And how can we protect ourselves? This book provides solid information and surprising insights for anyone seeking to understand this devastating condition. Don't want the mobile site? Switch to the full site. Applies only to prepaid online orders from US and Canadian customers. Discount is applied to the list price. You will receive the larger discount available for each item. Not applicable to journal renewals. Applies only to prepaid online orders from US customers. You may choose to pay for rush shipping instead.
Packages sent via CanPar. For bulk orders, please contact: The author would like to thank Daniel Valenti, Prashanth Nyalakanti, and Eyal Aharoni for their assistance with editing figures and Whitney Schulte for her help with citations. The author would like to thank his law clerk, Cameron Munier, and a former intern, Ethan Ice, for their research and editorial help. Both authors are indebted to the following people for their comments on earlier drafts: The manuscript surveys the history of psychopathic personality, from its origins in psychiatric folklore to its modern assessment in the forensic arena.
Individuals with psychopathic personality, or psychopaths, have a disproportionate impact on the criminal justice system. Psychopaths are twenty to twenty-five times more likely than non-psychopaths to be in prison, four to eight times more likely to violently recidivate compared to non-psychopaths, and are resistant to most forms of treatment. This article presents the most current clinical efforts and neuroscience research in the field of psychopathy. This review also highlights a recent, compelling and cost-effective treatment program that has shown a significant reduction in violent recidivism in youth on a putative trajectory to psychopathic personality.
Psychopaths consume an astonishingly disproportionate amount of criminal justice resources. The label psychopath is often used loosely by a variety of participants in the system—police, victims, prosecutors, judges, probation officers, parole and prison officials, even defense lawyers—as a kind of lay synonym for incorrigible. Law and psychiatry, even at the zenith of their rehabilitative optimism, both viewed psychopaths as a kind of exception that proved the rehabilitative rule.
Psychopaths composed that small but embarrassing cohort whose very resistance to all manner of treatment seemed to be its defining characteristic. The symptoms of psychopathy include shallow affect, lack of empathy, guilt and remorse, irresponsibility, and impulsivity see Table 1 for a complete list of psychopathic symptoms. The items corresponding to the early two-factor conceptualization of psychopathy, 89 subsequent three-factor model, 90 and current four-factor model are listed.
Psychopathy is astonishingly common as mental disorders go. It is twice as common as schizophrenia, anorexia, bipolar disorder, and paranoia, 5 and roughly as common as bulimia, panic disorder, obsessive-compulsive personality disorder, and narcissism. Psychopaths are not only much more likely than non-psychopaths to be imprisoned for committing violent crimes, 8 they are also more likely to finagle an early release using the deceptive skills that are part of their pathologic toolbox, 9 and then, once released, are much more likely to recidivate, and to recidivate violently.
But this exasperating picture of the hidden and incorrigible psychopath may be changing. Neuroscience is beginning to open the hood on psychopathy. The findings from this data and others, 11 summarized in Part IV, strongly suggest that all psychopaths share common neurological traits that are becoming relatively easy to diagnose using functional magnetic resonance imaging fMRI.
This paper will not attempt to answer the complex and controversial policy question of whether psychopathy should be an excusing condition under the criminal law, or even whether, the extent to which, and the direction in which a diagnosis of psychopathy should drive a criminal sentence. But of course not every cause is an excuse. That is, are you sufficiently rational to be blameworthy? On the contrary, those involved in the criminal justice system have a moral obligation, not just to the people incarcerated but also to those on whom the temporarily incarcerated will be released, to do everything they can, within the constraints of the punitive purposes of imprisonment, to reduce recidivism.
Given the facts that psychopaths make up such a disproportionate segment of people in prison and that they recidivate at substantially higher rates than non-psychopaths, the recent advances in the diagnosis and treatment of psychopathy discussed in this paper are developments anyone concerned with the criminal justice system simply cannot ignore. Even a modest reduction in the criminal recidivism of psychopaths would significantly decrease the exploding public resources we devote to prisons, not to mention reduce the risks all of us face as potential victims of psychopaths.
