Psychopathy

Not to be confused with Psychosis, Psychopathology, Psychic, or Sycophancy.

"Psychopaths" and "Psychopath" redirect here. For other uses, see Psychopath (disambiguation).

"Sociopathy" and "Sociopath" redirect here. For another usage of these terms, see Antisocial personality disorder.

Psychopathy
Pronunciation	/saɪˈkɒpəθi/
Specialty	Psychiatry, clinical psychology, criminology
Symptoms	Boldness, superficial charm, antisocial behavior, lack of empathy or remorse, inclination to violence and psychological manipulation, impulsivity, narcissism
Causes	Genetic factors, experiencing neglect or maltreatment
Risk factors	Family history, adverse environmental stressors
Differential diagnosis	Antisocial personality disorder, narcissistic personality disorder, sexual sadism disorder, psychosis, other psychotic disorders such as schizophrenia, schizotypal disorder, schizoaffective disorder
Prevention	Proper care of children
Treatment	Very few accepted treatments; use of psychotherapy is accepted, though benefits are weak
Medication	None
Prognosis	Poor

Psychopathy, or psychopathic personality, is a personality construct characterized by impaired empathy and remorse, and persistent antisocial behavior, along with bold, disinhibited, and egocentric traits. These traits are often masked by superficial charm and immunity to stress, which create an outward appearance of normality.

Hervey M. Cleckley, an American psychiatrist, influenced the initial diagnostic criteria for antisocial personality reaction/disturbance in the Diagnostic and Statistical Manual of Mental Disorders (DSM), as did American psychologist George E. Partridge. The DSM and International Classification of Diseases (ICD) subsequently introduced the diagnoses of antisocial personality disorder (ASPD) and dissocial personality disorder (DPD), respectively, stating that these diagnoses have been referred to (or include what is referred to) as psychopathy or sociopathy. The creation of ASPD and DPD was driven by the fact that many of the classic traits of psychopathy were impossible to measure objectively. Canadian psychologist Robert D. Hare later re-popularized the construct of psychopathy in criminology with his Psychopathy Checklist.

Although no psychiatric or psychological organization has sanctioned a diagnosis titled "psychopathy", assessments of psychopathic characteristics are widely used in criminal justice settings in some nations and may have important consequences for individuals. The study of psychopathy is an active field of research. The term is also used by the general public, popular press, and in fictional portrayals of psychopaths. While the abbreviated term "psycho" is often employed in common usage in general media along with "crazy", "insane", and "mentally ill", there is a categorical difference between psychosis and psychopathy.

Definition

Concepts

Psychopaths are social predators who charm, manipulate, and ruthlessly plow their way through life, leaving a broad trail of broken hearts, shattered expectations, and empty wallets. Completely lacking in conscience and in feelings for others, they selfishly take what they want and do as they please, violating social norms and expectations without the slightest sense of guilt or regret.

— Robert D. Hare, 1993, p. xi

There are multiple conceptualizations of psychopathy, including Cleckleyan psychopathy (Hervey Cleckley's conception entailing bold, disinhibited behavior, and "feckless disregard") and criminal psychopathy (a meaner, more aggressive and disinhibited conception explicitly entailing persistent and sometimes serious criminal behavior). The latter conceptualization is typically used as the modern clinical concept and assessed by the Psychopathy Checklist. The label "psychopath" may have implications and stigma related to decisions about punishment severity for criminal acts, medical treatment, civil commitments, etc. Efforts have therefore been made to clarify the meaning of the term.

It has been suggested that those who share the same emotional deficiencies and psychopathic features, but are properly socialized, should not be designated as 'psychopaths'.

The triarchic model suggests that different conceptions of psychopathy emphasize three observable characteristics to various degrees. Analyses have been made with respect to the applicability of measurement tools such as the Psychopathy Checklist (PCL, PCL-R) and Psychopathic Personality Inventory (PPI) to this model.

• Boldness. Low fear including stress-tolerance, toleration of unfamiliarity and danger, and high self-confidence and social assertiveness. The PCL-R measures this relatively poorly and mainly through Facet 1 of Factor 1. Similar to PPI fearless dominance. May correspond to differences in the amygdala and other neurological systems associated with fear.
• Disinhibition. Poor impulse control including problems with planning and foresight, lacking affect and urge control, demand for immediate gratification, and poor behavioral restraints. Similar to PCL-R Factor 2 and PPI impulsive antisociality. May correspond to impairments in frontal lobe systems that are involved in such control.
• Meanness. Lacking empathy and close attachments with others, disdain of close attachments, use of cruelty to gain empowerment, exploitative tendencies, defiance of authority, and destructive excitement seeking. The PCL-R in general is related to this but in particular some elements in Factor 1. Similar to PPI, but also includes elements of subscales in impulsive antisociality.

