Psychopathy: diagnosis and implications for treatment

Principles of Forensic Psychiatry

Psychopathy: diagnosis and implications for treatment

Historical conceptualizations In 19th century German psychiatry, ‘psychopathic personalities’ was a generic term for a heterogeneous group of abnormal personalities which were viewed as extreme variants of normal personality. By contrast, in England and the USA, the concept of psychopathy was based on the moral insanity tradition, which identified individuals as psychopathic based on their social deviance rather than their personality characteristics. The latter approach is still reflected in the 1983 Mental Health Act for England and Wales, in which the legal category of ‘psychopathic disorder’ is defined as ‘a persistent disorder or disability of mind … which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned.’ The ‘antisocial personality disorder’ (APD) category introduced in the third iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) American Psychiatric Association, 1980) also follows the moral insanity tradition, as psychological abnormality is inferred from social deviance.1 Cleckley’s seminal work The Mask of Sanity2 offered a hybrid conceptualization of psychopathic personality as he described a stable set of maladaptive personality traits, attitudes and behaviours that begin in childhood and lead to undesirable outcomes such as antisociality, criminality, violence and substance abuse in later life. Features specific to psychopathy include lack of guilt, low empathy, failure to learn from experience, arrogant, deceitful interpersonal style and superficial charm.

Mairead Dolan Michael Doyle

Abstract Psychopathy is a complex higher order personality construct characterized by a constellation of affective, interpersonal and behavioural features, including: egocentricity, deceitfulness and a tendency to manipulate; lack of empathy, guilt and remorse; and a tendency to violate social norms, usually including the criminal law. Psychopathy can be assessed across the lifespan and the construct has been shown to be reliable and valid in a range of clinical and correctional settings. The base rate of psychopathy is low in the general population (0.6%) but significantly higher in criminal justice settings. Research on the developmental origins of psychopathy suggests that social factors and, particularly, adverse ­upbringing contribute to causation, whilst also establishing its strong biological basis. There is a genetic component and consistent reports of an association between impulsive aggressive traits and dysregulation of the serotonergic system. Imaging studies point to both structural and functional deficits in fronto-temporal circuitry. Psychopathy generally shows a poor response to treatment and is a negative moderator of outcome. There are few well controlled intervention studies but there are suggestions that cognitive skills programmes may be of value. Obstacles to successful psychological treatment include the core personality traits of deceit, manipulation and lack of remorse, as well as general problems of poor motivation, non-compliance and failure to engage in a therapeutic alliance. Future interventions need to target putative proximal causes of psychopathy.

Investigations Assessment of psychopathy across the lifespan The psychopathy construct has been operationalized in the Psychopathy Checklist Revised (PCL-R)3 and its derivatives, the Psychopathy Checklist Screening Version (PCL: SV)4 and the Psychopathy Checklist: Youth Version (PCL: YV).5 These assessment tools are based on semi-structured interview, file review and collateral information. Each item is scored on a 3-point scale (0, 1, 2) according to the extent to which the rater judges that it applies to that individual. Scores on the PCL-R and PCL: YV range from 0–40 but cut-off scores are commonly used to classify individuals for research or clinical purposes. In North America a score of >30 on the PCL-R represents ‘prototypical’ psychopathy. In European samples, however, cut-off scores of 25 on the PCL-R have been advocated because a growing international literature suggests mean PCL-R scores in equivalent prisoner, patient and forensic samples are lower in Europe than in North America.6,7 There are cultural differences in the expression of psychopathic traits across settings and countries. Originally, a two-factor model of the PCL-R was widely accepted in which PCL-R items were thought to be underpinned by two distinct but correlated factors: the affective and interpersonal factor and the social deviance factor (see Table 1 for the PCL-R item content).3 More recently, three-factor6 and four­factor models7 have been proposed. Of more general importance is the 12 item PCL: SV, which was developed as a screening test for psychopathy. A score of ≥18 is usually taken to indicate the need for a full PCL-R assessment. The 20-item PCL: YV was designed for use in 13–18 year olds. Similarly to the PCL-R, scores can range from 0 to 40 but a cut- off

