CHRIS AIKEN: Can you teach empathy to antisocials? Find out as we probe the Dark Triad of Narcissism, Antisocial, and Machiavellianism in the Epstein story.

KELLIE NEWSOME: Welcome to The Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.

CHRIS AIKEN: I'm Chris Aiken, the editor-in-chief of The Carlat Psychiatry Report.

KELLIE NEWSOME: And I'm Kellie Newsome, a psychiatric NP and a dedicated reader of every issue

CHRIS AIKEN: At 10:30 at night, on August 9th, 2019, Jeffrey Epstein was locked into his prison cell for the last time. The two guards dutifully recorded their safety checks every half hour throughout that night, but the record, they later admitted, was falsified. No one saw Epstein until eight hours later, when he was found dead at 6:30 in the morning. The official cause was suicide by hanging. But in the days that followed, 42% of Americans believed he was murdered, and that number is growing. In 2025, only 16% accept the official story, and 50% believe he was murdered.

KELLIE NEWSOME: Take any detail from the case, and you can spin it both ways. Did the guards fail to monitor him because of corruption, or was that just the usual slacking off in a prison known for low morale, staffing shortages, and mandatory overtime? A few weeks before his death, the guards found a semi-conscious Epstein in what they ruled was a suicide attempt, but Epstein tells a different story. He said his cellmate was trying to kill him. Some say Epstein was depressed and contemplating death. Others say he was optimistic and expecting a pardon. And some say he was too narcissistic to take his own life.

CHRIS AIKEN: We don't know how Epstein died, but we can dispel that last myth. Narcissistic personality disorder raises the risk of suicide. The APA practice guidelines rank it among the major risk factors for suicide, listing “extreme narcissistic vulnerability” alongside past suicide attempts, substance use disorders, loss of executive function, and extreme black-and-white thinking. When you lack empathy for others, you also lack empathy for yourself. Your life becomes a transactional account, and if the account falls short, suicide starts to look like an option. Suicide by people with narcissism is more severe, lethal, and deliberate. When it comes to completed suicide, it's older white men who have the highest risk, and based on the cases I've seen, I suspect that narcissistic injury underlies some of that risk in older white men. At the other end of the demographic spectrum, suicide attempts are rising dramatically in the population that Epstein preyed upon, teenage girls. However, the rate of completed suicide hasn't budged much in this group. Most of this elevation is in suicide attempts for teenage girls.

KELLIE NEWSOME: Like narcissism, antisocial personality disorder also raises the suicide risk, approximately three-fold. But to better understand whether Epstein had one of these cluster B personality disorders, we need to go back to his work history. But first, a peek at the CME quiz, which you can take in the show notes.

TRUE or FALSE: The Dark Triad has influenced popular conceptions of personality disorders despite limited research support.

CHRIS AIKEN: Epstein's first job was as a math teacher at the Dalton School, which he lost for unclear reasons. Maybe it was because he fabricated his resume or had boundary violations, or the fact that he delivered his lectures wearing a fur coat, gold chains, and an open shirt that exposed his chest. The school kept no record of his sudden dismissal, which suggests an effort to cover up something both parties were ashamed of. But Epstein rebounded, leaning on a connection he made at Dalton to secure a position at Bear Stearns, a Wall Street firm that later fell on its own fraud in the 2008 financial collapse. Epstein rose quickly through the ranks, but was nearly stopped when the firm discovered that he had lied on his resume. When they confronted him, Epstein made a bold move. He came clean and accepted responsibility. The gesture so disarmed his boss that they kept him on, convinced that he had an honest core beneath his youthful mistake. They even promoted him, but the lack of repercussions made Epstein more brazen, and a few years later, he was suspended for security violations. The behavior was antisocial, and Epstein's response, narcissistic. Rather than remorse, he felt slighted, telling regulators that the way Bear Stearns handled the whole affair was “offensive to me [him], and he decided to resign”. On his way out, Epstein took the valuable Bear Stearns client list and started his own firm.

