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Psychopathy

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"Psychopath" redirects here. For other uses, see Psychopath (disambiguation).
Not to be confused with Psychosis.

Psychopathy (Template:Pron-en[1][2]) is a personality disorder whose hallmark is a lack of empathy. Robert Hare, renowned researcher in the field describes psychopaths as "intraspecies predators[3][4] who use charm, manipulation, intimidation, sex and violence[5][6][7] to control others and to satisfy their own selfish needs. Lacking in conscience and empathy, they take what they want and do as they please, violating social norms and expectations without guilt or remorse".[8] "What is missing, in other words, are the very qualities that allow a human being to live in social harmony."[9]

Psychopaths are glib and superficially charming, and many psychopaths are excellent mimics of normal human emotion;[10] some psychopaths can blend in, undetected, in a variety of surroundings, including corporate environments.[11] There is neither a cure nor any effective treatment for psychopathy; there are no medications or other techniques which can instill empathy, and psychopaths who undergo traditional talk therapy only become more adept at manipulating others.[12] The consensus among researchers is that psychopathy stems from a specific neurological disorder which is biological in origin and present from birth.[10] It is estimated that one percent of the general population are psychopaths.[13][14]

Classification

See Diagnosis

Characteristics

The prototypical psychopath has deficits or deviances in several areas: interpersonal relationships, emotion, and self-control. Psychopaths gain satisfaction through antisocial behavior, and do not experience shame, guilt, or remorse for their actions.[15][16][17] Psychopaths lack a sense of guilt or remorse for any harm they may have caused others, instead rationalizing the behavior, blaming someone else, or denying it outright.[18] Psychopaths also lack empathy towards others in general, resulting in tactlessness, insensitivity, and contemptuousness. All of this belies their tendency to make a good, likable first impression. Psychopaths have a superficial charm about them, enabled by a willingness to say anything without concern for accuracy or truth. Shallow affect also describes the psychopath's tendency for genuine emotion to be short lived and egocentric with an overall cold demeanor. Their behavior is impulsive and irresponsible, often failing to keep a job or defaulting on debts.[18] Psychopaths also have a markedly distorted sense of the potential consequences of their actions, not only for others, but also for themselves. They do not, for example, deeply recognize the risk of being caught, disbelieved or injured as a result of their behaviour.[19]

Perceptual/emotional recognition deficits

Facial affect recognition

In a 2002 study, David Kosson and Yana Suchy, et al. asked psychopathic inmates to name the emotion expressed on each of 30 faces; compared to controls, psychopaths had a significantly lower rate of accuracy in recognizing disgusted facial affect but a higher rate of accuracy in recognizing anger. Additionally, when "conditions designed to minimize the involvement of left-hemispheric mechanisms" (i.e. sadness) were used, psychopaths had more difficulty accurately identifying emotions. This study did not replicate Blaire, et al. (1997)'s findings that psychopaths are specifically less sensitive to nonverbal cues of fear or distress.[20]

Vocal affect recognition

In a 2002 experiment, Blair, Mitchell, et al. used the Vocal Affect Recognition Test to measure psychopaths' recognition of the emotional intonation given to connotatively neutral words. Psychopaths tended to make more recognition errors than controls with a particularly high rate of error for sad and fearful vocal affect.[21]

Stroop tasks

A 2004 experiment tested the hypothesis of overselective attention in psychopaths using two forms of the Stroop color-word and picture-word tasks: with color/picture and word separated and with color/picture and word together. They found in the separated Stroop tasks, psychopaths performed significantly worse than controls; however, on standard Stroop tasks, psychopaths performed equally well as controls.

When split into low-anxious and high-anxious groups, low-anxious psychopaths and low-anxious controls showed less interference on the separated Stroop tasks than their high-anxious counterparts; for low-anxious psychopaths, interference was very nearly zero. They conclude the inability to integrate contextual cues depends on the cues' relationship to "the deliberately attended, goal-relevant information."[22]

Causes

One twin study suggests that psychopathy has a strong genetic component. The study demonstrates that children with anti-social behavior can be classified into two groups: those who were also callous acquired their behavior by genetic influences, and those who were not callous acquired it from their environment.[23]

Pathophysiology

Recent studies have triggered theories on determining whether there is a biological relationship between the brain and psychopathy. One theory suggests that psychopathy is associated with both the amygdala, which is associated with emotional reactions and emotion learning, and the prefrontal cortex, associated with impulse control, decision-making, emotional learning and behavioral adaptation.[24] Some studies have shown a decrease in "gray matter" in these areas in psychopaths than non-psychopaths.

