Does the sociopath have a mental illness, and if so, is there an effective treatment for sociopathic behaviour?  For example, when a sociopath is convicted in court for the consequences of a lifetime of abnormal behaviour, should the district attorney arrange for his admission to hospital rather than sending him to jail? 

Disorders of the mind can mean different things to different people.  To quote journalist Alan Jasonoff ( New York Times ).  There is a fine line that separates creative genius from madness and one must always take into account , that what constitutes insanity reflects societies norms and social prejudices.   

Culture and ethnicity play an important role and influences how so called abnormal behaviour is interpreted and understood.  One culture’s abnormality is another’s cherished tradition.

For example what is it, that separates certain religious convictions from delusions?  If an individual regularly prays to God and the saints, he is perceived as pious and is likely to be respected by his neighbours.  However, if a person reports that he hears God and the saints talking to him, he runs the risk of being thought of as insane!

How do we distinguish the odd behaviour and bizarre ideas of eccentric individuals from people with schizophrenia?   Or understand and appropriately acknowledge a person’s firm belief that they have the power of extrasensory perception while avoiding the dismissive perspective that their belief may be a delusion?  At what point do we begin to consider strange beliefs a sign of mental illness?  

These challenges I think reflect the diversity found in human nature, especially in the human mind where normal and unusual or even bizarre mental phenomena may often co-exist, making it difficult for us to determine what our definition of normality might be.  Yet this is an important issue, as failure to identify serious mental illness in a person may have grave consequences.

The issue of over diagnosing in medicine has been a growing concern for many professionals in healthcare. The late Dr Lisa Schwartz, her husband Dr Steven Woloshin and Dr H. G. Welch in their book Over Diagnosed: Making People Sick in the Pursuit of Health (2011), warn of the emerging trend of over aggressive diagnosing in the medical field.

With advances in new technology there is a greatly increased ability to detect abnormalities in patients when undergoing investigations. Yet without fully understanding the clinical significance of these abnormalities the physician, fearful of being accused of negligence is more likely to make a diagnosis and later embark on unnecessary treatment. They question the impact that this trend may have on patients with milder symptoms and transient medical conditions.

The authors note: “While failing to make a diagnosis can result in lawsuits, there are no corresponding penalties for over diagnosis.”

They warn of an epidemic of diagnoses, where everyday experiences of physical or mental discomfort may become a diagnosis. This trend is seen especially in younger patients where sleep difficulties become insomnia, cough and breathlessness after exercise becomes asthma, a reading difficulty is dyslexia, restlessness and inattention is ADHD and unhappiness becomes a depressive disorder.

This issue is well exemplified by the results of a survey published in Ontario in 2019 which reported that 65% of college and university students stated experiencing overwhelming anxiety in the previous year and 46% complained of disabling depression.

One commentator has asked: “If everyday experiences are labelled in this manner, and more than half of us are sick, what does it mean to be normal?”

Mental Health: What is Normal?

So in terms of our mental health; what is normal? How do we define mental illness? Is a sociopath mentally ill?

Open a psychiatric textbook and you will read that mental illness refers to disorders of the mind that result in significant changes in a person’s thinking, emotions and/or behaviour and these disorders are classified into diagnostic categories. The two most important systems of these categories being the International Classification of Diseases (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

But what do these systems of categories really tell us? They provide us with a description of disorders neatly collected into tidy groups having in common shared symptoms. Examples being Major Depressive Disorder or Obsessive Compulsive Disorder. However these diagnoses tell us nothing about the complex biological, cultural or psychological human experiences in which these disorders are embedded.

Mental illness has been recognized throughout history in every society and has been known by many different names. Culture and ethnicity play an important role and influences how so-called abnormal behaviour is interpreted and understood. One culture’s abnormality is another’s cherished tradition.

Unlike medical illnesses such as pneumonia, where the diagnosis is decided by blood tests and X-rays, there are few objective laboratory tests for use in routine clinical practice in psychiatry. The making of a diagnosis of a disorder, is much more subjective and is biased in different ways by the rich complexity of human nature and the accepted mores of society at any given time.

And so to go back to our earlier question: Is a sociopath mentally ill? Well, in looking for an answer and we open the DSM-5 manual, we find that sociopathy is definitely catered for under the diagnosis of Antisocial Personality Disorder. Are we to conclude that the sociopath’s behaviour which can sometimes be criminal, be understood as a manifestation of a mental disorder which requires treatment rather than a jail sentence?

And more about this issue later!

Karl O’Sullivan MD

We hear a lot about depression these days and we are told that depression is experienced by increasing numbers of people. We read about it in the press and its increasing prevalence is widely reported on radio and on social media.