KELLIE NEWSOME: Antisocials are keen observers of human weakness, and Epstein found a weakness in people of great wealth that he could exploit. When they become victims of financial fraud, they don’t go to the police because they are too concerned with the reputational damage that might cause. So Epstein set up a private business as a financial bounty hunter, helping wealthy clients recover embezzled funds. Sometimes, he helped the embezzlers, and rumor has it that he may have embezzled from his clients. A few years later, he became a highly paid consultant to a collection agency. While he was there, the agency degenerated into a Ponzi scheme, embezzling 1 billion dollars in today’s money from their clients. It was the largest Ponzi scheme in US history, until Bernie Madoff toppled that record. People who worked at the firm said Jeffrey was intimately involved in the scheme, but he got off unscathed, while upper management served up to 20 years for the fraud.

STEVE BANNON: Is your money dirty money?

JEFFREY EPSTEIN: If you live? I—

STEVE BANNON: Just answer the question. Is your money dirty money?

JEFFREY EPSTEIN: No, it's not. So in fact—

STEVE BANNON: Why is it not dirty money?

JEFFREY EPSTEIN: Because I—I earned it—my—a heart that—

STEVE BANNON: But you—you earned it through—so you earned it. We went back to this before. You earned it. You earned it advising the worst people in the world, right? They do enormous bad things, and just to make more money.

CHRIS AIKEN: After the collection agency debacle, Epstein refashioned himself as a wealth manager, a job he kept from 1988 until his death. At its peak, his firm generated over 800 million in revenue in the 2000s. The source of this wealth was a mystery for years, fueling conspiracy theories of blackmail, theft, and espionage. But with the latest release of the Epstein files, we finally know the source, as broken down by Forbes magazine. So of that 800 million, 360 million came from investment returns, leaving 488 million in revenue from clients, and just five clients accounted for 90% of that. They were Leslie Wexner, the founder of Victoria's Secret, he contributed about 200 million, although people think that Jeffrey dipped his pen into Wexner's account much more than that. Then Leon Black, a private equity investor who paid Epstein 170 million. Glenn Dubin, a hedge fund manager who paid him 15 million. Ariane de Rothschild, who married into the famous banking family, paid him 25 million, and the real estate mogul Mortimer Zuckerman paid him 20 million.

KELLIE NEWSOME: That answers many questions and raises more. Why did these barons of finance pay such exorbitant fees for estate planning and tax advice from a man who didn’t have an accounting license or a college degree? Top financial advisers earn up to a million dollars a year. No one is paying them hundreds of millions for their services. We get a hint of what was going on from the Rothschilds. Recently released emails suggest Ariane de Rothschild paid him to negotiate a tax evasion fine with the Department of Justice.

CHRIS AIKEN: Epstein was skillful at getting out of the Department of Justice's crosshairs. He did it with the Ponzi scheme, and again in 2008 when he was first charged with sex trafficking. His ability to dodge these bullets suggests a Machiavellian trait, a term for people who skillfully manipulate their way up the ladder of power, cynical, cunning, and deceitful. Machiavellianism and antisocial traits overlap, but differ in some ways, like executive function, that's often impaired in antisocials. They are impulsive. They don't plan or anticipate consequences. The Machiavellian can delay gratification in pursuit of bigger long-term gains.

KELLIE NEWSOME: In 2002, psychologists Delroy Paulhus and Kevin Williams coined the term "Dark Triad" to describe a dangerous trio of traits: Machiavellianism, Narcissism, and Antisocial Personality. They work together like an unhinged racecar. Narcissistic entitlement fuels the engine, creating an insatiable desire to get whatever you want and the feeling that you deserve it. Antisocial removes the breaks, allowing them to pursue their desires without any thought of the consequences or the harm they cause. Finally, Machiavellianism steers the wheel with calculating skill. The Dark Triad is bad enough, but a fourth factor multiplied the damage further: Wealth. Epstein used money to attract, transport, and silence his victims. It bought him privacy, influence, and high-priced lawyers.

CHRIS AIKEN: Last year, a team of forensic psychologists led by Laszlo Pokorny pored through more than 10,000 pages of Epstein records to arrive at a postmortem diagnosis. Their conclusion: the dark triad. The dark triad is not a well-established concept. It overlaps too much with antisocial, a disorder with a longer history. Antisocial was the first personality disorder to earn its own category in DSM-I, the 1952 manual that lumped other personality disorders into a single category of “personality trait disturbances”. Unfortunately, DSM-I considered homosexuality a subtype of antisocial personality, a wrong the manual eventually corrected in the 1970s when a new generation of psychiatrists led by Robert Spitzer in the Washington School carved out DSM-III.