Keywords aetiology; assessment; comorbidity; criminality; psychopathy; treatment outcome

Mairead Dolan MBBCh MRCPsych is a Professor of Forensic Psychiatry and Neuroscience at the University of Manchester, UK, and Honorary Consultant Forensic Psychiatrist at Bolton, Salford and Trafford Mental Health NHS Trust. Her research interests include risk assessment, personality disorder and the neurobiology of antisocial behaviour. Conflicts of interest: none declared. Michael Doyle RMN MSc PhD is currently in the post of Nurse Consultant for Clinical Risk in the Adult Forensic Mental Health Directorate based at the Edenfield Centre, Manchester, UK. He is also an Honorary Research Fellow in the Department of Psychiatry at the University of Manchester. His research interests include risk assessment, psychosocial interventions and clinical effectiveness. Conflicts of interest: none declared.

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Features of psychopathy based on the Psychopathy Checklist – Revised items PCL-Items Factor I (affective/interpersonal items) Glib superficial charm Grandiose sense of self-worth Pathological lying Conning and manipulative Lack of remorse or guilt Shallow affect Callousness and lack of empathy

Failure to accept responsibility for own actions Factor 2 (social deviance/lifestyle items) Parasitic lifestyle Poor behavioural controls Need for stimulation or proneness to boredom Promiscuous sexual behaviour Early behaviour problems Lack of realistic long-term goals Impulsivity Irresponsibility Many short-term marital relationships Juvenile delinquency Revocation of conditional release Criminal versatility

Descriptor

Smooth-talking, charming, lacks self-consciousness, verbally facile Inflated view of own abilities, opinionated, arrogant and conceited Deceptive, deceitful, underhand, manipulative and dishonest Cheating and conning others for personal gain, fraud, lack of concern for the victims of scams and swindles Lack of concern for loss, pain and suffering of others; lack of remorse and guilt over suffering caused; contempt and disdain for others Limited range and depth of feeling; lack of warmth and emotional closeness Overlaps with lack of guilt and remorse; reflects more cruel, insensitive and contemptuous behaviours such as defiling a body post-mortem or gaining personal pleasure from another’s suffering Deny or refuse to accept responsibility Intentional, manipulative, selfish and exploitative use of others; use of threats and coercion to obtain support and help from others Hostility, aggression Thrill-seeking, low self-discipline, failure to stick with mundane jobs/tasks, unreliability and laxness in work ethic Brief superficial relationships, infidelity, exploitation of sexual partners A range of conduct problems and antisocial behaviour prior to age 13 years Lives day to day, lacks ambition, lacks direction and shows low discipline and commitment in a work environment Rash, reckless and shows little behavioural restraint Fail to honour obligations, defaults on loans, lax and negligent Lacks commitment to relationships, unreliable and undependable Violations of the law that warrant the attention of the criminal justice system Breaching parole violations Occurrence of a range of different types of offending behaviour

Table 1

score has not been recommended for diagnostic purposes. The 20-item Antisocial Process Device,8 which is rated by parents and teachers, has been developed for those aged 6–13 years. Research is emerging to suggest that these juvenile measures have reasonable construct and concurrent validity and similar external correlates to adult measures of psychopathy, but there remains a concern about the stigmatizing nature of this label in young people.9

Psychopathy and women The literature suggests that although the base rate of psychopathy in women is low, the reliability and factor structure of the PCL-R are consistent across gender.11,12 Studies in North American incarcerated samples report base rates of 11–30% depending on the cut-off score used. It has been suggested that sex bias by clinicians may account for these lower rates in women. There is also some evidence that base-rate differences may reflect differences in the manifestation of psychopathy, particularly in terms of social deviance. For example, some studies suggest that women show less overt violent behaviour, higher rates of comorbid borderline personality pathology, and more evidence of sexual misbehaviour such as prostitution. The assessment of psychopathy in women may require exploration of female expressions of antisocial behaviour such as child abuse/neglect or inciting violence by male partners, and of relational aggression such as ‘bitchiness’.11,12

Prevalence Despite extensive research and clinical interest in psychopathy in North American correctional facilities, work on the utility of this construct is in its infancy in the UK. It is being used in ­violence risk assessment and underpins the developing services for dangerous and severe personality disorder (DSPD). Recent data from a representative two-phase survey of adults aged 16–74 in households in the UK suggests that the prevalence of psychopathy in the general population is low at 0.6%, but rises to 7.7% in male prisoners and 1.9% in female prisoners (using North American cut-off scores).10 Psychopathy scores tend to be higher in prison and forensic samples because of the association with ­criminality.

