Revisiting the Age-Old Case of Diagnostic Confusion: Sociopath Versus Psychopath

Saturday, June 15, 2024

Primary Blog/clinical issues/Revisiting the Age-Old Case of Diagnostic Confusion: Sociopath Versus Psychopath

Many forensic psychologists and criminologists use the terms sociopathy and psychopathy interchangeably. Leading experts have disagreed on whether there are meaningful differences between them.

In an article written in 1996, “Psychopathy and Antisocial Personality Disorder: A Case of Diagnostic Confusion,” Robert Hare stated his concerns regarding the DSM-III decision made to lump sociopathy or antisocial personality disorder 301.7 (ASPD) and psychopathy together. Up to that point, they had been treated as separate entities with contrasting motivational and behavioral profiles, and diagnostic criteria. “In 1980 this tradition was broken with the publication of DSM-III when psychopathy was renamed antisocial personality disorder -- was now defined by persistent violations of social norms, including lying, stealing, truancy, inconsistent work behavior and traffic arrests.”

Hare suggested that a potential consequence of the ambiguity inherent in the DSM-III (as well as DSM IV and V) is likely to be a court case in which one clinician says the defendant meets the criteria for ASPD, another clinician say the client does not, and both are right! He added that such confusion, he added, could be a serious impediment for everyone working in the criminal justice system as well as for society.

Hare saw psychopath and sociopath (ASPD) as different animals and argued that treating them interchangeably puts a damper on our clinical assessment skills. If we lose track of what a psychopath is and don’t know what to look for -- or if the client’s presentation doesn’t match the criteria for sociopath, we will be unable to make a diagnosis of psychopathic personality disorder, which can lead to an inaccurate diagnosis that can potentially put public health and safety at risk.

Despite Hare’s concerns, efforts to stay apprised of the differences between psychopath and sociopath and maintain two separate diagnoses have fallen short. Clearly, more fleshed-out descriptions and psychopath-specific criteria are needed. It’s essential that diagnosticians be clear that these are in fact two separate diagnoses.

Let’s begin by looking at the most current DSM-V's description and diagnostic criteria for sociopathy (ASPD), and clarify which applies to both sociopathy and psychopathy, and those which apply only to sociopathy.

“The essential feature of sociopathy or ASPD is a pervasive pattern of disregard for, and violation of the rights of others that begins in childhood or early adolescence and continues into adulthood, as indicated by three or more of the following. . . ”

Deceitfulness, as indicated by repeated lying, use of aliases, or conning
others for personal profit or pleasure:

1- Lack of remorse and indifference when causing harm to others

2- Reckless disregard for safety of self or others

3- Impulsivity or failure to plan ahead — (Does not apply to psychopathy)

4- Irritability and aggressiveness, as indicated by repeated physical fights or
assaults -- (Does not apply to psychopathy)

5- Consistent irresponsibility, as indicated by repeated failure to sustain
consistent work behavior or honor financial obligations- - (Does not
apply to psychopathy)

6- Failure to conform to social norms with respect to lawful behaviors as
indicated by repeatedly performing acts that are grounds for
arrest – ((Does not apply to psychopathy)

We can see some overlapping description and criteria for diagnosing sociopathy that can also be applied to psychopathy, as they both fall under the heading of personality or characterological disorders associated with deep, longstanding and pervasive emotional disturbance, family of origin trauma and dysfunction.

They both carry with them an extremely poor prognosis and are presumed treatable - not “therapy material.” Common to both are: display reckless disregard for safety of self or others, pose a threat to individuals and society, prone to violent behavior, operate deceitfully, steal, lie, con; incapable of remorse, incapable of empathy, astounding coldness; socially isolated, live on the fringes, lack of self-awareness (ego syntonic) and cannot form relationship bonds.

Now, let’s shift attention to their differences and how to distinguish between the two. Consider the following never seen before set of ‘psychopathic-specific’ and profile criteria to diagnose psychopathy. This ‘psychopathic-specific’ can be categorized according to specific areas: (a) appearance, (b) socio-economic status, (c) level of Intelligence and Education, (d) modus-operandi, (e) etiology, (f) motivation and (g) criminal history.


Psychopaths and sociopaths tend to look different and come across differently from one another.

Sociopaths (ASPD) tend to look dangerous, like thugs, social misfits or criminals. Think of Richard Allen Davis could be a poster boy for sociopaths of the world. I saw a TV clip of Richard Allen Davis in a courtroom, being arraigned for the kidnapping, rape and murder of 10-year-old Polly Class. He was unkempt, had a cold, expressionless face and tattoos all over his body, and flashed his middle finger to the court and cameras.

