Also of interest are Robins’ findings that sociopaths showed an unusually high incidence of “conversion” symptoms (we would substitute “malingering” as discussed further on), as well as depressive symptoms and anxiety, and that these symptoms are in proportion to the sociopathic ones. Among women with sociopathic behavior there was a high incidence of hysterical manifestations—evidence that female hysteria may be the counterpart of male sociopathy. In Robins’ series, a search for evidence of encephalitis, often postulated in the past as the basis of sociopathy, was not revealing, nor was there any proof of other brain damage. In the current era, head trauma is often imputed as the cause of troublesome behavior in adolescents and young adults, but there is no basis for this view.
EEG abnormalities, taking the form of mild to moderate bilateral slowing, are more frequent in criminals and sociopaths than they are in the normal population in some series, but the validity of this finding is uncertain.
Other findings suggest a genetic predisposition to antisocial personality. In a Danish study of criminals by Christiansen, “inappropriate nonpsychotic impulse-ridden behavior” was found 5 times more frequently in first-degree biologic relatives than it was in the general population. Criminality was 2 times more frequent in monozygotic twins than it was in dizygotic twins. His study also confirmed an association between hysteria and sociopathy. More direct evidence of a genetic factor was provided by Cadoret’s study of adoptees who were separated at birth from antisocial biologic parents. A higher incidence of antisocial behavior was present in the adoptees than were in controls. His study also suggested that excessive childhood hyperactivity and classic female hysteria were phenotypic manifestations of an antisocial personality genotype, but this is by no means confirmed.
There is no information as to the best methods of treatment and the role of the medical profession has never been clear.
Treatment Most psychiatrists have been discouraged by the results of psychotherapy, but whether behavioral therapy, psychoanalysis, or drugs have more to offer cannot be determined from available data. Medical efforts should be directed to evaluating the patient’s neurologic status, assessing his intelligence, and explaining the nature of the disorder to parents and social agencies, tasks best performed by a psychiatrist.
This problem arises frequently in connection with both hysteria and sociopathy, and the physician should know how to deal with it. The term malingering refers to the conscious and deliberate feigning of illness or disability in order to attain a desired goal. It does not appear as an isolated phenomenon, and its occurrence must be interpreted as a sign of a serious personality disturbance, often one that prevents effective work or military service, as a means of obtaining recompense for an alleged injury, although noteworthy exceptions to this statement can be found.
In the malingerer one may observe pain, hyperesthesia, anesthesia, limping gait, tremor, contracture, paralysis, amaurosis, deafness, stuttering, mutism, amnesia, pseudoconvulsions and fugues, jumping of limbs with touch, and unexplained skin lesions—in short, the same array of symptoms and signs, singly or in combination, as in the patients with hysteria. Certainly there is a similarity between hysteria and malingering, but the nature of the relationship is nebulous and there may be great difficulty in establishing a clinical differentiation. As Jones and Llewellyn have observed:
Nothing…resembles malingering more than hysteria; nothing, hysteria more than malingering. In both alike we are confronted with the same discrepancy between fact and statement, objective sign and subjective symptom—the outward aspect of health seemingly giving the lie to all the alleged functional disabilities. We may examine the hysterical person and the malingerer, using the same tests, and get precisely the same results in one case as the other.