KELLIE NEWSOME: The rallying call for this new generation was a 1974 book: Goodwin and Guze's Psychiatric Diagnosis. It laid out the diagnoses that the authors considered valid – those that had a predictable course and treatment response, a consistent appearance across cultures, and something like a known cause or biological basis. Only 12 diagnoses met these strict criteria, and only one of them was a personality disorder: Antisocial.

JEFFREY EPSTEIN: The devil himself said, I'm gonna exchange some dollars for—

STEVE BANNON: Do you—do you—

JEFFREY EPSTEIN: your child's life—

STEVE BANNON: Do you think you're the devil himself?

JEFFREY EPSTEIN: No, but I—I do have a good mirror.

STEVE BANNON: It's a serious question. 

JEFFREY EPSTEIN: I'm sorry. 

STEVE BANNON: Do you—do you think you're the devil himself?

JEFFREY EPSTEIN: I don't know. Why would you say that?

STEVE BANNON: Because you have all the attributes. You're incredibly smart. You remember, the devil is somebody—

JEFFREY EPSTEIN: The devil's smart? 

STEVE BANNON: The devil's brilliant. You read Milton's Paradise Lost.

JEFFREY EPSTEIN: No, the devil scares me.

STEVE BANNON: Satan is—the—is the—he is the number one or two archangel. And the reason he goes to hell and leads the rebellion—it's because he can't be the top guy. And his thing is, I'd rather reign in hell than serve in heaven.

JEFFREY EPSTEIN: I saw that in a movie once called American Dharma. I don't remember who said it. Okay, we have to go.

STEVE BANNON: Okay, good.

CHRIS AIKEN: Antisocial first appeared in medical textbooks in the 1830s, but the idea dates back much further, embodied in evil spirits of religious texts who act out the antisocial criteria, cold, blooded devils who lie, manipulate, and break the rules for their own gain. Compared to other personality disorders, antisocial has a clear biological footprint. Their frontal lobes are less active on PET scans and EEG, explaining the problems with planning, executive functioning, and impulse control. They also have abnormal levels of androgens, steroids, and serotonin, although these results are not entirely consistent across studies. Twin and adoption studies point to a strong genetic basis, though not as strong as for other major psychiatric disorders, with an estimated genetic contribution of 40% for antisocial traits. Around three-quarters of those antisocial genes overlap with borderline personality disorder, as does the shared contribution of child abuse, which is causative in both disorders. One of these genes, dubbed the “warrior gene”, raises levels of dopamine, serotonin, and norepinephrine by impacting their breakdown. If you can forgive this oversimplification here, the research about the warrior gene tells an interesting story. People with the warrior gene are more likely to become criminals, but they're also more likely to become successful leaders and CEOs, depending on whether they were raised in an abusive or a nurturing environment. DSM-III is often called a revolution, but it was more like the televised version of the revolution. The APA watered down Goodwin and Guze's ideas, expanding their 12 core diagnoses into 265 disorders and dropping any mention of known causes. If you want to read the real manifesto, check out Psychiatric Diagnosis, which is updated more regularly than the DSM, now in its seventh edition. The book has only added two diagnoses to the original 12: borderline personality and PTSD.

KELLIE NEWSOME: You won’t find the Dark Triad in that book, or in the DSM, but it has spread like wildfire in popular culture and often comes up in my sessions. Here’s an example. A patient came in with a sense of inspired relief, saying they’ve finally figured out the cause of their problems. After talking with friends, their therapist, or reading online, they’ve realized their ex-spouse, parent, sibling, etc, is a Machiavellian narcissist. The Dark Triad has trickled into dating culture and online advice columns, bringing us terms like “gaslighting,” “trauma bond,” “Dark empaths,” and “toxic personality.” These are people who “triangulate” to manipulate others. They “love bomb,” showering their victims with gifts and compliments early in the relationship, only to neglect or abuse them later, but setting off shallow love bombs often enough to keep their hold on the insecure attachment. If you’ve seen the movie The Wolf of Wall Street, you’ve seen this play out between Jordan Belfort and his wife, Naomi Belfort. After their first date, he sent her more flowers than she had square footage in her Brooklyn apartment. The real-life Naomi Belfort is now known as Dr. Nadine Macaluso. She divorced the love bomber, became a therapist, and wrote books on domestic violence and the Dark Triad.