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Differential diagnoses Antisocial behaviour disorders The definitional boundaries of psychopathy and antisocial personality disorder (APD) (as defined in DSM-IV)13 and conduct 405

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disorder (CD) are blurred. The categories of APD and CD focus on overt behaviour, while psychopathy places more emphasis on interpersonal/affective symptoms such as callousness and lack of empathy. This difference is reflected in the asymmetric nature of the relationship between APD and psychopathy in adult offenders, where 90% of adult psychopathic offenders meet APD criteria but only 25% of those with APD are psychopathic. Similar asymmetries have been found in adolescents, where the majority of adolescents offenders (97–100%) meet the criteria for CD but only 30% of offenders with CD met diagnostic criteria for psychopathy on the PCL:YV.5 In some respects, psychopathy can be seen as a more severe subcategory of APD or CD.

outcomes in substance misuse, with higher rates of drop-out, relapse and re-offending in those with psychopathic traits.19

Pathology and pathogenesis The biological and environmental factors responsible for the development and maintenance of psychopathy are not well understood. Over the last five decades, several attempts have been made to identify a pathology that is specific or unique to psychopathy, based on the assumption that it is a homogenous construct. In reality, psychopathy is a multidimensional construct that is likely to be the product of complex interactions between biological and environmental factors.16 Although social adversity and adverse parenting contribute to psychopathy, there is strong and growing evidence that neurobiological factors are important. For example, genetic factors influence criminality and APD and callous unemotional traits in psychopathy are highly heritable.20 Research on the neurochemical basis of psychopathy has produced consistent evidence of an association between Factor 2 (impulsive aggressive and antisocial traits) and reduced central serotonergic function. Less consistently, there have been reports of altered receptor and neurotransmitter function in dopaminergic and noradrenergic systems. The neurochemical basis of the affective-interpersonal (Factor 1) component has not been extensively studied. Studies of neuropsychological function suggest that APD may be associated with a broad range of executive and memory deficits, while psychopathy may be associated with a more specific deficit in functioning in the amygdala–orbitofrontal circuitry.21 The imaging literature supports the notion that psychopathy and APD in offenders is associated with reduced prefrontal cortical grey matter and with functional deficits in the emotional/affective information processing circuitry.22 To date, there have been few studies looking at the neurobiology of psychopathy from a developmental perspective but the limited available data suggest that psychopathy may be associated with a primary developmental deficit in amygdala function, which accounts for the low empathy and callous unemotional traits seen across the lifespan.21

Personality disorders The relationship of PCL-R psychopathy to personality disorders other than APD has received relatively little attention but there is clear evidence of trait overlap with a number of DSM-IV axis II disorders. For example, items such as superficial charm, insincerity and egocentricity overlap with histrionic personality disorder. Grandiosity, lack of empathy and exploitativeness overlap with narcissistic personality disorder and impulsivity overlaps with borderline personality disorder (BPD). Research supports the notion that psychopathy is a superordinate personality dimension pervading many DSM-IV axis II disorders, including narcissistic, histrionic, borderline, paranoid and APD.14 Psychopathy and criminality/violence Psychopathy is associated with an earlier onset of offending, greater criminal versatility and higher rates of violent and nonviolent offending than in non-psychopathic criminal samples.15 High psychopathy scores are also associated with higher rates of assault and disciplinary infractions in institutional settings. In view of these facts it is no surprise to find that psychopathy assessments are included in many standardized violence risk assessment tools,15 although it would be a serious error to assume that absence of psychopathy implies a low risk of violence. Although psychopathy is associated with both reactive and instrumental violence, those with callous unemotional traits tend to exhibit more instrumental aggression. An important symptom of psychopathy is persistent, frequent and varied asocial and antisocial behaviour that starts early in life.16 There is some evidence, however, that criminal psychopaths show a reduction in non-violent but not violent criminality around the age of 40. This age-related change in criminality is not paralleled by a change in personality function, as the affective and interpersonal features (Factor 1) remain stable over time.17