There is DT-MRI evidence of breakdowns in the white matter connections between these two important areas in a small British study of 9 criminal psychopaths. This evidence suggests that the degree of abnormality was significantly related to the degree of psychopathy and may explain the offending behaviors.[25][26]

Diagnosis

Currently, there are no diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders for psychopathy. Labeling a person as a psychopath involves forensic measurement, using a diagnostic tool such as the Hare Psychopathy Checklist (PCL-R). The PCL-R is widely considered the "gold standard" for assessing psychopathy. Psychopathy is most strongly correlated with DSM-IV antisocial personality disorder (ASPD), and the ICD-10 antisocial personality disorder and dissocial personality disorder (DPD). However, the PCL-R criteria for identifying a psychopath are stricter than the diagnostic criteria for ASPD or DPD; psychopaths represent a subset of those with ASPD, and psychopaths' traits are more severe.[27]

Hare Psychopathy Checklist

Main article: Hare Psychopathy Checklist

Psychopathy is most commonly assessed with the PCL-R,[28] which is a clinical rating scale with 20 items. Each of the items in the PCL-R is scored on a three-point (0, 1, 2) scale according to two factors. PCL-R Factor 2 is associated with reactive anger, anxiety, increased risk of suicide, criminality, and impulsive violence.

PCL-R Factor 1, in contrast, is associated with extroversion and positive affect. Factor 1, the so-called core personality traits of psychopathy, may even be beneficial for the psychopath (in terms of nondeviant social functioning). A psychopath will score high on both factors, whereas someone with APD will score high only on Factor 2.[29] Both case history and a semi-structured interview are used in the analysis.

Because an individual's scores may have important consequences for his or her future, the potential for harm if the test is used or administered incorrectly is considerable. The test can only be considered valid if administered by a suitably qualified and experienced clinician under controlled conditions.[8][30]

PCL-R items

The following findings are for research purposes only, and are not used in clinical diagnosis. These items cover the affective, interpersonal, and behavioral features. Each item is rated on a score from zero to two. The sum total determines the extent of a person's psychopathy.[27]

Factor 1
Aggressive narcissism
  1. Glibness/superficial charm
  2. Grandiose sense of self-worth
  3. Pathological lying
  4. Cunning/manipulative
  5. Lack of remorse or guilt
  6. Emotionally shallow
  7. Callous/lack of empathy
  8. Failure to accept responsibility for own actions
Factor 2
Socially deviant lifestyle
  1. Need for stimulation/proneness to boredom
  2. Parasitic lifestyle
  3. Poor behavioral control
  4. Promiscuous sexual behavior
  5. Lack of realistic, long-term goals
  6. Impulsiveness
  7. Irresponsibility
  8. Juvenile delinquency
  9. Early behavioral problems
  10. Revocation of conditional release
Traits not correlated with either factor
  1. Many short-term marital relationships
  2. Criminal versatility

Comorbidity

Psychopaths may have various mental conditions,[31] although, in contrast to people with antisocial personality disorder, comorbidity among psychopaths is generally found to be low.[32][33]

Substance abuse has been associated with psychopathy.[34], particularly Factor 2 (anti-social behaviour), but not Factor 1 (emotional) scores of the PCL-R[31][32]. Conduct disorder and ADHD have both been associated with psychopathy; which may be explained by disruption to dorsolateral prefrontal cortex. This area is associated with executive function, which is affected in all three disorders.[31]

There is some evidence of an association between ASPD and other personality disorders (i.e. histrionic, narcissistic and borderline personality disorders),[32] however, evidence for a link with psychopathy is more tentative.[33]

Anxiety may be associated positively with antisocial behaviour, but it is inversely associated with Factor I (emotional) scores on the PCL-R.[31] Depression is inversely associated with psychopathy.[31] Although violence may be associated with schizophrenia, there is no conclusive evidence for a link between psychopathy and schizophrenia.[31][33]

It has been suggested that psychopathy may be comorbid with several other diagnoses than these[34], however limited work on comorbidity has been carried out. This may be because of difficulties in using inpatient groups from certain institutions to assess comorbidity, owing to the likelihood of some bias in sample selection[31]. Furthermore, comorbidity may be more reflective of poor discriminant validity of categories in the DSM-IV than reflective of underlying aetiologically separate conditions[32].