So what is happening? More and more people, especially the young complain that depression has become a feature in their emotional lives. Yet those of us who live in economically advanced countries have never had it so good in terms of our standard of living and general material benefits. To quote: western society has never been so prosperous, yet western society has never been so depressed!

So what is going on? Do we have an explanation for this paradox? Are we really becoming more susceptible to depression or as some experts have suggested, depression has become modern society’s label for unhappiness.

Perhaps it is an indication of an emerging perspective that bad things are not supposed to happen to us, and when bad things do occur, they are perceived as an abnormal intrusion into our lives and are relegated to the domain of pathology or disease. So rather than acquiring the skills to deal with an adverse experience ourselves, we seek help from the expert whom we expect to problem solve our difficulties and often with the assistance of pills.

This issue is especially relevant today with reports of rising rates of mental illness in our communities and particularly in young people.

A 2018 study published by Higher Education Research at the University of California, Los Angelas reported a consistent rise in anxiety in first year university students over a period of thirty years. For example in 1985, 18% reported overwhelming anxiety, this figure rose to 29% in 2010 and to 41% in 2017.

Another example; in 2019 the Ontario University and College Health Association reported the results of a survey completed in 2016. It revealed that 65% of students described experiencing overwhelming anxiety in the previous year while 46% stated that they experienced depression sufficiently severe that “they found it difficult to function“.

While closer to home here in Oakville, the emergency department of Halton Healthcare Services saw an increase in patients (of all ages) presenting with a major psychiatric diagnosis rising from 3,392 in 2009 to 12,333 in 2019. This trend was also seen in other hospitals in Ontario.

What does this mean? Is mental illness really on the rise? Are we as a society more susceptible to mental illness? Are we becoming more sychologically fragile, especially our youth?

The emerging influence of social media in society has been noted by many as one of the most significant social changes over the past twenty years. It has been further noted that the impact of these changes may have had a detrimental affect on the lives of young people.

For example, smart phones became available in 2007 and it is reported that by 2015 almost ninety percent of teenagers owned a smart phone. This increase in their availability coincided with a sharp spike in the number of young people seeking help for psychological issues. Problems identified included, low self esteem, sleep deprivation, social isolation with loss of social skills, and multitasking, resulting in ADHD type behaviour. Body image issues were a concern in younger women when they compare themselves to the idealized images they often saw on social media.

A paper published in the Canadian Medical Association Journal in 2020 raised the interesting point that what we are seeing are rising rates of psychological distress rather than strictly diagnosed psychiatric disorder. Other experts have noted, for example that prevalence rates for schizophrenia have not increased in recent decades.

Yet psychiatric illnesses that we consider culturally sensitive are making increasing demands on the health services and these include eating disorders, ADHD, addictions, autism spectrum disorder and post traumatic stress disorder.

Are we observing a true rise in mental illness or does this reflect a trend that we are becoming more expansive in our diagnostic habits? This trend has been described by social psychologist Professor Alex Haslam as “creeping clinicalism” or “concept creep” where concept boundaries are progressively stretched, and we run the risk of pathologizing behaviour that may be more a manifestation of temporary distress rather than an indication of the presence of a serious mental illness.

And more about this issue later!

Karl O’Sullivan MD

I believe that we must acknowledge Alcoholics Anonymous for this change in emphasis in psychological and psychiatric treatment. “Simple solutions for complex problems” has been a cornerstone of the Fellowship’s approach in dealing with the often overwhelming problems existing in the life of the Alcoholic as he or she finally seeks help after years of destructive drinking.

Where to start? What’s the cause? Where to begin? It’s all seems so complicated and daunting! Multiple issues, requiring complex and heavy-duty therapy. He/she appeals to the AA group at their first meeting. And the group’s reply? This group of seasoned experts reply with a chorus of “keep it simple: just stop drinking!”. But I can’t, I need to know the cause? I must uncover the causes and identify the psychological forces that are driving my self destructive behaviour. Otherwise, how can I stop? They repeat “Just stop drinking” and by doing this you deal with the problem and the rest will follow.

And so the shift of emphasis in this generation. An approach that in the past that would appear to be restrictive. Just dealing with the symptom! Yet dealing with the symptom behaviour is now the solution rather than the time-consuming search for background conflicts and stresses. Examples: “I worry myself into a depressed state” Then change the way you think,- cognitive therapy. “I have problems with my behaviour” Why not behaviour therapy? Or more recent reports from the psychiatric literature, That describe how blocking a persons ability to furrow their brow with Botox injections, gives relief from anxiety and even depression. Or stretching ones facial muscles (used for smiling) by biting on a pencil results in a feeling of relaxation. Or role modelling oneself on a relaxed person you happen to know, and over time one acquires a sense of being relaxed and free from anxiety. I could go on and on with further examples.