Neuropathology The empirical findings have led a number of theorists to develop models for understanding the neural basis of psychopathy, or its components. Key theories that account for impulsivity, risk-taking and abnormal punishment/reward functions include the Punishment/Low Fear,23 Somatic Marker24 and Response Modulation Deficit25 hypotheses. These theories focus on the prefrontal cortex as the primary seat of dysfunction. More recently, Blair developed an Integrated Emotion System (IES) theory which suggests that lack of empathy is the core deficit underlying the affective-interpersonal components of psychopathy and particularly callous/unemotional traits.21 He suggests the amygdala, which responds to images of facial emotions and especially to sadness and fear, is a key component of this model. Blair proposes that the amygdala mediates an innate tendency to empathetic emotion, which underlies socialization, and suggests that psychopathy results from an impairment of amygdala function relating to empathy and specific forms of reward and aversion learning.21 One consequence of amygdala-empathy impairments may be that individuals with callous unemotional traits learn to obtain rewards through instrumental aggression.

Psychopathy and substance abuse Substance abuse is a common comorbid disorder in those with APD and psychopathy. Verheul and colleagues reviewed 40 studies published between 1982–1994 and reported rates of APD between 24–30% for opiate users and 1–62% for poly-drug abusers.18 The variation in rates across studies reflected different research methods used. To date, there are no studies looking specifically at the prevalence of psychopathy in substance abuse samples, but there is evidence that substance misuse relates more to Factor 2 (social deviance) items than to the Factor 1 (affective/interpersonal) components of psychopathy. Research also suggests that psychopathy is associated with poor treatment

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suggestions that structured cognitive–behavioural and cognitive skills programmes offer most promise for psychopathic offenders. Losel outlined the key principles of designing a potentially effective programme for offenders with psychopathic traits, outlined in Table 2.27

Treatment and management Most of the research literature on treatment focuses on antisocial behaviour in general and there is a lack of well controlled studies on psychopathy. Nonetheless, psychopathy has traditionally been viewed with particular pessimism given the paucity of evidence that any particular mode of therapy is consistently effective.26,27 There is a very limited and largely anecdotal literature on the use of major tranquillizers, mood stabilizers and serotonergic agents in the control of impulsive and aggressive traits in antisocial samples, but there has been little investigation of the pharmacological treatment of psychopathy per se.27 Several reviews highlight the lack of efficacy of traditional democratic therapeutic community programmes in moderating personality characteristics in psychopathy and there is some evidence that insight-oriented programmes may enhance a psychopath’s ability to manipulate and deceive and increase risk.26,27 Several meta-analyses also point to the lack of efficacy of punishment, deterrence and formal justice reactions for antisocial behaviour in general and for psychopathy in particular.28–30 On the other hand, there are consistent

Future work on treatment The prospects for progress in the treatment of psychopathy are likely to be similar to other disorders such as schizophrenia, which have an underlying genetic and neurodevelopmental basis. Further basic research should clarify the aetiology of the core deficits seen in psychopathy and this information will inform the development of appropriate interventions. Nonetheless, key obstacles to positive outcome for psychological interventions will include the core personality traits (e.g. deceit, manipulation, lack of remorse), as well as more general lack of motivation, non-compliance and lack of engagement in a therapeutic alliance. For those with established antisocial behaviour, programmes will need to focus on risk reduction via high levels of supervision and structured interventions designed to shape behaviour in desired directions.