This paper will survey the history of psychopathy Part I , the impact psychopaths have on the criminal justice system Part II , the traditional clinical assessments for psychopathy Part III , the emerging neuroimaging findings Part IV , and will finish with a discussion of recent treatment studies and their potential economic impacts Part V. They are, to over simplify, people without empathy or conscience. Psychopaths have appeared in a steady stream of literature from all cultures since humans first put pen to paper: No cultures, or stations, are immune.
One of the modern fathers of the clinical study of psychopathy, Hervey Cleckley, famously opined that the Athenian general Alcibiades was probably a psychopath. But psychopaths much more typically come from the ranks of the ordinary. These people were able to navigate the demands of modern society, despite having the same clinical constellations as their less-functioning brethren, including grandiosity, impulsivity, remorselessness and shallow affect.
Predators-Killers Without A Conscience
These functioning psychopaths have become the objects of much recent attention. Although in this article we will focus on research efforts in the U. Psychopaths also appear in existing preindustrial societies, suggesting they are not a cultural artifact of the demands of advancing civilization but have been with us since our emergence as a species. While the capacity to identify with the thoughts and feelings of fellow human beings undoubtedly has innumerable cultural variations, it is beginning to be clear that evolution has built into the human brain a central core of moral reasoning that is more or less universal.
Psychopaths have hidden from psychiatry too. Well into the eighteenth century, medicine recognized only three broad classes of mental illness: Even today, the bible of diagnostic psychiatry—the Diagnostic and Statistical Manual of Mental Disorders DSM does not formally recognize psychopathy, but uses instead the largely subsuming diagnosis of antisocial personality disorder ASPD.
But as discussed in more detail below, 34 it has since become clear, if it was not at the time, that in their efforts to compromise the authors of the DSM missed the psychopathic mark. And yet, even though psychopathy has never fit comfortably into the psychiatric pigeonholes du jour, clinicians have long been noticing and documenting their encounters with people whose perceptive and logical faculties seemed entirely intact, but who nevertheless seemed profoundly incapable of making moral choices.
The term psychopathy comes from the German word psychopastiche , the first use of which is generally credited to the German psychiatrist J. Koch in , 39 and which literally means suffering soul. The term gained clinical traction through the first third of the s, but for a time was replaced by sociopathy, which emerged in the s. The two terms were often used interchangeably by clinicians and academics. Sociopathy was preferred by some because the lay public sometimes confused psychopathy with psychosis. In contrast, psychopathy evoked a deeper genetic, or at least developmental, cause.
The causes of psychopathy, like the causes of most complex mental disorders, are not well understood. There is a growing body of evidence, including the research discussed in Part IV of this article, showing that psychopathy is highly correlated to aberrant neuronal activity in specific regions of the brain. Those neurological causes are in turn almost certainly either genetic or the product of very early developmental problems.
This is just one example of the nature versus nurture gnarl endemic to the larger question of why humans behave the way they do. Psychopathy is a particularly good example of why it is so difficult to tease out these causative influences. There are studies galore that correlate the neglect and abuse of children to those children growing up with increased risks of depression, suicide, violence, drug abuse and crime. On the contrary, a paper Hare and his colleagues presented in shows that on average there is no detectable difference in the family backgrounds of incarcerated psychopaths and non-psychopaths.
There is also evidence that even if young psychopaths cannot be cured, the environment in which they grow up is highly correlated to whether they will become criminal psychopaths or the kind of psychopaths who avoid crime and manage to function among us. Many psychiatrists at the turn of the century were uncomfortable with general descriptions of psychopathy as a lack of moral core.
Such labels seemed more judgmental than scientific, a concern that no doubt touched a nerve of a young discipline already self-conscious about its early descriptive excesses and empirical voids. Psychiatrists like Henry Maudsley in England and J. Koch in Germany began thinking and writing about more comprehensive ways to describe the condition.
But in exchange for more theoretical diagnostic clarity, the so-called German School of psychopathy expanded the diagnosis to include people who hurt themselves as well as others, and in the process seemed to lose sight of the moral disability that was at the core of the condition. By the time of the Great Depression, psychiatry was using the word psychopath to include people who were depressed, weak-willed, excessively shy and insecure—in other words, almost anyone deemed abnormal.
