Constructive Functions of Aggression in Psychopaths

Willem H. J. Martens MD, PhD - Director of the "W. Kahn Institute of Theoretical Psychiatry and Neuroscience. " Address: Beatrixstraat 45, 3921 BN Elst (Utrecht), The Netherlands; email: WimmartensW@netscape.net.

Abstract

Psychopathic aggression may have constructive functions, which might be involved in enhancement of social-emotional and moral development of psychopaths that might lead to improvement or remission. Furthermore, it can contribute to the realization and preservation of self-structure, -esteem, -respect, -knowledge; reality testing; social awareness; a new mental, emotional balance and associated healthier neurobiological functioning; and to obtain useful feedback information from other individuals. More research is needed into a) the hidden motives of aggression, b) the precise etiological routes from the original motives into specific expressions and dimensions of aggressive behavior, c) and different constructive roles, which may be related to aggression in (the different categories) psychopaths in order to develop and provide adequate therapeutic and preventive strategies.

Diagnostic Features

According to the criteria of the fourth edition Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association; DSM-IV, 1994) antisocial personality disorder (ASPD) are characterized by features such as irritability and aggressiveness, impulsivity or failing to planning ahead, social maladjustment, reckless disregard for the safety of self and others, consistent irresponsibility, a lack of guilt or remorse, deceitfulness, pathological egocentricity, and criminality. In the DSM-IV "Associated Features and Disorders" persons with ASPD are described as lacking empathy and they may have an inflated and arrogant self-appraisal, display a glib, superficial charm. These features also apply to psychopathic personality disorder (PPD). Additional diagnostic characteristics of psychopathy, which are not included in the DSM-IV criteria of ASPD are absence of delusions and other signs of irrational thinking; absence of "nervousness' or psychoneurotic manifestation; and incapacity for love; specific loss of insight; unreliability; untruthfulness and insincerity; suicide rarely carried out; sex life impersonal, trivial, and poorly integrated (Cleckely, 1984); a conning/manipulative attitude; a parasitive lifestyle; proneness to boredom/need for stimulation; pathological lying; promiscuous sexual behavior; and grandiose sense of self-worth (Hare, 1998). Today the official term is antisocial personality disorder as defined in the DSM-IV (1994).

Introduction

Freud (1932) wrote, "Aggressiveness is an inherited, independent and instinctive disposition in human being," and, "Civilization tries to put up barriers against the human aggressive instinct." Freud cited Schiller by saying that the greed of love lets the world turn around, and he suggested that the aggressive instinct is subordinated to our self-defence. But, he stated also that the aggressive instinct is in fact a death-instinct that is opposite to the life-giving and pro-social erotic instinct and the society that creates this instinct.
PPD and ASPD are significantly linked to violence (Hicks et al., 2000; Martens, 1997, 1999, 2000), aggression (Edens et al., 2001; Martens, 1997, 1999, 2000), anger and impulsivity (Grisso et al., 2000; Martens, 1997, 1999, 2000; Myers & Monaco, 2000). Violence and aggression in PPD and ASPD correlates with poor health (Johnson, 1990); poor neurobiological functioning (Martens, 2001a); social-emotional learning process deficits (Birnbaum, 1914, Martens, 2003b) verbal and cognitive dysfunctions (mainly in aggressive psychopaths with low intelligence), stress and an inability to internal dialogue (Miller, 1987) and associated lack of modulation of attention, affection, thought and behavior.
Psychopathic and antisocial aggression (which is a diagnostic feature) is intertwined with other psychopathic/antisocial characteristics such as impulsivity, irritability, hostility; lack of remorse and guilt; lack of empathy; irresponsible behavior; sensation seeking; recklessness; irresponsibility; incapacity for love; social-emotional and moral incapacities, - unawareness and/or - immaturity (Martens, 1997, 1999, 2002a, 2002c). Emotional, social and moral impairments might result in lack of empathy, lack of understanding of emotion, social and moral dimensions of life, and an incapacity for social-emotional interactions. Impulsivity contributes to the process of psychopathic/antisocial aggression by means of frequent neurobiological determined irrational, unconscious, sudden stimuli that may lead to aggressive acts (Martens, 2002c). Social, emotional and moral aspects of aggression in ASPD and PPD may also be determined by neurobiological dysfunctions (Martens, 2000, 2002c) such as brain injuries, frontal lesions (Martens, 2000), poor prefrontal functioning (Herpertz & Sass, 2000), frontotemporal dysfunctions (Mychack et al., 2001), cerebrovascular disorders, EEG-abnormalities, low serotonin (5-HT), SCF 5-HIAA (5-hydroxy indoleacetic) (Martens, 2000), genetic factors (Martens, 2000) and a history that is characterized by physical/sexual abuse; chaotic family life; lack of parental guidance; parental divorce, drug abuse, and/or antisocial behavior; adoption; neglect and rejection; poor neighbourhood (Martens, 1997, 2000).
Aggression in ASPD or PPD is frequently considered as a form of unreasonable, impulsive-irritative acting out. However, psychopathic and antisocial aggression may be linked to (hidden) non-aggressive motives and purposes such as efforts to restore a sense of self-esteem, self-confidence; external locus of control; expressions of assertively, reduction of pain and frustrations (Martens, 1997). But, the psychopath is frequently unable to cope with problems and to satisfy his needs in a non-aggressive way. It is clear that the intensity of the aggression in PPD or ASPD is often not in due proportion to the provocation of that moment, if there is any provocation at all. Moreover, the psychosocial origins of their aggression can be mostly found rather in the past than in current frustrating events and/or experiences (Martens, 1997).