Psychopathy has been conceptualized as a hybrid condition marked by a paradoxical combination of superficial charm, poise, emotional resilience, and venturesomeness on the outside but deep-seated affective disturbances and impulse control deficits on the inside. From this perspective, psychopathy is at least in part characterized by psychologically adaptive traits. Furthermore, according to this view, psychopathy may be linked to at least some interpersonally successful outcomes, such as effective leadership, business accomplishments, and heroism.

Measurement

An early and influential analysis from Harris and colleagues indicated that a discrete category, or taxon, may underlie PCL-R psychopathy, allowing it to be measured and analyzed. However, this was only found for the behavioral Factor 2 items they identified, child problem behaviors; adult criminal behavior did not support the existence of a taxon. Marcus, John, and Edens more recently performed a series of statistical analyses on PPI scores and concluded that psychopathy may best be conceptualized as having a "dimensional latent structure" like depression.

Marcus et al. repeated the study on a larger sample of prisoners, using the PCL-R and seeking to rule out other experimental or statistical issues that may have produced the previously different findings. They again found that the psychopathy measurements do not appear to be identifying a discrete type (a taxon). They suggest that while for legal or other practical purposes an arbitrary cut-off point on trait scores might be used, there is actually no clear scientific evidence for an objective point of difference by which to label some people "psychopaths"; in other words, a "psychopath" may be more accurately described as someone who is "relatively psychopathic".

The PCL-R was developed for research, not clinical forensic diagnosis, and even for research purposes to improve understanding of the underlying issues, it is necessary to examine dimensions of personality in general rather than only a constellation of traits. The PCL-R test has been used to determine "true" or primary psychopaths (individuals that score a 30 or higher on the PCL-R test). Primary psychopaths are distinguished from secondary psychopaths, and contrast with those who are legitimately considered antisocial.

Personality dimensions

Studies have linked psychopathy to alternative dimensions such as antagonism (high), conscientiousness (low), and anxiousness (low).

Psychopathy has also been linked to high psychoticism—a theorized dimension referring to tough, aggressive, or hostile tendencies. Aspects of this that appear associated with psychopathy are lack of socialization and responsibility, impulsivity, sensation-seeking (in some cases), and aggression.

Otto Kernberg, from a particular psychoanalytic perspective, believed psychopathy should be considered as part of a spectrum of pathological narcissism, that would range from narcissistic personality on the low end, malignant narcissism in the middle, and psychopathy at the high end.

Psychopathy, narcissism, and Machiavellianism, three personality traits that are together referred to as the dark triad, share certain characteristics, such as a callous-manipulative interpersonal style. The dark tetrad refers to these traits with the addition of sadism. Several psychologists have asserted that subclinical psychopathy and Machiavellianism are more or less interchangeable. There is a subscale on the Psychopathic Personality Inventory (PPI) dubbed "Machiavellian Egocentricity". Delroy Paulhus has asserted that the difference that most miss is that while both are characterized by manipulativeness and unemotionality, psychopaths tend to be more reckless. One study asserted that "the ability to adapt, reappraise and reassess a situation may be key factors differentiating Machiavellianism from psychopathy, for example". Psychopathy and Machiavellianism were also correlated similarly in responses to affective stimuli, and both are negatively correlated with the recognition of facial emotions. Many have suggested merging the dark triad traits (especially Machiavellianism and psychopathy) into one construct, given empirical studies that show immense overlap.

Criticism of current conceptions

The current conceptions of psychopathy have been criticized for being poorly conceptualized, highly subjective, and encompassing a wide variety of underlying disorders. Dorothy Otnow Lewis has written:

The concept and subsequent reification of the diagnosis "psychopathy" has, to this author's mind, hampered the understanding of criminality and violence. [...] According to Hare, in many cases one need not even meet the patient. Just rummage through his records to determine what items seemed to fit. Nonsense. To this writer's mind, psychopathy and its synonyms (e.g., sociopathy and antisocial personality) are lazy diagnoses. Over the years the authors' team has seen scores of offenders who, prior to evaluation by the authors, were dismissed as psychopaths or the like. Detailed, comprehensive psychiatric, neurological, and neuropsychological evaluations have uncovered a multitude of signs, symptoms, and behaviors indicative of such disorders as bipolar mood disorder, schizophrenia spectrum disorders, complex partial seizures, dissociative identity disorder, parasomnia, and, of course, brain damage/dysfunction.