Relationship to propensity toward committing sex crime

No clinical definition of psychopathy indicates that psychopaths are especially prone to commit sexually-oriented murders, and scientific studies do not suggest that a large proportion of psychopaths have committed these crimes.[citation needed] Although some claim a large proportion of such offenders have been classified as psychopathic, this evidence comes from a single, unrepeated research study using the Rorschach Inkblot Test, an invalid test for psychopathy and for sex offenders,[35] references not considering psychopathy,[36] and studies concerning sexual homicide, a somewhat different population than the general class of sex offenders and not from meta-studies combining repeatable results.

Conceptual models

As a discrete disorder

Hare believes that the Diagnostic and Statistical Manual of Mental Disorders should list psychopathy as a unique disorder, given that psychopathy has no precise equivalent[30] in either the DSM-IV-TR, where it is most strongly correlated with the diagnosis of antisocial personality disorder, or the ICD-10, which has a partly similar condition called dissocial personality disorder.

Primary-secondary distinction

Primary psychopathy was defined by those following this theory as the root disorder in patients diagnosed with it, whereas secondary psychopathy was defined as an aspect of another psychiatric disorder or social circumstances.[37] Today, primary psychopaths are considered to have mostly Factor 1 traits from the PCL-R (arrogance, callousness, manipulativeness, lying) whereas secondary psychopaths have a majority of Factor 2 traits (impulsivity, boredom proneness, irresponsibility, lack of long-term goals).[38]

Secondary psychopaths show normal to above-normal physiological responses to (perceived) potential threats. Their crimes tend to be unplanned and impulsive with little thought of the consequences.[39] According to those using this theory, this type have hot tempers and are prone to reactive aggression. They experience normal to above-normal levels of anxiety but are nevertheless highly stimulus-seeking and have trouble tolerating boredom. Their lifestyle may lead to depression and even suicide.

Mealey uses the term "primary psychopathy" to differentiate between psychopathy that is biological in origin and "secondary psychopathy" that results from a combination of genetic and environmental influences.[40] Lykken prefers sociopathy to describe the latter.

Sellbom and Ben-Porath (2005) describe the distinction:

Some people who engage in violent behavior possess psychopathic personality traits, such as callousness, grandiosity, and fearlessness, and presumably engage in such conduct because they care little about others. Others are impulsive and experience considerable anger, anxiety, and distress and may commit violent acts as a reaction to negative emotions, which are sometimes referred to as "crimes of passion." Indeed, the distinction between primary and secondary psychopathy (including so-called neurotic psychopathy) has long been noted in the psychopathy literature (Karpman, 1947; Lykken, 1995).[41]

This distinction closely resembles the distinction between instrumental and impulsive/reactive crime/violence in the field of criminology.

Joseph P. Newman et al., who use this concept of psychopathy, have validated David T. Lykken's conceptualization of psychopathy subtypes in relation to Gray's behavioral activation system and behavioral inhibition system.[42] Newman et al. found measures of primary psychopathy to be negatively correlated with Gray's behavioral inhibition system, a construct intended to measure behavioral inhibition from cues of punishment or nonreward.[42] In contrast, measures of secondary psychopathy to be positively correlated with Gray's behavioral activation system, a construct intended to measure sensitivity to cues of behavioral approach.[42]

Psychopathy vs. sociopathy

Hare writes that the difference between sociopathy and psychopathy may "reflect the user's views on the origins and determinates of the disorder."[43]

David T. Lykken proposes psychopathy and sociopathy are two distinct kinds of antisocial personality disorder. He believes psychopaths are born with temperamental differences such as impulsivity, cortical underarousal, and fearlessness that lead them to risk-seeking behavior and an inability to internalize social norms. On the other hand, he claims sociopaths have relatively normal temperaments; their personality disorder being more an effect of negative sociological factors like parental neglect, delinquent peers, poverty, and extremely low or extremely high intelligence. Both personality disorders are the result of an interaction between genetic predispositions and environmental factors, but psychopathy leans towards the hereditary whereas sociopathy tends towards the environmental.[38]

Three-factor model

Recent statistical analysis using confirmatory factor analysis by Cooke and Michie[44] indicated a three-factor structure, with those items from factor 2 strictly relating to antisocial behaviour (criminal versatility, juvenile delinquency, revocation of conditional release, early behavioural problems and poor behavioural controls) removed from the final model. The remaining items are divided into three factors: Arrogant and Deceitful Interpersonal Style, Deficient Affective Experience and Impulsive and Irresponsible Behavioural Style.[44]

