Sadistic Personality Disorder Dsmiiir Appendix A

Clinical Description

People with Sadistic Personality Disorder are pervasively cruel, demeaning, and verbally and physically aggressive in most of their relationships. The sadistic behavior is typically more evident when the sadistic individual is in a position of power, as in the role of a father, mother, or uncle, or in occupational settings as a boss or in any position where there are subordinates. In contrast, individuals with Sadistic Personality Disorder often manage to contain their behavior when they are in subordinate positions, at least toward the person in the position of power over them. Sadistic individuals take pleasure in the suffering of others, including animals. Like the antisocial personality, lying is frequent, but the sadistic personality lies with the intent of inflicting pain on others and not merely to achieve some other goal. Although the DSM-III-R indicated that the pattern must be evident by adulthood, numerous studies have found the onset of sadistic behavior as early as childhood.

Individuals with Sadistic Personality Disorder often use physical violence and cruelty to establish their dominance and complete control in a relationship. An excellent example of such a person was Martin Burney (played by Patrick Bergin) in the 1991 movie, Sleeping with the Enemy. Laura Burney (played by Julia Roberts) looks to be a happily and wonderfully married woman. However, we discover that Martin is a highly threatening, abusive, and brutally controlling husband. Laura comes to live in constant fear of his pervasively tyrannical behavior.

The sadistic person's threatening behavior will often escalate to interpersonal violence if he or she thinks that the person being subordinated is resisting control or is no longer intimidated. It is thought that there may be nonviolent forms of Sadistic Personality Disorder, that is, those individuals may not resort to physical violence in relationships although they may still be psychologically abusive, and they still may harbor deep fascinations for weapons of violence, torture, and literature and media with such themes (Millon & Davis, 2000). Notably, a diagnosis is not typically given if the sadistic behavior has been directed toward only a single individual, like a spouse, nor should it be given if the behavior is exhibited solely for purposes of sexual arousal (a diagnosis of Sexual Sadism should be given in such cases although it is highly debatable whether a comorbid diagnosis of Sadistic Personality Disorder should not also be given).

Millon and Davis (2000) have proposed four types of Sadistic Personality Disorder: explosive, spineless, enforcing, and tyrannical. Explosive sadistics react suddenly with verbal abuse and violence. It appears as if they reach a threshold of tolerance, and then respond rapidly and violently against what they consider "safe" targets, that is, ones that cannot retaliate. Millon and

Davis hypothesize that explosive sadistic types are hypersensitive to any hint of betrayal by those with whom they have relationships, and they explode with rage when their feelings of humiliation reach intolerable levels. In this regard, they may also have features of borderline personality disorder.

In contrast, spineless sadistics have predominately avoidant personality disorder features. These individuals are essentially highly insecure, and they have a "strike first" attitude to counter their insecurities and feelings of powerlessness. Millon and Davis (2000) propose that people who join hate groups often have the spineless type of Sadistic Personality Disorder. They also hypothesize that spineless types take out their aggression and hostility on especially defenseless or helpless targets.

According to Millon and Davis (2000), the enforcing Sadistic Personality Disorder type has obsessive-compulsive personality disorder features. They sublimate their hostility by enforcing rules, often in a demanding and authoritarian manner, that allows no dissent or even rational objection. They may see themselves as defenders of justice and correctness, but it often is a mask to hide their basically cruel and hostile nature. They may be typified by the "hanging" judge and the "mean" cop. A milder version of this type was seen by one of us in therapy. This patient reported "compliance problems" with his spouse, and for an example said his wife resisted his demands that she face all cans and boxes in the pantry with the labels outward. He said he was trying to get her to understand that her labeling problem was only a symptom of her general inability to become a good wife. He went to great lengths in therapy to justify his demands on his spouse. Ironically, he sought therapy not for himself but to help him manage his wife better.

Tyrannical sadistic types have depressive and paranoid personality disorder features. Millon and Davis (2000) propose that they are perhaps the most frightening and pathological of all four types. Tyrannical types are cruel and absolutely inhumane. They often instigate and carry out the most verbally and physically abusive sadistic acts on other people and animals, and they will also direct others to carry out these horrible acts. There have been numerous world dictators who have exhibited these traits, such as Joseph Stalin, Adolf Hitler, and more recently Pol Pot and the Khmer Rouge movement.