Half of the Hare Psychopathy Checklist consists of symptoms of mania, hypomania, and frontal-lobe dysfunction, which frequently results in underlying disorders being dismissed. Hare's conception of psychopathy has also been criticized for being reductionist, dismissive, tautological, and ignorant of context as well as the dynamic nature of human behavior. Some have called for rejection of the concept altogether, due to its vague, subjective and judgmental nature that makes it prone to misuse. A systematic review determined that the PCL is weakly predictive of criminal behavior, but not of lack of conscience, or treatment and rehabilitation outcomes. These findings contradict widespread beliefs among professionals in forensics.

Psychopathic individuals do not show regret or remorse. This was thought to be due to an inability to generate this emotion in response to negative outcomes. However, a study found that psychopathic people experience regret but did not use the regret to guide their choice in behavior.

In an experiment published in March 2007 at the University of Southern California neuroscientist Antonio R. Damasio and his colleagues showed that subjects with damage to the ventromedial prefrontal cortex lack the ability to empathically feel their way to moral answers, and that when confronted with moral dilemmas, these brain-damaged patients coldly came up with "end-justifies-the-means" answers, leading Damasio to conclude that the point was not that they reached immoral conclusions, but that when they were confronted by a difficult issue – in this case as whether to shoot down a passenger plane hijacked by terrorists before it hits a major city – these patients appear to reach decisions without the anguish that afflicts those with typically functioning brains. According to Adrian Raine, a clinical neuroscientist also at the University of Southern California, one of this study's implications is that society may have to rethink how it judges immoral people: "Psychopaths often feel no empathy or remorse. Without that awareness, people relying exclusively on reasoning seem to find it harder to sort their way through moral thickets. Does that mean they should be held to different standards of accountability?"

Signs and symptoms

Socially, psychopathy typically involves extensive callous and manipulative self-serving behaviors with no regard for others and often is associated with repeated delinquency, crime, and violence. Mentally, impairments in processes related to affect and cognition, particularly social mental processes, have also been found. Developmentally, symptoms of psychopathy have been identified in young children with conduct disorder and suggest at least a partial constitutional factor that influences its development.

Primary features

There is disagreement over which features should be considered part of psychopathy, with researchers identifying around 40 traits supposedly indicative of the construct, though the following characteristics are almost universally considered central.

Core traits

In 2001, David J. Cooke and Christine Michie proposed a three-factor model of the Psychopathy Checklist-Revised, which has seen widespread application in other measures, such as the Youth Psychopathic Traits Inventory and Antisocial Process Screening Device.

• Arrogant and deceitful interpersonal style: impression management or superficial charm, inflated and grandiose sense of self-worth, pathological lying/deceit, and manipulation for personal gain.
• Deficient affective experience: lack of remorse or guilt, shallow affect (coldness and unemotionality), callousness and lack of empathy, and failure to accept responsibility for one's own actions.
• Impulsive and irresponsible lifestyle: impulsivity, sensation-seeking and risk-taking, irresponsible and unreliable behavior, financially parasitic lifestyle, and a lack of realistic, long-term goals.

Low anxiety and fearlessness

Hervey M. Cleckley's 1941 original description of psychopathy included the absence of nervousness and neurotic disorders, and later theorists referred to psychopaths as fearless or thick-skinned. While it is often claimed that the Psychopathy Checklist-Revised (PCL-R) does not include low anxiety or fearlessness, such features do contribute to the scoring of the Facet 1 (interpersonal) items, mainly through self-assurance, unrealistic optimism, brazenness, and imperturbability. Indeed, while self-report studies have been inconsistent using the two-factor model of the PCL-R, studies which separate Factor 1 into interpersonal and affective facets, more regularly show modest associations between Facet 1 and low anxiety, boldness and fearless dominance (especially items assessing glibness/charm and grandiosity). When both psychopathy and low anxiety/boldness are measured using interviews, both interpersonal and affective facets are both associated with fearlessness and lack of internalizing disorders.

The importance of low anxiety/fearlessness to psychopathy has historically been underscored through behavioral and physiological studies showing diminished responses to threatening stimuli (interpersonal and affective facets both contributing). However, it is not known whether this is reflected in the reduced experience of state fear or where it reflects impaired detection and response to threat-related stimuli. Moreover, such deficits in threat responding are known to be reduced or even abolished when attention is focused on the threatening stimuli.