We can also drawn on films whose lead characters were classic sociopaths; most notably, Travis Bickel (Robert de Niro in Taxi Driver), Max Cady – (Robert de Niro in Cape Fear), Alex Delarge (Malcolm McDowell in A Clockwork Orange (the movie) and Aileen Wuornos (Charlize Theron in Monster). The character of Aileen was a woman who had killed several men throughout Florida claiming they had all tried to rape her while she was working as a prostitute. She was eventually executed by lethal injection.

Sociopaths tend to elicit fear when you see them. You want to walk the other way. They give off many clues in their appearance and behavioral profile that scream out ‘antisocial’, violent, hateful against the establishment, or other agency, whom they feel has wronged them. And they live on the fringes.

In contrast, Psychopaths tend to look just like you or me, no different from anyone else and do not stand out in any way. They are masters of deception, wolves in sheep’s clothing, hiding in plain sight. Once people realize they’re in danger, it’s too late.

The movie Primal Fear is about a psychopath, Aaron Sampler (actor Norton) dupes a hot-shot defense attorney, Martin Vail (actor Gere), into believing he has a multiple personality disorder. The character Vail obtains a verdict of “not guilty” (by reason of insanity.) It is not until the end of the movie that the truth is revealed and Vail realizes that he had been played. Sampler manipulates Vail into getting him a “not guilty” verdict by reason of insanity; bright and sophisticated enough to know how to act like a multiple personality disorder when he actually wasn’t one. It becomes evident that he was a psychopath who was acting with conscious intent all along.

There are also a number of notorious real-life psychopathic serial killers who have earned the reputation of being the most dangerous of all characterological disorders, sociopathy included. Selecting from the ones who immediately come to mind are Richard Speck, who systematically tortured a group of student nurses he kept hostage in a house for hours, murdering them one by one, leading them separate rooms only stab or strangle them to death; John Wayne Gacy, who was nicknamed “The Killer Clown” because of his affinity for dressing as "Pogo" at birthday parties to ensnare double digit number of young boys he murdered; Jeffrey Dahmer who picked up dozens of teenage boys and younger men on the streets, and drugging, raping and murdering them, is famous for dismembering his victims and storing portions of their bodies in his freezer; Ted Bundy who killed a string of women after raping them, and the list goes on and on.

Socio-economic status(H)

Differences in appearance as described above are often tied to socioeconomic status.
Sociopaths tend to come from poorer, urban, drug-infested, gang and crime-laden, blue collar, uneducated, and disadvantaged backgrounds.
Psychopaths tend to come from more clean-cut, polished, upper-crust, white-collar backgrounds and reside in middle to upper class suburbia; they are likely working so they do not have to resort to crime to survive, and they operate in mainstream society. A large part of their modus operandi is to not being how they appear. They live secret lives, “with plans for everyone” no one else knows about. Clinicians can often make the mistake of judging them according to their charm wealth or apparent success.

Level of intelligence and Education(H)

Sociopaths tend to be less educated and are often viewed as less intelligent (as measured by traditional intelligence testing instruments); they are less verbal and have less command of the English language than psychopaths have.

Psychopaths tend to be more educated and show higher intelligence on testing instruments; they are more thoughtful and verbal. They are known to be deliberate and calculated and to have tremendous command over their behavior, which is not surprising given that they sometimes operate under the radar for decades before they get caught.

The character of Aaron Sampler (Edward Norton in Primal Fear) was brilliant enough to masquerade as having multiple personality disorder (MPD) so convincingly that he was able to trick the prosecutor into defending him and win a “not guilt by reason of insanity verdict. Aaron was so sophisticated that he could mimic emotions and convince the prosecutor that he had MPD.


Sociopaths are known to be volatile, prone to rages and emotional meltdowns. They are unsophisticated psychologically, acting overtly, recklessly and mechanically without hesitation or internal control, without ever flinching or registering the gravity of their actions; do not seem to care about exposure; are disorganized, and act impulsively without forethought or planning, which is why they will most likely be caught sooner and faster than will psychopaths.

In his article, “How to Tell a Sociopath from a Psychopath,“ Dr. Bonn said that what makes psychopaths dangerous is their level of psychological sophistication and intelligence, mastery of disguise and deception, and zeal when inflicting large-scale mayhem. They often carefully plan their attacks and select their prey to kidnap, imprison, torture and murder. “Their crimes, whether violent or non-violent will be highly organized and generally offer few clues for authorities to pursue.
Psychopaths are also known for their uncanny abilities to detect and exploit others’ vulnerabilities. They can figure out ahead of time how to get their victims alone and what they are going to do when that time comes. They are known to lean toward being loners or recluses.