This began to change in the late s and early s, largely as the result of the work of two men, the Scottish psychiatrist David Henderson and the American psychiatrist Hervey Cleckley. In it, Henderson focused on his observations that the psychopath is often otherwise perfectly normal, perfectly rational, and perfectly capable of achieving his abnormal egocentric ends. Another organic difficulty with the notion of including psychopathy in a diagnostic and treatment manual is that these manuals were never designed for forensic use. The DSM, first published in , dealt with the problem under the category Sociopathic Personality Disturbance, and divided this category into three diagnoses: In , the DSM-II lumped the two diagnoses together into the single category of antisocial personality, retaining both affective and behavioral criteria.
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It was too broad because by fixing on behavioral indicators rather than personality it encompassed individuals with completely different personalities, many of whom were not psychopaths. It was also too narrow because it soon became clear that the diagnostic artificiality of this norm-based version of ASPD was missing the core of psychopathy. In the meantime, beginning in the s, some clinicians began to rethink a working clinical definition of psychopathy.
SV , 61 and in Hare coauthored the Psychopathy Checklist: They combine affective criteria Factor 1 and socially deviant criteria Factor 2 but do so with detailed rules for measuring those criteria to create a diagnostic score that has proven validity and high interrater reliability. Thus, ASPD-targeted treatment will do a good job of reaching prisoners with deviance trait disorders, including a large slice of psychopaths, but will miss almost half with Factor 1 affective disorders. Figure 2 depicts the comorbidity of substance abuse and psychopathy for incarcerated populations, again using the Hare definition of psychopathy.
Notice that the psychopaths with drug and alcohol problems make up a little less than half of all the incarcerated psychopaths. Psychopaths generally recidivate because they are psychopaths, not because they have drug problems. The Hare instruments have proved to be extremely useful, and, as discussed in more detail in Part II below, they are the gold standard for the clinical diagnosis of psychopathy. They have been translated into a dozen languages, and are used around the world.
The debate remains robust, 67 though, like many issues with psychopathy, is asymmetric. There are dozens of peer-reviewed papers published each year that validate the assessment of psychopathy using the Hare criteria, but very few arguing that ASPD is the better diagnostic tool. The roots of this continuing, if decelerating, debate lie not only in the historical skepticism of describing a condition in moral, seemingly judgmental, terms, and in continuing doubts about the reliability of detecting the affective traits, but also in the problem of diagnostic tautology.
Academic psychiatry is justifiably troubled by diagnostic criteria that include too many behavioral components. It is theoretically unsettling to define a condition as a mental disorder just because it is has been declared to be antisocial by the legal system. The law has treated psychopathy with the same benign neglect as psychiatry has, and for much longer. An institution dedicated to the regulation of social behaviors hardly could excuse a general class of miscreants simply because, well, they are miscreants.
The law attributes all antisocial acts, psychopathic or no, to the same forces it attributes all acts of people whose reason is sufficiently intact to be presumed to have free will: It has never recognized that people whose central disability is that they chronically make antisocial choices should be excused for those antisocial behaviors. On the contrary, the persistently bad arguably should be punished more than the occasionally bad. This is the very difference between good people doing bad things, mad people doing bad things, and bad people doing bad things.
Reflecting these deep and long-standing notions of responsibility, in the American Law Institute adopted what has become known as the caveat paragraph in its definition of insanity, crafted specifically to exclude defenses smacking of psychopathy: The idea that psychopathy could be an excusing condition appears to be as dead a letter as there ever is in law.
And yet this dead letter seems to be stirring a bit in the academy. As we are coming to learn that moral cognition is not a tabula rasa, but has some deeply rooted evolutionary and neurological attributes, 75 some legal scholars have argued that those who lack that moral core might, at the extreme, be no more responsible for their immorality than those who lack the cognitive ability to perceive the world with sufficient accuracy to allow their reason to guide them through it.
The law has always recognized that if John kills Miriam by squeezing her neck, but in fact thinks he is squeezing a lemon, he cannot be held legally responsible for her death. But there is a slightly more complicated, and more common, defect in reasoning that the criminal law recognizes as an excusing condition. This, in short form, is the insanity defense. If it were true that there was a massive Tory plot to kill him, then his preemptive strike on the Tory prime minister made perfect sense, and he was able to perform step-by-step all the logical acts necessary to accomplish his goal.