Offending

Criminality

Psychopathy is strongly correlated with crime, violence, and antisocial behavior.

In terms of simple correlations, the PCL-R manual states that an average score of 22.1 has been found in North American prisoner samples, and that 20.5% scored 30 or higher. An analysis of prisoner samples from outside North America found a somewhat lower average value of 17.5. Studies have found that psychopathy scores correlated with repeated imprisonment, detention in higher security, disciplinary infractions, and substance misuse.

Psychopathy, as measured with the PCL-R in institutional settings, shows in meta-analyses small to moderate effect sizes with institutional misbehavior, post-release crime, or post-release violent crime, with similar effects for the three outcomes. Individual studies give similar results for adult offenders, forensic psychiatric samples, community samples, and youth. The PCL-R is poorer at predicting sexual re-offending. This small to moderate effect appears to be largely due to the scale items assessing impulsive behaviors and past criminal history, which are well-established but very general risk factors. The aspects of core personality often held to be distinctively psychopathic generally show little or no predictive link to crime by themselves. For example, Factor 1 of the PCL-R and Fearless Dominance of the PPI-R have a smaller or no relationship to crime, including violent crime. In contrast, Factor 2 and Impulsive antisociality of the PPI-R are associated more strongly with criminality. Factor 2 has a relationship of similar strength to that of the PCL-R as a whole. The antisocial facet of the PCL-R is still predictive of future violence after controlling for past criminal behavior, which, together with results regarding the PPI-R, which by design does not include past criminal behavior, suggests that impulsive behaviors are an independent risk factor. Thus, the concept of psychopathy may be a poor fit when attempting to use it as a general theory of crime.

Violence

Studies have suggested a strong correlation between psychopathy scores and violence, and the PCL-R emphasizes features that are somewhat predictive of violent behavior. Researchers, however, have noted that psychopathy is dissociable from and not synonymous with violence.

It has been suggested that psychopathy is associated with "instrumental aggression", also known as predatory, proactive, or "cold-blooded" aggression, a form of aggression characterized by reduced emotion and conducted with a goal differing from but facilitated by the commission of harm. One conclusion in this regard was made by a 2002 study of homicide offenders, which reported that the homicides committed by homicidal offenders with psychopathy were almost always (93.3%) primarily instrumental, significantly more than the proportion (48.4%) of those committed by non-psychopathic homicidal offenders, with the instrumentality of the homicide also correlated with the total PCL-R score of the offender as well as their scores on the Factor 1 "interpersonal-affective" dimension. However, contrary to the equating of this to mean exclusively "in cold blood", more than a third of the homicides committed by psychopathic offenders involved some component of emotional reactivity as well. In any case, FBI profilers indicate that serious victim injury is generally an emotional offense, and some research supports this, at least concerning sexual offending. One study has found more serious offending by non-psychopathic offenders on average than by offenders with psychopathy (e.g., more homicides versus more armed robbery and property offenses), and another has found that the Affective facet of the PCL-R predicted reduced offense seriousness.

Studies on perpetrators of domestic violence find that abusers have high rates of psychopathy, with the prevalence estimated to be at around 15-30%. Furthermore, the commission of domestic violence is correlated with Factor 1 of the PCL-R, which describes the emotional deficits and the callous and exploitative interpersonal style found in psychopathy. The prevalence of psychopathy among domestic abusers indicates that the core characteristics of psychopathy, such as callousness, remorselessness, and a lack of close interpersonal bonds, predispose those with psychopathy to committing domestic abuse, and suggest that the domestic abuses committed by these individuals are callously perpetrated (i.e. instrumentally aggressive) rather than a case of emotional aggression and therefore may not be amenable to the types of psychosocial interventions commonly given to domestic abuse perpetrators.

Some clinicians suggest that assessment of the construct of psychopathy does not necessarily add value to violence risk assessment. A large systematic review and meta-regression found that the PCL performed the poorest out of nine tools for predicting violence. In addition, studies conducted by the authors or translators of violence prediction measures, including the PCL, show, on average, more positive results than those conducted by more independent investigators. Several other risk assessment instruments can predict future crime with an accuracy similar to that of the PCL-R, and some are considerably easier, quicker, and less expensive to administer. This may even be done automatically by a computer, based on data such as age, gender, number of prior convictions, and age at first conviction. Some of these assessments may also identify treatment changes and goals, identify quick changes that may help short-term management, identify more specific kinds of violence that may be at risk, and establish specific probabilities of offending for specific scores. Nonetheless, the PCL-R may remain popular for risk assessment due to its pioneering role and extensive research using it.