CHRIS AIKEN: The advice in these writings is always the same: cut off all contact with the toxic person. The problem with that advice is that these dark triad traits occur on a spectrum. Everyone has a few of them, and in close, conflicted relationships, they get magnified. Empathy shuts down on both sides when people fight tooth and nail in zero-sum games like employment disputes and divorce litigation.

KELLIE NEWSOME: When it comes to full narcissistic personality disorder, not just a few traits, around 2-6% of the population has it, much smaller than the widespread complaints would suggest. Antisocial personality has a similar prevalence, around 1-4%, about 3 times more common in men than women.

CHRIS AIKEN: John Oldham, a psychoanalyst who chaired DSM-IV's personality disorder section, wrote a popular book on personality that is full of sound advice. Oldham breaks down each personality disorder into two sides. On the normal end are people with some traits, but they're not so inflexible as to cause major problems. On the pathological side are those who are inflexible, unbalanced, and problematic in those traits. Oldham uses clever, non-pathologizing terms here, like borderline is called the “mercurial type”, obsessive-compulsive is the “conscientious type”, and antisocial the “adventurous type”. For each type, he gives practical advice. For example, he suggests that obsessive-compulsives practice showing emotions and making spontaneous decisions by flipping a coin instead of running everything through an Excel spreadsheet of pros and cons. For mercurial borderlines, they may need to step back and make lists of pros and cons before jumping into action. Then Oldham gives advice for those who are dealing with these personalities, the spouses, friends, and coworkers. In each case, he finds a way to manage it, with one exception: pathological antisocial personality disorder. If you are in a relationship with them, Oldham has only two words of advice: Get out.

KELLIE NEWSOME: Today’s research update is a 2025 randomized controlled trial by Peter Fonagy and colleagues titled “Mentalisation-based treatment for antisocial personality disorder in males convicted of an offence on community probation in England and Wales.” The trial tested a new psychoanalytically-informed therapy in 313 men with antisocial personality who had committed a crime. Half got the group and individual therapy, and half got treatment as usual, monitoring by a probation officer. A year of mentalization therapy reduced aggression and improved their ability to communicate with and understand others, with continued benefits 2 years later. The main limitation was a high dropout rate and the lack of an active control.

CHRIS AIKEN: The results suggest that empathy can be taught, even for people with profound empathic deficits. In this therapy, patients learned to mentalize, to understand other people's motivations and feelings. The therapy was originally developed for borderline personality disorder, and this study modified mentalization for antisocial personality. The manual for the therapy is free online. Google  “mentalization therapy for antisocial personality manual pdf.” After we recorded this podcast, news broke that takes us back to the morning of August 10th, 2019, when Epstein was found dead in his cell. Ten days prior to his death, the prison guard on that shift made a suspicious cash deposit of $5,000 in her bank, that was flagged as suspicious, and one hour before his body was found, the same guard searched the internet for media updates about Epstein. This podcast is not a whodunit thriller. The psychiatric interest here is why people believe what they believe. Sure, this all looks suspicious, but we could spin the data another way. The guard started making these cash deposits over a year before Epstein went to prison and made 12 of them over that year, totaling $12,000. Sure, maybe it was money laundering, but not necessarily about Epstein. Whether we're assessing delusions or rethinking our own closely held beliefs about psychiatry, it's a reminder that we can never be too certain. As for Googling a famous prisoner online, I'm sure lots of guards do that; it could be coincidence. As for us, please remember that psychiatrists and psychotherapists are held to a different standard. It is generally considered unethical for therapists to Google their patients without prior consent, as it violates privacy, trust, and boundaries.

KELLIE NEWSOME: For over 20 years, The Carlat Report has operated free of industry funding. You can support that mission by subscribing online, where podcast listeners get $30 off their first year’s subscription with the promo code PODCAST. 

CHRIS AIKEN: In our audio excerpt, Steve Bannon compares Jeffrey Epstein to the devil, and Epstein deflects the question by referencing a movie, American Dharma. American Dharma is an Errol Morris documentary about Steve Bannon that compares the political strategist to Satan.