Losel’s principles for effective psychological interventions in psychopathy27 Theoretically sound conceptualization

Cognitive–behavioural approaches, recognition and treatment of comorbidity including substance misuse, use of pharmacological interventions in subgroups with high levels of impulsivity/reactive aggression

Thorough dynamic assessment of the client

Formal assessment of psychopathy assessed using standardized operational measures; more detailed assessment of personality disorders and clinical syndromes with a lifetime perspective; social functioning; criminogenic factors, victim empathy and insight into risk factors for antisocial behaviour Regular, intensive high-dosage sessional work with a minimum of 12–18 months Clear rules, regulations, duties and responsibilities outlined at the outset; reward system for prosocial behaviours and engagement; dedicated therapeutic environment separated from general prison setting Firm and consistent staff behaviour; interpersonally sensitive, constructive and supportive

Intensive service Clearly structured and distinct setting Development of a prosocial institutional climate and regime The need principle

Responsivity principle Treatment integrity Thorough selection, training and supervision of staff Neutralization of unfavourable social networks Strengthen natural protective mechanisms Relapse prevention Early intervention

Reducing societal reinforcement

Target criminogenic needs; focus on changing antisocial attitudes, modify hostile attributional biases; increase anger management and impulse control; reduce substance misuse, enhance problem-solving skills and encourage engagement with prosocial peers and family members Match treatment with the needs of the offender; use a range of cognitive–behavioural programmes to target key symptoms and behaviours Monitor quality and quantity of the programme and record data on client and staff compliance and adherence to the programme Detailed knowledge of psychopathy, key professional and treatment skills and attitudes; continuous supervision to ensure maintenance of boundaries and professional attitudes Counteract exploitative relationships, encourage peer group reinforcement of prosocial behaviours Identify potential turning points in an individual’s career; build on core strengths and support positive interpersonal relationships Thorough planning and implementation of relapse prevention and aftercare; multi-agency communication and supervision Recognition of psychopathic traits in younger cohorts will help identify those that are at increased risk of persistent antisocial behaviour; successful measures for at-risk children must include elements that improve social and cognitive skills and competencies and reduce impulsivity and aggression; these should be complemented by parenting skills programmes that promote support, supervision and consistency in managing antisocial behaviour Research suggests that cultural factors may influence the expression of psychopathic traits; society and organizations need to ensure that maladaptive and antisocial behaviours are not rewarded and that psychopathic traits are not seen as an adaptive strategy

Table 2

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Given the difficulties of intervening in those with a high level of psychopathy, established offending behaviour and an ingrained antisocial lifestyle, early intervention may be a more effective strategy. The aim would be to intervene in the developmental trajectory that begins with neurobiology and early childhood disadvantage. So, for example, social and psychological interventions may be targeted at high-risk groups with the intention of reducing the likelihood of persistent antisocial behaviour (see Seto and Quinsey for a good review of key issues30). ◆

19 Vaglum P. Antisocial personality disorder and narcotic addiction. In: Millon T, Simonson E, Burket-Smith M, Davis R, eds. Psychopathy: antisocial, criminal, and violent behaviour. New York: Guilford Press, 1998. 20 Waldman ID, Rhee SH. Genetic and environmental influences on psychopathy and antisocial behaviour. In: Patrick CJ, ed. Handbook of psychopathy. New York: Guilford Press, 2006. 21 Blair RJ. Applying a cognitive neuroscience perspective to the disorder of psychopathy. Dev Psychopathol 2005; 17: 865–91. 22 Dolan M. What neuroimaging tells us about psychopathic disorders. Hosp Med 2002; 63: 337–40. 23 Lykken DT. The antisocial personalities. Hillsdale, NJ: Erlbaum, 1995. 24 Damasio AR. Descartes’ error: emotion, rationality and the human brain. New York: Putnam, 1994. 25 Newman JP. Psychopathic behaviour: an information processing perspective. In: Cooke DJ, Forth AE, Hare RD, eds. Psychopathy: theory, research and implications for society. Dordrecht: Kluwer, 1998. 26 Dolan B, Coid J. Psychopathic and antisocial personality disorders: treatment and research issues. London: Gaskell, 1993. 27 Losel F. Treatment and management of psychopaths. In: Cooke DJ, Forth AE, Hare RD, eds. Psychopathy: theory, research and implications for society. Dordrecht: Kluwer, 1998. 28 Gendreau P, Little T, Goggin C. A meta-analysis of the predictors of adult offender recidivism: what works! Criminology 1996; 34: 575–607. 29 Salekin RT. Psychopathy and therapeutic pessimism clinical lore or clinical reality? Clin Psychol Rev 2002; 22: 79–112. 30 Seto MC, Quinsey VL. Towards the future: translating basic research into prevention and treatment strategies. In: Patrick CJ, ed. Handbook of psychopathy. New York: Guilford Press, 2006.