Like most other personality disorders, persons with Sadistic Personality Disorder typically do not see any problems with their behavior (and, in fact, usually see the positive outcomes of getting what they want). As consequence, treatment is particularly difficult with this personality disorder. The longer one has exhibited these behaviors and the longer symptoms have gone uncorrected, the more difficult therapy becomes. Table 5.1 lists the diagnostic criteria for Sadistic Personality Disorder.

Table 5.1 Diagnostic Criteria for Sadistic Personality Disorder (DSM-III-R, Appendix A)

A. A pervasive pattern of cruel, demeaning, and aggressive behavior, beginning by early adulthood, as indicated by the repeated occurrence of at least four of the following:

(1) has used physical cruelty or violence for the purpose of establishing dominance in a relationship (not merely to achieve some noninterpersonal goal, such as striking someone in order to rob him or her)

(2) humiliates or demeans people in the presence of others

(3) has treated or disciplined someone under his or her control unusually harshly, e.g., a child, student, prisoner, or patient

(4) is amused by, or takes pleasure in, the psychological or physical suffering of others (including animals)

(5) has lied for the purpose of harming or inflicting pain on others (not merely to achieve some other goal)

(6) gets other people to do what he or she wants by frightening them (through intimidation or even terror)

(7) restricts the autonomy of people with whom he or she has a close relationship, e.g., will not let spouse leave the house unaccompanied or permit teen-age daughter to attend social functions

(8) is fascinated by violence, weapons, martial arts, injury, or torture

B. The behavior in A has not been directed toward only one person (e.g., spouse, one child) and has not been solely for the purpose of sexual arousal (as in Sexual Sadism).

Source: From Diagnostic and Statistical Manual of Mental Disorders, third edition, revised, American Psychiatric Association, 1987, Washington, DC: Author. Copyright 1987 by American Psychiatric Association. Reprinted with permission.

142 Chapter 5 Other Personality Disorders and Aging Potential Age-Bias of Criteria

Criterion A1 (has used physical cruelty or violence for the purpose of establishing dominance in a relationship) is likely problematic due to decreased physical strength and stamina associated with normal aging. However, emotional cruelty seems to know no age limits, so this particular symptom may be acted out in proxy fashion especially among frail sadistics. Additionally, a common pattern with aging is to have fewer social relationships. Along with reduced interpersonal contacts due to retirement, these contextual factors may restrict the sample of safe or helpless targets for aging sadistic individuals. The sadistic criteria that involve dominance relationships (parent-child, boss-worker) may indeed be no longer applicable throughout the life span.

Theorized Pattern in Later Life and Possible Impact of Aging In our experience, it is likely that most Sadistic Personality Disorder traits persist as people age. Indeed, pathologically mean people do not become nice simply as a function of age. Whereas the sadistic criteria that involve physical domination may be somewhat less appropriate for older persons, the general sadistic demeanor and pattern of cruelty often persists throughout the life span. Thus, aging may restrict some physical expressions and symptoms of the Sadistic Personality Disorder, yet the overall cruel and demeaning behaviors remain. Age by itself, however, does not preclude physically sadistic acts. One of us consulted on a case where the husband, in his late 70s, was continuing to rape his wife, who was helpless with dementia and profoundly frail, until she ended up in the hospital.

We have also seen some cases in which the sadistic behaviors seem to exacerbate as the older person's phenomenal and real world shrinks, for example, to those who provide physical assistance, that is, nursing staff and caretakers and other residents. When the aging individual with Sadistic Personality Disorder moves to a congregate living or long-term care facility, the targets for their abuse increase. Their old predilections for humiliating and demeaning people in front of others may persist, as well as their well-practiced penchants for taking pleasure in the suffering and misery of those around them. They make take secret delight in obstructing the work of their caretakers, medical professionals, mental health professionals, and their own family members. They may similarly take pleasure in the misfortunes and deteriorations in the health of fellow residents.

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