Once we recognize that the key to criminal responsibility is rationality, and a sufficiently rich kind of rationality not only to navigate the perceived world but also to perceive it with reasonable accuracy, then what about psychopaths? They are certainly rational in the narrow sense of being able to determine their best interest and to navigate in the world to achieve that interest. In fact, in some sense they are hyperrational. They consider only their self-interest and they are masters, at least in the short run, of manipulating the world to those interests.
But do they perceive the world with sufficient accuracy to be held responsible for their highly rational manipulations of it? In the end, of course, this is a policy question that requires lawmakers to make a myriad of judgments. On the one hand, it is difficult to justify a system whose entire function is to punish those who incorrectly balance their self-interest against their social duty, if the system is completely insensitive to a whole class of people who do not even own an internal balance.
If I am a psychopath, the question is not whether the advantages of a given act under consideration outweigh or otherwise justify the harm I will cause to other people, it is whether I should help myself to what I perceive is a cost-free benefit. Other people are not even on my radar.
But the counter arguments are just as powerful. First, of course, the criminal law is a strategic enterprise, and whenever it recognizes exceptions to blameworthiness it can count on people faking the excusing conditions. This has forced the law to recognize only a few narrow exceptions to responsibility—only those that resonate with its original recognition that lunatics, imbeciles, and children are not legally responsible, and even then, more modernly, only when the clinical sciences can speak with at least some degree of reliability about the excusing conditions.
If psychiatry, despite all of its waxing and waning efforts and compromises, will still not recognize psychopathy as a formal diagnosis apart from ASPD, you can be sure the law will not recognize it as an excuse. Psychopaths are not deluded at all about the external world except their relative importance in it , and they certainly do not lack free will; their will is in fact too free.
Every person who commits a crime has, by definition, failed to resist committing it. Perhaps most significantly, how can the system morally punish those of us who on occasion breach the social contract, sometimes for our own gain and sometimes not, but forgive a whole category of criminals who breach it all the time for their own gain? What would a judge say to a defendant about to be sentenced to prison for 10 years for selling crack after sending a serial killer merely to the hospital to cure his psychopathy?
This debate, robust in the academy, has not yet gained the attention of the law, which, with a few tangential and relatively recent exceptions, continues to ignore the psychopath. Just as it grossly distorts our recidivism statistics, psychopathy grossly distorts our sense of the extent to which our fellow man is willing to be antisocial. Psychopathy dumbs down the moral integrity of us all, precisely because we do not recognize that so many serious violations are being committed by so few.
All these doctrines, to be sure, have a disproportionate impact on psychopaths because psychopaths disproportionately recidivate and disproportionately commit sex crimes. But they are not specifically targeted at psychopaths. Interestingly, the English have historically treated psychopathy more openly, at least theoretically.
For example, English psychopaths who are getting treatment, either as hospital outpatients or as individual psychiatric patients, are specifically excused from jury duty. That is, psychopaths in England are not being targeted for civil commitment; they get into the system just like all others do—by committing crimes and then getting diverted to civil commitment. In any event, it seems problematic at best, and arguably immoral, for any government to hold psychopaths under some claimed medical regimen until their disorder is treated, when the widely held view has been that there is no effective treatment.
American law has continued to ignore psychopathy, creating the over- and underinclusive category of sexually violent predator to allow the commitment at least of some sexual psychopaths, even after their criminal sentences are completed. The English have been more direct in defining psychopathy as a stand-alone mental condition justifying commitment, but then have backed off as a practical matter in actually committing psychopaths qua psychopaths under their laws.
To qualify as a psychopath under the Hare standards, a subject must exhibit a sufficient number of the Factor 1 and Factor 2 criteria. Those criteria are shown in Table 1. The Hare instrument requires the clinician to give a score on each of these criteria of 0 item does not fit , 1 item fits somewhat or 2 item definitely fits. Thus, the minimum score is zero and the maximum Hare himself defined psychopathy as a score of 30 or more, which will exclude most individuals with ASPD unless the subject also exhibits a number of interpersonal and affective traits.