References 1 American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-III), 3rd edn. Washington, DC: American Psychiatric Association, 1980. 2 Cleckley H. The mask of sanity, 6th edn. St Louis, MO: CV Mosby, 1976. 3 Hare RD. The Hare psychopathy checklist – revised. Toronto: MultiHealth Systems, 1991. 4 Hart SD, Cox DN, Hare RD. The Hare psychopathy checklist: screening version. Toronto: Multi-Health Systems, 1995. 5 Forth AE, Kosson DS, Hare RD. The psychopathy checklist: youth version. Toronto: Multi-Health Systems, 2003. 6 Cooke DJ, Michie C, Hart SD, Clark D. Assessing psychopathy in the United Kingdom: concerns about cross-cultural generalisability. Br J Psychiatry 2005; 186: 339–45. 7 Hare RD. Manual for the Hare psychopathy checklist – revised, 2nd edn. Toronto: Multi-Health Systems, 2003. 8 Frick PJ, Hare RD. Antisocial process screening device. Toronto: Multi-Health Systems, 2001. 9 Dolan M. Psychopathic personality in young people. Advances in Psychiatric Treatment 2004; 141: 39–54. 10 Coid J, Yang M. The epidemiology of psychopathy. In: 6th Annual International Association of Forensic Mental Health Services Conference. A safe society: effective assessment, prevention and treatment in forensic mental health, Amsterdam, 14–16 June 2006. 11 Cale EM, Lilienfeld SO. Sex differences in psychopathy and antisocial personality: a review and integration. Clin Psychol Rev 2002; 22: 1179–207. 12 Vitale JE, Newman JP. Using the Psychopathy checklist – revised with female samples: reliability, validity, and implications for clinical utility. Clin Psychol: Sci Pract 2001; 8: 117–32. 13 American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-IV), 4th edn. Washington, DC: American Psychiatric Association, 1994. 14 Blackburn R. Psychopathy as a construct of personality. In: Strack S, ed. Handbook of personality and psychopathology. New York: Wiley, 2005. 15 Dolan M, Doyle M. Violence risk prediction: clinical and actuarial measures and the role of the Psychopathy Checklist. Br J Psychiatry 2000; 177: 303–11. 16 Hare RD. Psychopaths and their nature: implications for the mental health and criminal justice systems. In: Millon T, Simonson E, Burket-Smith M, Davis R, eds. Psychopathy: antisocial, criminal, and violent behaviour. New York: Guilford Press, 1998. 17 Harris GT, Rice ME, Cormier CA. Psychopathy and violent recidivism. Law Hum Behav 1991; 15: 625–37. 18 Verheul R, van den Brink W, Hartgers C. Prevalence of personality disorders among alcoholics and drug addicts: an overview. Eur Addict Res 1995; 1: 166–77.

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Practice points • Psychopathy is a higher order personality construct that overlaps with a number of DSM-IV axis II personality disorders. It represents a complex constellation of affective, interpersonal and social deviance traits and behaviours and is comorbid with substance abuse and shows a robust association with criminality and violence in particular • Although social factors contribute to the aetiology of psychopathy, there is growing evidence that psychopaths show deficits in information processing, particularly emotional/affective processing, which reflects a neurobiological basis for this disorder • Key obstacles to positive outcome for psychological interventions include the core personality traits (e.g. deceit, manipulation, lack of remorse), lack of motivation, noncompliance and lack of engagement in a therapeutic alliance • Future interventions should explore the antecedents of psychopathy and early interventions should target high-risk groups • For those with established antisocial behaviour, programmes will need to focus on risk reduction via high levels of supervision and structured interventions designed to shape behaviour in desired directions

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