Differences Between Psychopathic and Other Forms of Aggression

Moyer (1968) offers us the following useful definition of aggression. He considers aggression as behavior that leads to, or seems to result in damage or destruction of a target entity. According to Daniels et al. (1970), violence or destructive aggression should be understood as (the involvement in) inflict of injuries on other persons and/or dealing with damages of other's properties. From my point of view, it is desirable to make a distinction between aggression (hostile or destructive tendency or behavior) and violence (intense, vehement, passionate, furious, impetuous, vivid actions; which involves a great force). In the rest of my paper I will make this distinction.
In my opinion, the following classification of Moyer (1968) is the most adequate and successful effort to make a subdivision of the range of aggressive and violent behavior: predatory, intermale, frightening, territory, maternal, and instrumental. This wide spectrum of aggressive/violent behavior, however, can be divided in two main categories, namely affective and predatory aggression/violence, which follows different neuroanatomic pathways that were controlled by distinctive sets of neurotransmitters (Eichelman et al., 1981; Meloy, 1988). Psychopaths demonstrated mainly predatory (Martens, 1997, 1999) and instrumental expressions (Martens, 1997, 1999; Woodworth & Porter, 2002) of aggressive/violent behavior, which seem to be most effective in attaining their goals and gratifying their needs. In fact, many violent psychopaths behave like wounded predators and are continuously dangerous because of their life-long pain (Martens, 2002a).

Motives and Intrapsychic Constructive Mechanisms which Underlie Psychopathic Aggression

Self-defence, Obtaining and Maintaining of Self-Structure

Many psychopaths demonstrate violent and/or aggressive forms of self-defence and gratification of needs that might be brought about by deep-rooted frustrations and negative experiences in the past such as being rejected, neglected, abused, and humiliated; a lack of parental attention, warmth, guidance and chaotic and/or violent family life; parental antisocial behavior, - substance abuse and/or - divorce; and a bad and violent neighbourhood (Martens, 1997, 2000). It is quiet understandable that psychopaths, like normal individuals, try to avoid further negative, painful experiences. Antisocial and psychopathic persons did only learn antisocial coping styles and they believe that these are a) most suitable for surviving in a hostile world (Martens, 1997, 1999, 2002a), and therefore b) often unavoidable. Antisocial and psychopathic aggression might be an (unconscious) attempt a) to neutralize or eliminate devastating, harmful external forces, b) to remain or restore their self-respect, -structure, - esteem, -confidence and to "protect" their right to exist, c) to prevent in this way depression, psychosis, suicide, anxiety; and a poor self-organization, -structure and -image. Antisocial and psychopathic personalities demonstrate strong defence against depression and anxiety and they are characterized by an absence of depression and anxiety (Martens, 1997, 2000; Hare, 1998; Cleckley, 1984). Antisocial coping, however, may evoke depressive symptoms (Monnier et al., 2000). Since depression in ASPD and PPD may correlate with remission (Martens, 1997, 1999, 2002a), antisocial coping may contribute indirectly to the process of recovery.