Hare and colleagues have published detailed critiques of the Cooke & Michie hierarchical ‘three’-factor model, citing severe statistical problems. Hare and colleagues note that the Cooke & Michie model actually contains ten factors, and results in impossible parameters (negative variances). Hare and colleagues also note conceptual problems with this model.[45]

Discrete vs. continuous

As part of the larger debate on whether personality disorders are distinct from normal personality or extremes on various dimensions of normal personality is the debate on whether psychopathy represents something "qualitatively different" from normal personality or a "continuous dimension" shading from normality into severely psychopathic. Otto Kernberg believed psychopathy should fall under a spectrum of pathological narcissism, that ranged from narcissistic personality on the low end, malignant narcissism in the middle, and psychopathy at the high end.[46]

Early taxonometric analysis from Harris and colleagues[47] indicated a discrete category may underlie psychopathy, however this was only found for the behavioural Factor 2 items, indicating this analysis may be related to Anti-social Personality Disorder rather than psychopathy per se. Marcus, John, and Edens more recently performed a series of statistical analysis on previously attained PCL–R and PPI scores and concluded psychopathy may best be conceptualized as having a "dimensional latent structure" like depression.[48]

Screening

Childhood precursors

Psychopathy is not normally diagnosed in children or adolescents, and some jurisdictions explicitly forbid diagnosing psychopathy and similar personality disorders in minors. Psychopathic tendencies can sometimes be recognized in childhood or early adolescence and, if recognised, are diagnosed as conduct disorder. It must be stressed not all children diagnosed with conduct disorder grow up to be psychopaths, or even disordered at all, but these childhood signs are found in significantly higher proportions in psychopaths than in the general population. Conduct disorder, as well as a related disorder, Oppositional Defiant Disorder, can sometimes develop into adult psychopathy. However, conduct disorder "fails to capture the emotional, cognitive and interpersonality traits - egocentricity, lack of remorse, empathy or guilt - that are so important in the diagnosis of psychopathy."[49]

Children showing strong psychopathic precursors often appear immune to punishment; nothing seems to modify their undesirable behavior. Consequently parents usually give up, and the behavior worsens.[50]

The following childhood indicators are to be seen not as to the type of behavior, but as to its relentless and unvarying occurrence. Not all must be present concurrently, but at least a number of them need to be present over a period of years [51]

  • An extended period of bedwetting past the preschool years not due to any medical problem.
  • Precocious sadism, often expressed as profound animal abuse.
  • Pathological firesetting lacking in obvious homicidal intent. Not to be confused with playing with matches, which is not uncommon for preschoolers. This is the deliberate setting of destructive fires with utter disregard for the property and lives of others.
  • Lying, often without discernible objectives, extending beyond a child's normal impulse not to be punished. These lies are so extensive it is often impossible to know lies from truth.
  • Theft and truancy.
  • Aggression to peers, not necessarily physical, which can include getting others into trouble or a campaign of psychological torment.

The three indicators—bedwetting, cruelty to animals and firestarting, known as the MacDonald triad—were first described by J.M. MacDonald as "red flag" indicators of psychopathy and future episodic aggressive behavior.[52]

The question of whether young children with early indicators of psychopathy respond poorly to intervention compared to conduct disordered children without these traits have only recently been examined in controlled clinical research. The empirical findings from this research have been consistent with broader anecdotal evidence, pointing to poor treatment outcomes.[53]

Management

Clinical management

In practice, mental health professionals rarely treat psychopathic personality disorders as they are considered untreatable and no interventions have proved to be effective.[54]

It has been shown that punishment and behavior modification techniques do not improve the behavior of psychopaths. Psychopathic individuals have been regularly observed to become more cunning and better able to hide their behaviour. It has been suggested by them traditional therapeutic approaches actually make psychopaths if not worse, then far more adept at manipulating others and concealing their behavior. They are generally considered to be not only incurable but also untreatable.[12]

United Kingdom

In the United Kingdom, "Psychopathic Disorder" is legally defined in the Mental Health Act (UK)[55] as, "a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned."

In England and Wales the diagnosis of dissocial personality disorder is grounds for detention in secure psychiatric hospitals under the Mental Health Act if they have committed serious crimes, but since such individuals are disruptive for other patients and not responsive to treatment this alternative to prison is not often used.[56]

In the United States

Psychopathy has quite separate legal and judicial definitions that should not be confused with the medical definition. The American Psychiatric Association is vigorously opposing any non-medical or legal definition of what purports to be a medical condition "without regard for scientific and clinical knowledge".[57] Various states and nations have at various times enacted laws specific to dealing with psychopaths.

