.

Also, neither sociopaths nor psychopaths will seek "treatment" unless compelled to do so by a court, and even then they will simply use the opportunity to improve their skill–set, such as faking empathy for their victims while facing a parole board.

But there are distinctions between the two. A psychopath is generally incapable of (or dismissive of) cost–benefit analysis, unlike a sociopath, who will engage in such calculation. So for example, a sociopath who is an intrafamilial child sexual offender is likely to continue his behavior with subsequent children of his own, or even to seek out "single moms" who advertise their status in various forms of social media ... but he is not likely to abduct children of strangers. Both offenders are predatory pedophiles, but their target range will vary radically.

A psychopath is capable of bonding only to the extent of creating a folie à deux relationship, which psychiatry calls a "shared psychosis," (but would be more correctly termed a toxic gestalt, as there is always a far more dominant "half" in such a relationship). Examples include Bradley and Hindley, Leopold and Loeb, Bianchi and Buono. One psychopath might quote Nietzsche eloquently; another might not even be able to read his tripe. But a serial'killing psychopath always writes his own script, seeking a level of internal stimulation available to them only through the pain of others.

The utter helplessness of their victims is always a trail–marker of psychopaths. Some, such as Gertrude Baniszewski, take advantage of opportunities; others, such as Ted Bundy, create them. Unlike sociopaths, psychopaths have no "goal" which, if attained, would cause their behavior to cease. Their need never goes away, although the fulfillment of that need is often dose–related ... what once "satisfied" them eventually will no longer suffice. And escalation is virtually guaranteed.

Psychopaths are characterized by implacable relentlessness. They can neither be deterred by any law (including the death penalty), nor benefit from any "treatment." They have all the insight into their own behavior they need, because they know what they want to do. Fear of consequences is non–existent with them—the very possibility of consequences doesn't register.

Psychopaths are the ultimate toxin in the bloodstream of humanity, but they are not "born bad." Fetal alcoholism, pre–frontal lobe malformation, closed–head injuries, the XXY chromosome ... all have been found in psychopaths. And all have been found in those who never walk the psychopath's chosen road.

The essential difference between a sociopath and a psychopath is that a sociopath's goals—money, success, attention—are shared by most of us, to some extent. But because they are not dragged down by all our ethical "baggage," sociopaths can move more quickly toward such goals, and they would have no reservations about removing anything that stood between them and what they want. In contrast, a psychopath seeks gratification—rape, torture, murder–for–entertainment—that most of us don't. We have great difficulty imagining why any human being would want to commit the acts psychopaths engage in.

It gets murky when we run across sociopaths who produce child pornography but who are not what are generically called "pedophiles." They are simply selling a product, and completely indifferent as to how that product is produced, or to what use it is put. No different from arms dealers or contraband traffickers (from cocaine to children), the gratification is the money and the power that comes with accumulating it.

Put more bluntly: a sociopath would sell a snuff film; a psychopath would make one.

But when it comes to predatory pedophiles, knowing the difference makes no difference, because there is no cure. So the sooner we stop being lulled into a false sense of security by the mythology that peddles "treatment," the safer our children will be.

What we call something doesn't matter. There is one undeniable truth about predators: if we refuse to see them while we still have a chance, we'll never see them coming later—when we don't.

© 2012 Andrew Vachss. All rights reserved.


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