Claims for Respect, Attention and Special Treatment

Many psychopaths realize continuously that their life is determined significantly by bad luck and adverse circumstances (this is discussed before) in comparison with the life of most of the normal people (Martens, 1997, 2002a). For that reason, most psychopaths require extra respect, attention, chances and special treatment of normal people, because they believe that they must be compensated by them for bad luck and negative experiences. Unfortunately, most normal individuals do not feel responsible for the psychopath's misfortune (many of them even do not know or are unaware of it). But, when others reject their claims psychopaths take often what they believe they deserve, if necessary in an aggressive way.
The hidden motives of the psychopaths' claims for respect, special attention and treatment could be linked to their (unconscious) conviction that in this way a) their emotional, social and moral capacities and self-esteem will increase, and b) that real attention, respect will heal the wounds caused by negative experiences in the past. The author speculates, that these claims of psychopaths are not necessarily (mainly) the product of narcissistic arrogance, grandiosity and/or excessive feelings of hate, but sometimes it may be rather the result of awareness of their limitations that could be discontinued by favourable and positive external stimulation.

Envy as Possible Link to Social Adaptation

In persons with ASPD and PPD envy can produce aggression, but in the long run as a result of the frequent imagination of the benefits of normal people's life they can feel the need to adjust themselves to normal social standards and rules. Aggressive envy is sometimes a kind of acting out, that may have positive side effects like a growing wish to transform their hate gradually in a kind of respect for the normal man's capacity to live a social and stable life and to build and maintain adequate and/or harmonious relationships with partner, relatives, friends and neighbors. Some envious psychopaths and antisocial persons believe that the gap between them and normal people is unbridgeable, and their anger and frustration will usually continue. But, individuals with ASPD or PPD who realize that (the benefits of) a normal life is also reachable and desirable for them may become gradually less and less envious (Martens, 1997). Martens (1997, 1999; 2002a) revealed that patients with ASPD or PPD in remission demonstrate gradually less envy of and more respect for normal individuals, and an increased wish and willingness to transform their attitude into a more social direction, although they continued to dislike the overadjusted and fearful attitude of many normal people. Some improved and remitted psychopaths have also learned to see the motives, limitation and adverse effects of their (aggressive) envy, and they became more and more able to convert those envious feelings into more positive and active prosocial emotions and life strategies.

Encounter with the Victim as an Expression of the Wish to Share Emotions, Reality Testing and Avoidance of Loneliness

Healing Effect of Encounter with the Victim

Many patients ASPD or PPD were witnesses to or victims of aggressive/violent acts in the past (Martens, 1997, 2000). The patients' aggression might be linked to his or her experiences as victim or witness in the past. Unfortunately, many of these patients do not make an association between their aggressive/violent acts and their own experiences as victim of aggressive/violent behavior. Nevertheless, during some aggressive/violent acts this link between the psychopath's own suffering from aggression in the past and active aggression/violence may be restored (Martens, 1997, 1999, 2001c, 2002a). The patient can experience an intense wish for constructive and pro-social change and further social-emotional and moral development (which may lead to recovery) as a consequence of a) effective confrontation with the victim or other people's responses, b) and eventually associated shame or remorse (there is an example of a psychopath who experienced deep shame and remorse after that he had killed his victim who wanted to pray first in order to find a solution), c) full awareness of the suffering of and correlated awakening of empathy with their victim, d) realization that not the victim caused his or her suffering but rather other individuals in the past, e) recognition that the victim in not a thing but a human being (the psychopath is not able anymore to devaluate the other person)..