Typical group studies break down the Hare scores into the low 20 and below , moderate 21—29 and high 30 and above ranges. Studies also examine whether the different models of psychopathy 88 are related to forensic issues that is, risk assessment and neurobiology. Like all diagnostic criteria for mental disorders, the devil is in the details of the clinical evaluation and in the training of the examining clinicians.
The typical Hare evaluation takes between two and six hours, over one or two separate interviews.
Without Conscience
The Factor 1, or affective criteria, have been widely documented and analyzed in the context of other mental disorders, but the Factor 2 criteria—the behavioral criteria—warrant further discussion. It is extremely common for psychopaths to need virtually constant stimulation. They rarely if ever can sit and read, or even sit and watch television. As one might imagine, such a trait does not mix well with the tedium of prison. If things are not happening around them, psychopaths often will make them happen. Their need for stimulation and their impulsivity drive many of the other Factor 2 criteria, including their sexual promiscuity, their inordinate number of marriages, and even their criminal versatility.
Psychopaths are notoriously parasitic. One incarcerated psychopath reported to our investigators that his mom and dad were always supportive, always ready to help him out and always had some money around that he could borrow. The letter explained that the family, with agony, had decided on this course after 20 years of being deceived and manipulated by their son. They decided they no longer wanted him in their lives.
Anger is never far from the surface in the psychopath. A perplexing aspect of that anger, particularly to the victims, is that the aggression is often over trivialities. Psychopathy does not show up unannounced at the door of adulthood. There are always early signs of it, which is why the Factor 2 list includes early behavioral problems and juvenile delinquency among its diagnostic criteria.
The typical incarcerated psychopath has a long criminal career stretching back into the juvenile courts, often with serious and violent juvenile adjudications. Recidivism statistics are discussed at length below, 92 but a short vignette may put a more personal touch on the numbers. When the scientist-author was at the University of British Columbia in Vancouver, he and his fellow graduate students worked with psychopathic prisoners.
One of the prisoner-psychopaths constantly walked around with a car mechanics book under his arm and constantly talked about how he was planning to go to a car mechanics school in the interior of British Columbia when he was released. Coincidentally, on the very morning this man was released, the scientist-author was driving to the prison and saw him, still carrying his car repair manual under his arm, on his way to the bus stop.
There were two buses waiting outside the prison—one headed east to his car mechanics school and the other headed west to Vancouver. He looked at both buses, then casually dropped his car repair book in the trash and jumped on the bus to Vancouver. Two weeks later, the scientist-author was doing his rounds at the prison recruiting new volunteers for research when he came across the same inmate. Consequently, we need to move cautiously, but we still need to move.
The Hare instruments are reliable enough to be used to identify the most severe psychopaths in the system, both to manage them appropriately and insure that treatment efforts are guided by the best possible practices. Since group therapy is so common in prison settings, it will be critical for prison officials to be able to distinguish non-psychopaths, for whom such treatment might be effective, from psychopaths, for whom it might be contraindicated.
The psychopath has had and continues to have a grossly disproportionate impact at virtually every point in the criminal justice system. There is no other variable that is more highly correlated to being in prison than psychopathy.
Without Conscience: The Disturbing World of the Psychopaths Among Us
Substance abuse, for example, on which our corrections systems have spent untold trillions, is a distant second. When one looks at violent crimes as opposed to any crime landing a person in prison, psychopathy continues to be impressively predictive. For psychopaths, their propensity to engage in sexual and nonsexual violence seems to decrease very little with age. The correlation between high scores on the Hare scale and prison exists even at scores well below the arbitrary cutoff of All prisoners, psychopathic and not, tend to have much higher scores on the Hare scale than non-incarcerated males, which is not surprising given the tautological nature of some of the Factor 2 criteria.
The general nonprison population scores a median of 6. After a psychopath has been sentenced to prison but before the adult system labels him incorrigible, data suggests that he is more likely to be released early than his non-psychopathic cohorts despite a typically long and uninterrupted juvenile record. In a study published in January , Stephen Porter and his colleagues examined the files of male offenders serving at least two years in a Canadian prison between and Once released, psychopaths are much more likely to recidivate than non-psychopaths.