In the United States approximately twenty states currently have provisions for the involuntary civil commitment for sex offenders or sexual predators, under Sexually violent predator acts, avoiding the use of the term "psychopath". These statutes and provisions are controversial and are being reviewed by the U.S. Supreme Court as a violation of a person's Fourteenth Amendment rights.[58] (See Foucha v. Louisiana for an example.[59])

Washington

Washington State Legislature [60] defines a "Psychopathic personality" to mean "the existence in any person of such hereditary, congenital or acquired condition affecting the emotional or volitional rather than the intellectual field and manifested by anomalies of such character as to render satisfactory social adjustment of such person difficult or impossible".[58] The same statute defines the "sexual psychopath" as "any person who is affected in a form of psychoneurosis or in a form of psychopathic personality, which form predisposes such person to the commission of sexual offenses in a degree constituting him a menace to the health or safety of others" for prison sentencing purposes in the Sentencing Reform Act of 1981.[60]

California

California enacted a psychopathic offender law in 1939, since greatly outmoded and revised [61], that defined a psychopath solely in terms of offenders with a predisposition "to the commission of sexual offenses against children." A 1941 law[62] attempted to further clarify this to the point where anyone examined and found to be psychopathic was to be committed to a state hospital and anyone else was to be sentenced by the courts. However, these laws were enacted years before the American Psychiatric Association began publishing the Diagnostic and Statistical Manual of Mental Disorders which is used today for diagnosis and does not include "psychopathic offender". Hence, these laws are of historical interest only.

Prognosis

Release rate among convicted criminals

Findings indicate psychopathic convicts have a 2.5 time higher probability of being released from jail than undiagnosed ones even though they are more likely to recidivate.[63]

Epidemiology

It is estimated that approximately one percent of the general population are psychopaths.[13][14]

History

The origins of the concept of psychopathy go back to Theophrastus, a student of Aristotle, whose description of The Unscrupulous Man embodies the characteristics of psychopathy.[64]

In 1801, Philippe Pinel described patients who were mentally unimpaired but nonetheless engaged in impulsive and self-defeating acts. He saw them as la folie raisonnante ("insane without delirium") meaning they fully understood the irrationality of their behavior but continued with it anyway. By the turn of the century, Henry Maudsley had begun writing about the "moral imbecile", and was arguing such individuals could not be rehabilitated by the correctional system.[65]

Maudsley included the psychopath's immunity to the reformational effects of punishment, owing to their refusal to anticipate further failure, and punishment.[citation needed] In 1904, Emil Kraepelin described four types of personalities similar to antisocial personality disorder. By 1915 he had identified them as defective in either affect or volition, dividing the types further into different categories, only some of which correspond to the current descriptions of antisocial personality disorder.[66]

The Mask of Sanity by Hervey M. Cleckley, M.D., first published in 1941,[39] is considered a seminal work and the most influential clinical description of psychopathy in the 20th century.[citation needed] The basic elements of psychopathy outlined by Cleckley are still relevant today.[citation needed] The title refers to the "mask" of normality that conceals the mental disorder of the psychopathic person.[67]

Society and culture

Fictional portrayals of psychopaths are common in horror films. Anthony Hopkins' character Hannibal Lecter in the film The Silence of the Lambs is one of the best-known.

Research directions

Currently, many researchers focus on the neurological and biological aspects of psychopathy.[citation needed]

In other animals

Several studies note the role of serotonergic functioning in impulsive aggression and antisocial behavior in animals.[68][69][70][71]

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  70. ^ Lee R, Coccaro ER. Neurobiology of impulsive aggression: Focus on serotonin and the orbitofrontal cortex. In: Flannery DJ, Vazsonyi AT, Waldman ID, editors. The Cambridge handbook of violent behavior and aggression. New York: Cambridge University Press; 2007. pp. 170–186. ISBN 9780521607858
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Bibliography

  • Michael H. Thimble, F.R.C.P., F.R.C. Psych. Psychopathology of Frontal Lobe Syndromes.
  • Widiger, Thomas; et al. (1995). Personality Disorder Interview-IV, Chapter 4: Antisocial Personality Disorder. Psychological Assessment Resources, Inc. ISBN 0-911907-21-1. {{cite book}}: Explicit use of et al. in: |last= (help)
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