Sharing Emotions with the Victim

Aggressiveness in ASPD and PPD can be an effective strategy to attract (emotional) attention from others, because of the victims fear, intimidation, suffering, and dependence of the aggressor's power. Some antisocial and psychopathic individuals need desperately attention, they even prefer negative attention over an absence of attention. Some psychopaths are inspired to aggressive actions by a deep-rooted need to share emotions with their victims (Martens, 1997). Many normal individuals try to avoid serious contact with patients with ASPD or PPD, and most patients are aware of that and they like to create circumstances in which the victim cannot escape (Martens, 1997). Some aggressive patients with ASPD or PPD have the desire to let their victims suffer in such way, which is comparable to their own intense suffering. In this way they want to share their pain with their victims. By means of such interaction these patients hope (unconsciously) to evoke or to increase the victim's comprehension of the aggressor's emotional and mental condition. However, some aggressive/violent patients with ASPD or PPD become aware of this intrapsychic mechanism, and try to reduce these violent impulses when they realize that the suffering of their victims a) is not identical with their own suffering, b) will not contribute to the victims understanding of the patient's suffering, c) can not provide a solution of their own suffering, d) is not justified because these victims do often not have caused their pain. This might be the road to improvement or remission (Martens, 2002b).

Reality Testing

Psychopathic and antisocial aggression may lead to a) reality testing, and associated b) exploration of their external and internal world. Some persons with ASPD or PPD are able to reveal during their numerous acting outs the real motives and targets of their aggression or violence. They can find out that particular situations and/or persons in the past, rather than current events and/or individuals provoke their anger, frustration and (self-) hate. When these patients become aware of this translocation of hostile emotions from the past into today, they might be able to correct their current impulses and behavior, eventually supported by psychotherapeutic, psychopharmacological, and/or neurofeedback treatment (Martens, 2002a).
There are amazing examples of victims who were able to show their aggressor in an impressive manner their anger, anxiety, gentle emotions, or in contrary a their fearless, strong, gentle and/or elevated attitude (Martens, 1997, 2001c). It is possible that a victim makes clear that his or her emotions and interests are as valuable as that of the aggressor, and/or what the exact reprehensible aspects are of the aggressor's behavior. The victim can become actually the "winner" of this confrontation, when he or she succeeds to make the aggressive psychopathic or antisocial patient aware of the reality of that moment, the unknown dimensions of his or her behavior, and the emotional world of the victim.
Martens (1997, 1999, 2001c) discovered that some aggressive patients with ASPD or PPD in remission are increasingly interested in and capable to utilize feedback provided by their victims or other involved persons. As a result they may become more and more aware of the negative consequences of their behavior. The aggressor might be influenced so much by their victim that they may change their attitude, or show after such violent acts more and more confusion, depression, despair, and associated growing emotional social and moral awareness (Martens, 1997, 1999, 2001c), which may lead to improvement or remission. During agitation therapy in forensic psychiatric settings aggressive antisocial and psychopathic patients may learn in a controlled and structured way (is also a form of reality testing) from their own aggression and the responses of other patients and staff members (Martens, 2001c). As a consequence, the patient may become aware of all unknown dimensions of his or her behavior and personality, and the consequences of his or her aggression. Antisocial and psychopathic patients may experience how their aggression/violence is linked to their emotional, social and moral immaturity and this awareness may awake an intense need for change and maturation (Martens, 2001c). By means of ethics therapy these patients might increase their moral and associated social-emotional awareness and capacities and reality testing, which may form a stable basis for long-lasting change, maturation and reduction of aggressive behavior (Martens, 2001b). This is the first important step to recovery.
Psychopathic or antisocial persons in remission are able to react increasingly mild and gently upon threatening and/or frustrating events and persons, because they realize that they are capable and mature enough:
- not to associate frustrating or threatening incidents and/or individuals constantly with negative events or persons in the past,
-to experience and maintain self-respect, self-structure and their right to exist despite of painful and frustrating experiences,
-to gather positive experiences as a result of their growing social, emotional and moral capacities, which can compensate and/or make it possible to consider negative experiences in the right perspective and/or bring them back to the right proportions.