Canadian studies have been most instructive on this issue because the Canadian federal government keeps national recidivism statistics. In a study, Canadian researchers identified a group of prisoners about to be released, gave them all clinical assessments for psychopathy using the Hare instrument, divided them into low, moderate and high categories of psychopathy based on their Hare score, and then followed them for three years.
Recidivism Among Psychopaths The recidivism patterns are similar if we look only at violent recidivism Figure 4 or, even more narrowly, violent sexual recidivism Figure 5. Violent Recidivism Among Psychopaths Violent Sexual Recidivism Among Psychopaths The picture is almost as bad for violent sexual recidivism. Psychopathy is a significant predictor of sexual violence. Psychopathic traits in youths have also been shown to predict high recidivism. Figure 6 shows the results from a study by Vincent et al. Violent Recidivism Juvenile Offenders The average psychopath is back and forth to prison three times before the average non-psychopath with the same sentence makes it back once.
Many of the following statistics will be familiar to readers steeped in the public policy of crime control; they are visited here in an attempt to tease out the costs associated only with psychopathy. How do the social costs of other conditions high in the public consciousness compare with the criminal costs of psychopathy? They all pale in comparison. Given the grossly disproportionate contribution that psychopaths make to the exploding costs of our criminal justice and correctional systems, one might expect that criminologists and corrections officials would be very interested in reducing the recidivism of psychopaths.
Alas, psychopath being a synonym for incorrigible, psychopaths have been not been the objects of sustained treatment efforts either in or out of prison. Given the neuroscience and therapeutic discoveries discussed in the next two sections, perhaps this neglect may soon come to an end. Psychopathy has been just as elusive to neuroscientists as to everyone else, and for the same reasons. Much work has been done identifying the neurobiology of violence, showing a strong genetic component as well as a robust interaction between early childhood trauma to the frontal lobes and the emotional effects of abuse.
As one neuroscientist writing about psychopathy has said:. When we attempt to focus on the psychopath, we find various difficulties. Most large-scale studies are based on behaviors childhood aggression, criminal arrests, etc. This point is crucial, as the majority of aggressive individuals or even convicted criminals are not psychopaths, even though committing criminal acts is needed to fulfill definitions for either antisocial personality disorder or psychopathy.
For example, Antonio Damasio and his colleagues published anecdotal cases of lesions to the inferior and medial surfaces of the frontal lobes that produced apparent psychopathic behaviors. But even as late as the s, the neurological hallmarks of psychopathy remained unclear, and there were no hallmarks that came close to being reliable enough to be diagnostic. Moreover, the hypothesis that psychopathy was generally a reflection of reduced frontal lobe activity seemed to conflict with a long-standing series of studies that began in the s showing that psychopaths in fact have greater than normal frontal EEG signals, both waking and sleeping.
Static images of brain morphology tell only the tiniest part of the story. Seeing brains functioning as they navigate social problems has shown us, with remarkable reliability, that psychopathic brains cannot navigate those problems. Like muscles, neurons consume oxygen when they are working.
I. A BRIEF HISTORY OF PSYCHOPATHY
The MRI can be tuned to locate regions in the brain where oxygen is being recruited. In a typical fMRI study, researchers present subjects with stimuli—videos, pictures, sounds or words—while the subjects are lying in the MRI scanner. The regions of the brain that are engaged with processing the given stimuli are mapped, and brains faced with the stimuli are compared with brains at a resting state.
FMRI involves many technical and statistical processes, and significant training is required to understand its strengths, weaknesses and limitations. Nevertheless, fMRI provides an unprecedented opportunity to study clinical disorders in general and psychopathy in particular. In , the first study to use fMRI to study the brains of criminal psychopaths was published; this study is discussed in detail below. It is difficult to find psychopaths and expensive and time-consuming to administer the Hare instruments to them. Statistically, one of the best places to find psychopaths is in prisons.
But prisons typically have no MRI equipment, so early investigators had to transport psychopathic prisoners to and from prisons to local hospitals. The logistics, cost, and security issues associated with such arrangements kept the subject numbers on these studies low. In collaboration with the New Mexico Corrections Department that equipment is brought to the prisoners rather than the other way around.