Etiology: Nature Versus Nurture(H)

Research and expert commentary indicate a consensus on nature versus nurture in regard to sociopathy and psychopathy.

Sociopathy is believed to be more nurture rather than nature (innate) – more the result of a “bad upbringing,” a product of families riddled with abuse, absent parents, addictions, crime, guns and violence. “Genetics is not responsible for sociopathy.” 6 Perhaps it’s where they have lived their whole lives, and that’s all they know -- what they learned to do and how to be to survive.
Psychopathy is believed to be the result of nature (genetics, faulty “brain wiring”). The dysfunction and abuse in their family systems were of a more subtle nature. It’s not at all unusual for family members of psychopaths to have no idea how deeply disturbed the person is or what horrific acts they are planning or have already committed. Psychopaths were cut off from and invisible to their parents. Their lack of remorse and inability to empathize are attributed to genetics and neurobiology. Their penchants for ritualistically torturing and humiliating their victims, and exploiting their vulnerabilities point to a deeper disturbance of biological origins.


Sociopaths’ anti-social behaviors are fueled by their alienation, rage, and hatred as well as being in environments where crime and violence are the norm. If they want to rape, hurt or kill someone, they’ll do so without a second thought. It doesn’t matter to them whether they are going after children or innocent people; they are unaffected when inflicting pain or harming others, nor do they care whether anyone knows what they did or if anyone saw them. They learned their behaviors to survive in the world where they grew up.

Psychopaths’ motivations appear to be power-driven and sadistic. Psychopaths get off on control, manipulation, humiliation, and exploiting their victims’ vulnerabilities.

Criminal History(H)

Sociopaths generally have extensive criminal histories filled with assaults, robberies, rapes and murders. The overwhelming majority have contributing drug/alcohol problems, whether they are using, dealing or both. Our prisons are filled with sociopaths, those with antisocial personality disorders.

In contrast, psychopaths tend to have shorter criminal records because they operate incognito and covertly. No one is around when they are terrorizing their victims, which makes identifying and apprehending psychopaths more complicated, and which is why there are many fewer psychopaths in our prisons than there are sociopaths.

Closing Thoughts(H)

Neither sociopaths nor psychopaths should ever be considered, ‘not guilty’ by reason of insanity, never be exonerated from responsibility for their behavior and the harm they caused to others. Their crimes are usually not isolated incidents and they have extensive histories of criminal behavior.

If we have to choose between psychopaths and sociopaths as far as whether one has a more favorable prognosis or is more treatable, it would have to be sociopath.
Going back to the nature versus nurture issue, sociopathy is often sourced from a history of trauma, abuse, violence, addiction and emotional deprivation. Wounded souls needing healing have a better chance of somehow being reached, touched, or spiritually inspired or, at some point, discovering the wonder of human connection.

They are slightly more likely to be ego-dystonic, that is, to have at least a modicum of self-awareness.

The same is not true for psychopaths, who I consider to be more deeply disturbed and menacing. They cannot and never will change, or be capable of compassion, empathy, or remorse, despite punishment or time in prison. They will always be looking for and deriving satisfaction, pleasure or excitement from power over and ability to control, from gaslighting, manipulating, exploiting, torturing, raping, murdering, or humiliating their victims, never an iota of anxiety related to their plans or actions.

We have to assume that we’re not going to find ourselves treating sociopaths or psychopaths unless they are court mandated or in prison. However, our responsibility doesn’t end there. We will be called upon to assess, diagnose, develop treatment or containment plans, but we will have our hands tied as long as we don’t distinguish between them, that they are two separate diagnoses and require diagnosis-specific criteria to assess and diagnose them.


1. How to tell a sociopath from a psychopath, Understanding important distinctions between criminal sociopaths and psychopaths; Dr. Bonn

2,3 Psychopathy and antisocial personality disorder: A case of diagnostic confusion; Robert Hare, PhD; Psychiatric Times; 1996
4 Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association; Library of Congress; Washington DC; 2013 (DSM-III, 1980; DSM-IV, 2000)
5 How to tell a sociopath from a psychopath, Understanding important distinctions between criminal sociopaths and psychopaths; Dr Bonn
​6 Psychopath vs. sociopath: What’s the difference? Blog post from the Masterminds series produced by the Huffington Post in partnership with NBC’s The Blacklist.

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Hi, Daniel

Daniel A. Linder is a licensed Marriage & Family Therapist, Relationship Therapist and Trainer, an Addiction and Intervention specialist, with nearly four decades of experience working with individuals, couples and families.

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