What we have learned is that solutions though simple, can be surprisingly effective. Yet, it is a mistake to think that because a solution is simple that is easy to execute. How often I have heard “Doctor you make It all so simple”. I reply “yes it is simple, but believe me it’s not easy” for the alcoholic to stop drinking. A simple idea but a most difficult step to take and one that may require a lot of support.

As a psychiatrist it has been my experience that simple solutions work. Regarding recovery: the issue is not that simple solutions don’t work, rather, it is getting people to do the things they know they need to do to get better.

And more about this later!

Karl O’Sullivan MD

The Relationship

It is generally recognized that the relationship between alcoholism and depression is complex and this relationship has been studied extensively in psychiatry. Depression is a frequent experience in the lives of alcoholics and alcoholism is often seen as a symptom of depression. Some people when depressed turn to alcohol as a form of self-medication, while alcoholics become depressed as a result of the problems caused by their drinking behaviour.

Yet given the complexity of the alcoholic’s life and the fact that depression is not a fully understood condition, it is not surprising that it is difficult to establish the exact link between these two disorders. While many young people are heavy drinkers, only a small minority go on to become alcoholics, and though stress is a common experience in life only relatively few people succumb to clinical depression when faced with stress.

Family research studies have discovered that there is a relationship between alcoholism and depression and have found a high incidence of alcoholism in the families and relatives of patients with depressive disorder and conversely have uncovered the fact that there is a high incidence of depression in the families of alcoholics.

Depression and Drinking Behaviour

For those alcoholics who also suffer from depression, we would expect that successful treatment of the depression would result in an improvement in their drinking behaviour. Research however has produced mixed results. One study revealed that women alcoholics who suffered from primary depression and secondary alcoholism did much better when followed-up, compared to those whose problem was primarily alcoholism. Another study of alcoholics undergoing treatment for their alcoholism showed that while treatment improved their drinking behaviour, this treatment however had no influence on their depression. Yet another study which compared alcoholics with a mood disorder with those who had only alcoholism found that while patients with a mood disorder received more intensive treatment, this extra treatment was not translated into an improvement in their alcoholism. The findings of this study suggested that stabilization and treatment of the mood disorder may not necessarily be followed by an improvement in drinking behaviour.

The Chemical Effects of Alcohol

From a strictly scientific point of view, alcohol is described as a central nervous system depressant yet in reality, its effect on a given individual varies enormously. It is well known that the effect of alcohol on behaviour and mood depends on the concentrations of alcohol in the body: the more you drink, the greater the impact. At first alcohol exerts a relaxing effect by the release of inhibition and the person becomes more talkative, sociable and even euphoric. Later however, with further drinking individuals may become argumentative, withdrawn and morose. Previous drinking experiences are also important and this impacts on the expectations that the person will have when drinking, as will the environment in which the drinking takes place. Personality makeup may also contribute to the person’s response to alcohol and so we see the shy introverted person becoming self-confident and outgoing while the extrovert personality may become a troublesome social nuisance.

As noted earlier, people who are depressed may turn to alcohol as a form of self-medication and sometimes they do have a positive result from drinking, with a reduction in tension and anxiety. This early positive experience with alcohol may of course result in their turning to this substance in the future, more and more for relief of their psychological problems including depression and eventually they may end up with two problems given the addictive potential of alcohol. The cure in turn becomes an illness as they develop alcoholism in addition to their original depression.

An interesting finding is the research that reveals that people with more severe depressions are less likely to benefit even temporarily from an improved sense of wellbeing after drinking. Excessive alcohol consumed by the more severely depressed person results in diminishing returns, alcohol becoming more often a contribution to the depression rather than a solution. The traditional assumption that drinking produces an improvement in mood in alcoholics is not always correct. In fact, bouts of heavy drinking may cause insomnia and may be followed by states of sadness and anxiety, while persistent heavy drinking can cause almost any psychiatric disorder including severe depression, auditory hallucinations and paranoid delusions.

Depression and Alcoholism: Treatment Dilemmas

When faced with the challenge of treating depression in the alcoholic or alcoholism in the depressed person, the therapist needs to be on full alert. The evaluation of depression is often difficult, as alcoholics are frequently seen by the therapist immediately after a drinking bout when the results of alcohol overindulgence predominates. The therapist may be seeing the pharmacologically induced depression of heavy drinking or the depression associated with the withdrawal phase of treatment. Often these depressions are very similar to the depression of major depressive disorder.