In the first three years of deployment, more than 1, inmates volunteered to participate in fMRI studies. This collection of brain scans is the largest forensic brain imaging database in the world. The fMRI data shows a robust and persistent pattern of abnormal brain function in psychopaths: These are the regions generally below the neocortex, including and adjacent to the limbic structures, as shown in Figure 7.
The Paralimbic System The paralimbic regions form a kind of girdle surrounding the medial and basal aspects of the two hemispheres. They contain many important structures, including the anterior temporal cortex, ventromedial prefrontal cortex, amygdala, insula, temporal pole and cingulate, many of which are associated with moral reasoning, affective memory and inhibition, exactly the kinds of puzzle pieces one would expect might be involved in psychopathy. In the moral reasoning task, 72 incarcerated subjects, of whom 16 were psychopaths with Hare scores of 30 or greater, were shown a series of pictures and asked to rate them on a scale of 1 to 5 for moral violation, 1 being no moral violation and 5 being severe moral violation.
Behaviorally there was no significant difference between the ability of psychopaths and non-psychopaths to recognize the moral content of these scenarios. Compared with non-psychopaths, psychopaths showed decreased activation in the right posterior temporal cortex and increased activation in the amygdala, two areas well known to be associated with moral reasoning.
Moral Decision Making in Psychopaths A simple word recognition test was used for the affective memory study. They then were shown additional lists of words and asked whether the additional words were on the original memorized list. Different word lists are presented over the course of the study. Some of the words on the lists were negative in affective content words including misery, blood, frown, scar, wreck and some neutral words including gallon, oat, brass, card.
It is well established that unimpaired people are better at remembering words that have an emotional content than they are at remembering words with no emotional content. Researchers have also known for some time that psychopaths remember emotional words just as well as non-psychopaths do, even though it takes psychopaths longer to recognize the emotional content of the words.
But this study showed those memories seem to take a very different path in psychopathic brains than they do in non-psychopathic brains. Prisoner-psychopaths showed greatly reduced activations in the amygdala and posterior cingulate, somewhat reduced activations in the ventral striatum and anterior cingulate, and greatly increased activation in the frontal gyrus.
That is, they showed reduced activity in paralimbic regions—amygdala, anterior and posterior cingulate—and increased activity in the lateral frontal cortex, an area typically associated with cognition, not emotion. The figure shows the rendering of the neural areas in which criminal psychopaths showed significantly less affect-related activity than noncriminal control subjects for the comparison of affective words versus neutral words of an affective memory task.
Also shown are the regions in which criminal psychopaths showed greater affect-related activity than noncriminal control subjects and criminal non-psychopaths bottom panels; depicted in gray scale; see Kiehl et al. These regions include bilateral inferior frontal gyrus.
In turns out that the regions of the brain involved in inhibition overlap the paralimbic regions, primarily the anterior and posterior cingulate. Both adults and juveniles high in psychopathic traits exhibited dramatically decreased activity in these inhibitory regions. Putting these results together begins to paint a picture of the psychopathic brain as being markedly deficient in neural areas critical for three aspects of moral judgment: Along with several other researchers, we have demonstrated that each of these tasks recruits areas in the paralimbic system, and that those precise areas are the ones in which psychopaths have markedly reduced neural activity compared with non-psychopaths.
What does all this mean? First, it suggests that the story of psychopathy is largely limbic and paralimbic rather than prefrontal. He is missing the moral core, a core that appears intimately involved with the paralimbic regions. If the key to psychopathy lies in these lower regions, then it is no mystery that the psychopath is able to recruit his higher functions to navigate the world. In fact, when he gives a moral response, it seems the psychopath must recruit frontal areas to mimic his dysfunctional paralimbic areas.
That is, the psychopath must think about right and wrong while the rest of us feel it. Second, these neurological results should go a long way toward ending the debate about whether psychopathy is just too difficult to diagnose to justify inclusion in the DSM. Any lingering doubts about the clinical reliability of the Hare instruments disappear now that those instruments have been shown to be robustly predictive of a demonstrable neurological condition. Third, and perhaps more significantly, these imaging techniques may help us identify and then understand the development of psychopathic traits in juveniles.
