The present volume, I believe, is destined to become a classic in psychiatry and a landmark in our understanding of severe antisocial behavior and criminality. The early understanding of the psychopathic personality provided by Hervey Cleckley in his 1941 book The Mask of Sanity has evolved, in Michael Stone's book, to a comprehensive, updated, detailed, sophisticated analysis of what is implied in our intuitive concept of Evil. Dr. Stone provides instruments with which to differentiate evil actions from evil purpose, and a conceptual etiological frame that incorporates genetic and constitutional as well as environmental influences, personality structure, and psychiatric pathology. Stone defines, in the process, a broad spectrum of threatening, violent, and criminal behavior, pinpointing its severity and mapping out potentially preventive and prognostic features.

The nature of evil emerges as the shocking expression of primitive aggression, destructive behavior toward others that, in its violence, evinces a widely excessive quality, a radical callousness, and a lack of compassion that seem to defy the basic nature of humanity. Stone proposes a twenty-two-point scale that provides a fine differentiation of severity of antisocial behavior, with prognostic implications built into it. His proposed classification corresponds largely with the present DSM-IV system of the American Psychiatric Association, applying the concept of antisocial personality, in a broad sense, to refer to persons with chronic aggressive and/or exploitive behavior toward others. Within that broad spectrum this diagnostic scale further refines our understanding of the most dangerous and malignant group, the psychopathic personality, characterized by a total incapacity for compassion, combined with total lack of concern for others and self.

Because the entire spectrum of patients with severe antisocial behavior usually present an underlying narcissistic personality structure, I have preferred to classify this field into the narcissistic personality with antisocial behavior, the syndrome of malignant narcissism (referred to by Stone as occupying the intermediate zone of severity of his classification system), and the antisocial personality proper, using the latter term in a restrictive way that corresponds to the psychopath in Michael Stone's classification. He convincingly points to the fact that patients with schizoid and sadistic personality features also may enter the most severe group of psychopathy, and we do agree that the large majority of psychopaths present strongly predominant narcissistic features.

The great importance of Michael Stone's contribution resides not only in the detailed description of antisocial behavior along its entire spectrum but in the careful attention and updated review of the contribution to severe psychopathology of genetic factors, severely traumatic childhood experiences, and the social environment. He points to the mutual influences of genetic and environmental features that culminate in a personality structure that lacks a capacity for concern for self and others, for guilt feelings and remorse, and, in the worst cases, presents a fused experience of violence and lust as a fundamental pleasurable excitement in making others suffer.

Stone raises important questions regarding our present management of these cases in terms of a protection of both the civil rights of patients and those of the community. Patients with severely antisocial behavior who enter psychiatric inpatient services often prevent the hospital from obtaining crucial information about them from external sources. Confidentiality laws interfere with the possibility of gathering such information in order to arrive at an accurate diagnosis and an optimal treatment of that particular case. The need for protective, possibly lifelong custody for the most dangerous cases of those patients who enter the forensic system is hampered by the absence of the principle of “indeterminate sentencing,” which would allow the legal system to individualize imprisonment and custodial treatment in terms of a realistic assessment of the dangerousness of patients along the dimensions specified by Stone. There are a few cases where psychiatric treatment, long-term psychotherapeutic engagement, and social rehabilitation may be effective, but in the immense majority of psychopathic criminals the possibility for successful treatment approaches zero. As Stone rightly observed, although we do not have absolute prognostic certainty at this time, we do have sufficient knowledge to decide what the optimal protective treatment should be once all the facts can be gathered and analyzed over a period of time.

Evil exists; it presents itself in the form of psychopathy, of blind violence geared to destroy without reason, often accompanied by an orgy of pleasure. But it also exists, as Stone points out, in the context of socially sanctioned mass murder and genocide, which, in turn, we have begun to understand in terms of the regressive nature of certain group processes, a psychological development in groups for which a potential exists in every individual. There are extreme social circumstances in which ordinary citizens, or rather, those with significant personality disorders that ordinarily would not show antisocial behavior, do become violent and destructive, evincing a total loss of compassion for an entire social group or oppressed minority. Here again, we have to differentiate social, political, and historical features from personality predispositions, and come to terms with the fact that our present-day understanding may exceed by far our capacity to influence those phenomena.

The core enigma of the psychopath, as Stone underlined, relates to the striking incapacity of compassionate reaction, of emotional empathy, and of concern for self and others. Neurobiological studies have pointed to certain cortical-limbic structures of the brain, particularly the complex relation between prefrontal and preorbital cortex, the anterior cingulum and the insula, with deeper layers of brain structures, particularly the amygdala and nucleus accumbens. While our knowledge of neurobiological systems and their specific functions is rapidly progressing, these structures and their functions may be indirectly related to complex behavioral, intrapsychic symbolic structures, with all of them implicated in influencing the capacity for empathy and for the internalization of moral values. As Stone points out, we have to advance simultaneously in research on the pathology of psychic structures embedded in the personality, and research on the personality determinants embedded in neurobiological structures.

This book is indispensable reading for all concerned citizens and all mental health professionals, particularly, of course, all those who deal with personality disorders at the boundary with forensic psychiatry. By the same token, it is hoped that all those in the legal system who deal with the social and legal problems involved in the management of antisocial behavior and criminality will find clear, updated information about an area that, unfortunately, still shows much discrepancy between our evolving level of new knowledge, on the one hand, and the practicality of dealing with the criminally ill, on the other.