Attempting to identify stress factors in the alcoholic’s life is also difficult as he or she may have difficulty recalling stressful events that may have occurred immediately prior to the period of intoxication. Once again the therapist has to deal with separating out those stressors that have been caused by heavy drinking from stress factors or pressures that may have resulted in the individual turning to alcohol in the first place as a means of relief from stress.

So the important step in treatment is to determine quickly and accurately the type of intervention that is required by the alcoholic patient and this does require a careful evaluation. This evaluation needs to establish if the drinking problem is secondary to a hidden depressive disorder, or alternatively is the depression secondary to a primary alcoholic problem. In the majority of cases depression when present, is likely to be secondary to alcoholism and this type of depression will improve once drinking is brought under control. It is important to emphasize however that although temporary in nature, this type of depression may be serious and not without risk, including suicide risk. These patients need a lot of support until they are free of depressive symptoms and fully recovered from the effects of both alcohol overindulgence and alcohol withdrawal.

In a smaller percentage of cases, the depression may persist and require specific treatment and these are people where a diagnosis of primary depressive disorder with secondary alcoholism may be considered. They may have a family history of depression or bipolar mood disorder and are likely to report that their first major life difficulty was a depressive episode rather than problem drinking. They may also complain that they experience serious depressions even during those times when they are not drinking. Once this small group has been identified, they will require treatment with appropriate strategies after their alcohol withdrawal symptoms have cleared; this is usually five to ten days after they have stopped drinking.

Treatment of Depression and Mood Disorder

In patients who have primary depression or a primary mood disorder, the indications for the use of antidepressant Lithium and other mood stabilizing medications, are the same as for non-alcoholic patients with a mood disorder. It is important however to stress that medication should be introduced only as part of a comprehensive treatment program and not as the only treatment that the alcoholic receives. It is a mistake to consider one illness simply as a consequence of the other and to focus all treatment efforts on one to the exclusion of the other. It is worth repeating that although a mood disorder may benefit from antidepressant treatment, stabilization of mood in the alcoholic patient is not necessarily followed by an improvement in drinking behaviour. This, in part may explain why the use of antidepressants and Lithium in the treatment of alcoholism has frequently been disappointing in the past.

Treatment of Alcoholism

Treatment goals for their alcoholism should be negotiated with the patient in the context of a trusting and helping relationship. Previously, abstinence from alcohol was the major criterion for the successful outcome of treatment and other issues tended to be ignored in the drama which so often accompanies acute alcohol excess and the struggle to recovery. This is now recognized as a restricted perception of therapeutic improvement. Level of functioning in all areas of life must be carefully monitored as this will indicate the degree to which the patient has successfully rehabilitated himself or herself, from previous faulty patterns of behaviour and has achieved the goal of contented sobriety. In the early phase of therapy, control over drinking takes priority. Once the alcoholic has achieved successful abstinence, underlying psychological problems previously concealed can be expected to emerge and may be dealt with over time. The type of treatment offered the patient, will depend on many factors including the patient’s capacity for insight, the intactness of his personality and the presence or absence of intellectual damage.

Family and Supports

A history obtained from a relative or close acquaintance is always very valuable as the therapist is unlikely to get a full account of the drinking problem from the alcoholic due to problems with memory or denial. The presence of support figures in the patient’s life in the form of family members or employers should be identified as they become important resources during the early months of abstinence when the alcoholic is at risk to situational depression as he struggles to cope with the demands of reality without the buffer of alcohol.

In addition, family dynamics are likely to require attention, as previous patterns of communicating and relating were probably distorted as a result of the patient’s drinking practices and acting out behaviour. Also, changes in family dynamics can be expected, as the now sober patient attempts to assume responsibilities previously neglected, forcing family members to redefine their roles in the home.

Conclusion

Although the majority of alcoholics lead productive lives, they are frequently seen as unrewarding patients to treat. Therapists, psychiatrists and physicians are sometimes ambivalent about involving themselves in their treatment and long-term follow-up. This traditional pessimism about treatment has probably arisen from the indiscriminant mixing in treatment programs of individuals with poor prognosis with those having a good prognosis, resulting in mediocre overall picture of treatment effectiveness.

Failure to carry out a careful evaluation and define specific treatment strategies may lead to ineffective or unachievable treatment goals. It is worth remembering that the treatment outcome of alcoholics may range from very modest changes in life habits, to a successful rehabilitation into a new lifestyle. Alcoholism is a chronic disorder and recovery not cure is the goal of treatment. Relapses may be a feature of the alcoholic’s life. These, however, need not induce therapeutic despair because with quick intervention and prompt treatment, their disruptive impact can be minimalized.