Psychopathic Violence As a Result of Unbearable loneliness

The major reason for psychopathic violent acts in some serial killers such as Jeffrey Dahmer and Dennis Nilsen was unbearable loneliness and an intense need for human company. When they took strangers home, who were superficial encounters from gay pubs for one-night sex, they sometimes feared so desperately to be left alone again soon that they murdered them. They did not enjoy the act of killing itself, they said, but it was just a necessary evil. Dahmer and Nilsen told that they did not hate their victims (Master, 1993a, 1993b). Nilsen and Dahmer were unable to interact adequately with living human beings and they felt much more comfortable with dead bodies. Their violent behavior was not only an expression of terrible suffering from loneliness, but it was also an attempt to survive. As a consequence of their incapacity to make friends and associated social isolation they felt so worthless and empty that only killing for company could fill up this gap somewhat. In this way they also tried to revive themselves emotionally and socially. Nilsen wrote poems for his dead victims, he talked to them, watched TV with them, admired their beauty, and felt empathy with their unlucky life (Masters, 1993b). Killing for company was away to regain and maintain some control over their life, while their control was lost in other important domains of their life.

The Need for Punishment

Freud (1916) and Reich (1946) wrote that some criminal psychopaths feel unconsciously guilty, and experience relief when they were caught and punished. Psychopathic serial killers like Dennis Nilsen and Jeffrey Dahmer are good examples. They felt indeed relief after arrest and showed a cooperative, communicative and honest attitude towards the police, prison staff and psychiatrists (Masters, 1993a, 1993b). Dennis Nilsen wanted to talk about his crimes so very badly that he even could not wait to make his confessions until they arrived at the police station (Masters, 1993b). This need for punishment and the fact that some persons with ASPD and PPD even orchestrate their own arrest can be considered as a gesture of reconciliation and a sign that they are aware and feel guilty of their deviant behavior. In these cases, the patients' conscience is in conflict with their aggressive and other antisocial impulses, and it is linked to a (growing) wish/need a) to keep control over or b) to eliminate their antisocial and psychopathic features (Martens, 1997, 1999), and/or c) to transform them in social acceptable traits (Martens, 2003c).

Self-hate and Associated Aggression Towards Others

In spite of the arrogant and narcissistic attitudes of patients with ASPD or PPD, their aggression is often grafted onto self-hate, because these patients are aware of their social- emotional limitations, hidden feelings of inferiority, and involuntary expressions of deviant behavior. Many patients with ASPD or PPD wish, at least episodically, to change their personality and behavior in order to avoid excessive interpersonal difficulties and to become a normal person, because they dislike their antisocial attitude (Martens, 1997, 1999, 2002a). But, as a consequence of their neurobiological abnormalities and/or adversive psychosocial factors, they are not capable to realize such difficult and radical transformations on their own (Martens, 1997, 2002a). Aggression towards others is frequently an act of self-destructiveness too, because the mind that produces, prepares and realizes the destruction of others, will be "infected" by those negative thoughts and emotions. Nonetheless, self-hate, and (self-) aggression/violence may have instructive moments. Aggressive/violent behavior will be often coupled with feelings of power and victory, but afterwards as a result of introspection and/or contemplation some patients with ASPD or PPD (who are vulnerable to remission) may experience doubt, depression, shame, and feelings of powerlessness (because of the involuntary, impulsive nature of their behavior) and associated low self-esteem. In fact, in their good moments these patients wish, like normal human beings, to have influence on other persons in a controlled, non-aggressive, positive and social way, and they realize that they need meaningful, intense, affective relationships in which equivalence plays an important role. This awareness can be the start of seeking (neuro)psychiatric and psychotherapeutic help. However, as a result of growing self-knowledge (and insight in their limitations) some patients are able without professional help to obtain gradually more and more control over their destructive impulses and to increase their social, emotional and moral capacities.

Aggression As A Search for a New Balance

Aggression or violence in ASPD or PPD may be a trial to find a new periodical and finally a more profound, long-lasting mental and social-emotional balance and associated healthy neurobiological functioning. Martens (1997) observed that aggressive and violent patients with PPD or ASPD (with and without neurobiological determined aggression/violence) calmed down episodically. The very relaxed condition of psychopaths between episodes of acting out and other restless behavior is characterized by a) a remarkable absence of active neurobiological determination of aggression, violence and impulsivity, and b) stabilized mood as a consequence self-healing psychophysiological (normalization autonomic activity/reactivity) and neurobiological mechanisms (normalization of biochemical correlates of impulsivity and aggression) of the acting out (Martens, 1997, 2001a). Martens (1997, 2001a) hypothesized that remitted and improved psychopaths have learned to anticipate and use this self-healing psychophysiological/ neurobiological mechanisms in order to prevent episodically excessive and aimless aggression. In a further stage they may also learn to recognize, foresee, prepare on and cope adequately with risky situations (Martens, 1997, 2001a, 2002a) by means of a) analysing their own experiences concerning aggression, b) reality testing, c) self-knowledge, d) enhancement of social-emotional and empathic (moral) abilities, and e) growing awareness of the negative consequences of their violent acts.