It is difficult, and controversial, to assess psychopathic traits in young people. No one wants the label psychopath to become self-fulfilling, especially given the hopeful treatment possibilities discussed in Part V. Brain imaging may help us improve our understanding of the developmental trajectories of these traits in ways that might improve treatment. Still, caution is in order. Neuroimaging has its own embedded limitations, making the reliability of conclusions based on imaging data a complex and still developing story. One also might argue that these results support the position that psychopathy should be an excusing condition.
We have known forever that psychopaths are rational yet persistently immoral. The received dogma has been that psychopathy is untreatable, based on study after study that seemed to show that the behaviors of psychopaths could not be improved by any traditional, or even nontraditional, forms of therapy. Nothing seems to have worked—psychoanalysis, group therapy, client-centered therapy, psychodrama, psychosurgery, electroshock therapy or drug therapy —creating a largely unshakable belief among most clinicians and academics, and certainly among lay people, that psychopathy is untreatable, though as we will discuss below few if any of these studies were properly controlled and designed.
Most talking therapies, at least, are aimed at patients who know, at one level or another, that they need help. Psychotherapy normally requires patients to participate actively in their own recovery. But psychopaths are not distressed; they typically do not feel they have any psychological or emotional problems, and are not only generally satisfied with themselves but see themselves as superior beings in a world of inferior ones.
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Clinicians report that psychopaths go through the therapeutic motions and are incapable of the emotional insights on which most talking therapy depends. No one yet knows how to restore the paralimbic functions that seem so impaired in psychopathy. Treatment not only seems not to work, there is evidence that some kinds of treatment make matters worse.
In a famous study of incarcerated psychopaths about to be released from a therapeutic community, those who received group therapy actually had a higher violent recidivism rate than those who were not treated at all. They teach you how to put the squeeze on people. But all treatment hope for psychopaths is not lost. Like many mental health treatment efforts, prior efforts to treat psychopaths, as well intentioned and numerous as they have been, have almost never been designed to meet acceptable scientific and methodological standards.
Even the better studies typically involved moderate rather than intense treatment, and over relatively short durations. And of course one of the self-defeating aspects of these studies is that the psychopaths themselves often become disruptive in therapeutic settings not designed to deal with such levels of disruption. The good news about all this bad science is that maybe something does, in fact, work. There may be some room for some thoughtful, targeted, well-designed, and controlled treatment efforts—efforts that might even prove effective, especially with juveniles.
In a landmark metastudy focused on the treatment of juveniles with psychopathic tendencies, Mark Lipsey and David Wilson concluded that, although the reported treatment outcomes were not encouraging, pieces of many different studies might be. Inspired by Lipsey and Wilson, Michael Caldwell and his colleagues at the Mendota Juvenile Treatment Center in Madison, Wisconsin and the University of Wisconsin, reviewed the treatment literature in detail, noticed all of its failings and promises, and decided to design a specific treatment program for psychopathic juvenile offenders.
Early results were encouraging. This pilot study suggested that Lipsey and Wilson might be right—that treatment might work if juvenile psychopaths are treated early enough, intensely enough and for long enough. But of course the numbers, though promising, were extremely small. Caldwell and his colleagues subsequently conducted a larger follow-up study. In the latest published study, Caldwell and his colleagues followed 86 maximum security juvenile offenders in the Mendota center, and again looked at arrest recidivism, this time four years out.
All of these quantitative measures were analyzed and correlated. Caldwell and his group reached several conclusions. The best predictor of reductions in institutional misconduct and recidivism was the length of the decompression treatment. Short-term treatment seemed to have no effect. But long-term treatment, lasting up to and beyond one year, significantly reduced both institutional misconduct and recidivism, at least for the subjects scoring 31 and less on the Hare instruments. These results are just the first shots across the bow of the conventional wisdom that psychopaths are incorrigible.
But they are nevertheless very encouraging, not only because of the poor results of past studies but also because psychopathy is such a big problem that even a small and costly improvement is likely to be cost effective.