Case Report of a Violent Sexual Psychopath in Remission

Robin grew up in a working-class family and was the youngest of five sons. His mother was very emotional instable and physical vulnerable, and his father was an aggressive, antisocial, authoritarian man, who required of his sons a Spartan, tough attitude. Robin, however, was a very sensitive, insecure boy who suffered from a serious eye disease. Furthermore, he was crossed-eyed. He felt inferior because he could never fulfill the requires of his dad, and because of his handicap. Only with his mother he developed a strong bond. His father, brothers, and peers rejected him, and as a result he developed gradually a manipulative, histrionic, unreliable, disobedient, aggressive, and ruthless attitude. But, at the same time he was a lonely boy who missed friends and positive attention. He revealed that he felt better when he was cruel to other children who rejected him. It was a way for him to save his honour and to regain his self-esteem, because he had the power to punish those who made of him a cast-out. During his puberty Robin struggled with strong sexual feelings, and he suffered from his incapacity to make social contacts. He made numerous fruitless attempts to get a girl-friend or a boy-friend. At the age of 15 he sexually assaulted a 5-year old girl. After his arrest and during psychiatric examination he demonstrated no sign of guilt or remorse. He said that this was the only way for him to gain sexual experiences. He was sentenced to 1-year juvenile prison. After his discharge he finished secondary school and he had numerous jobs until he was 22 years of age. Since a couple of years he had dubious friends and Robin was aware of it, but bad company was better than loneliness. When he was 22 he sexually assaulted 2 little boys and again he was arrested and was sentenced to 3 years prison. One year after his release he got a relationship with a girl of 17. That relationship gave him for the first time in his life a safe and nice feeling and he believed that he was on his way to become a normal person. He loved her and he gave her many presents. Unfortunately, after a year the girl broke off their relationship. Robin was now 26 years of age. As a consequence of this experience he became very angry and emotional unstable, and he suffered from a very negative self-image. A few weeks later he raped an 18-year old girl, while threatening her with a knife. He was arrested and the forensic psychiatric assessment revealed that he suffered from a psychopathic personality disorder (see diagnostic criteria). He declared that this rape was an unavoidable act, because of his lust, and, moreover, he needed revenge, control and affection.


During his 7 years forensic psychiatric treatment Robins development was remarkable. In the first episode of 2 years he refused all kinds of therapy except labour-, sports-, drama-, and sociotherapy. Because he needed physical affection he played around or have a romp with other fellow-patients or staff members as much as he could. He also demonstrated cross-bordering behavior towards female staff-members of the clinic, and he was deeply emotionally injured when they reprimanded him. He had an attitude of "I get what I a want, because I deserve it." Gradually he formed a bond with his female mentor/sociotherapist. During his 5-th year of residence there was an accident, which was crucial in his development. A fellow-patient made perverse remarks to his female mentor. Robin became so angry that he stabbed this men several times with a knife and raped him. He reported that this man showed him his own perversions and limitations and that it in fact on act of self-punishment, reality testing, self-insight, willing to change and catharsis. After this incidence Robin was replaced to another forensic hospital where he worked hard during psychotherapy to work out this experience and his core problem. He showed gradually a more open mind, and increase of social-emotional and moral capacities, and a decrease of cross-bordering behavior towards women. Furthermore, he seemed in remission, and he did not meet the criteria of psychopathy anymore. After discharge from forensic psychiatric treatment he got a job. Since 12 years he is happily married and has two children. Robin is now 15 years a free man, and he never reoffended.

Discussion

Until now, hardly attention was paid to the constructive functions of psychopathic or antisocial aggression and violence. There exist many non-aggressive motives of aggression and violence in ASPD and PPD such as need for restoration of self-structure, self-esteem, gathering of valuable feedback, finding of a new balance, locus of control and so on.
In order to provide adequate treatment and prevention programs more research is needed into:

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