The U.S. Federal Bureau of Investigation (FBI) reports that psychopathic behavior is consistent with traits common to some serial killers, including sensation seeking, a lack of remorse or guilt, impulsivity, the need for control, and predatory behavior. It has also been found that the homicide victims of psychopathic offenders were disproportionately female in comparison to the more equitable gender distribution of victims of non-psychopathic offenders.

Sexual offending

Psychopathy has been associated with the commission of sexual crime, with some researchers arguing that it is correlated with a preference for violent sexual behavior. A 2011 study of conditional releases for Canadian male federal offenders found that psychopathy was related to more violent and non-violent offences, but not more sexual offences. For child molesters, psychopathy was associated with more offences. A study on the relationship between psychopathy scores and types of aggression in a sample of sexual murderers, in which 84.2% of the sample had PCL-R scores above 20 and 47.4% above 30, found that 82.4% of those with scores above 30 had engaged in sadistic violence (defined as enjoyment indicated by self-report or evidence) compared to 52.6% of those with scores below 30, and total PCL-R and Factor 1 scores correlated significantly with sadistic violence. Despite this, it is reported that offenders with psychopathy (both sexual and non-sexual offenders) are about 2.5 times more likely to be granted conditional release compared to non-psychopathic offenders.

Hildebrand and colleagues (2004) have uncovered an interaction between psychopathy and deviant sexual interests, wherein those high in psychopathy who also endorsed deviant sexual interests were more likely to recidivate sexually. A subsequent meta-analysis has consolidated such a result.

In considering the issue of possible reunification of some sex offenders into homes with a non-offending parent and children, it has been advised that any sex offender with a significant criminal history should be assessed on the PCL-R, and if they score 18 or higher, then they should be excluded from any consideration of being placed in a home with children under any circumstances. There is, however, increasing concern that PCL scores are too inconsistent between different examiners, including in its use to evaluate sex offenders.

Other offending

See also: § In the workplace

The possibility of psychopathy playing a role within organized crime, economic crime, and war crimes has been considered. Terrorists are sometimes considered psychopathic, and comparisons may be drawn with traits such as antisocial violence, a selfish worldview that precludes the welfare of others, a lack of remorse or guilt, and blame externalization. However, John Horgan, author of The Psychology of Terrorism, argues that such comparisons could also then be drawn more widely: for example, to soldiers in wars. Coordinated terrorist activity requires organization, loyalty, and ideological fanaticism often to the extreme of sacrificing oneself for an ideological cause. Traits such as a self-centered disposition, unreliability, poor behavioral controls, and unusual behaviors may disadvantage or preclude psychopathic individuals from conducting organized terrorism.

It may be that a significant portion of people with psychopathy are socially successful and tend to express their antisocial behavior through more covert avenues, such as social manipulation or white collar crime. Such individuals are sometimes referred to as "successful psychopaths" and may not necessarily always have extensive histories of traditional antisocial behavior as characteristic of traditional psychopathy.

Childhood and adolescent precursors

The PCL:YV is an adaptation of the PCL-R for individuals aged 13–18 years. Like the PCL-R, it needs to be administered by a trained rater and proceeds based on an interview of the subject and examination of relevant criminal and other records. The "Antisocial Process Screening Device" (APSD) is also an adaptation of the PCL-R. It can be administered by parents or teachers for individuals aged 6–13 years. High psychopathy scores for both juveniles (as measured with these instruments) and adults (as measured with the PCL-R and other measurement tools) have similar associations with other variables, including similar ability in predicting violence and criminality. Juvenile psychopathy may also be associated with more negative emotionality such as anger, hostility, anxiety, and depression. Psychopathic traits in youth typically comprise three factors: callousness or apathy, narcissism, and impulsivity or irresponsibility.

There is a positive correlation between early (before age 5) negative life events and the emotion-based aspects of psychopathy. There are moderate to high correlations between psychopathy rankings from late childhood to early adolescence. The correlations are considerably lower from early- or mid-adolescence to adulthood. In one study, most of the correlations were on the impulsivity and antisocial behavior scales. Of those adolescents who scored in the top 5% psychopathy scores at age 13, less than one-third (29%) were classified as psychopathic at age 24. Some recent studies have also found a poorer ability to predict long-term (adult) offending.

Conduct disorder

Main article: Conduct disorder

Conduct disorder is diagnosed based on a prolonged pattern of antisocial behavior in childhood or adolescence, and may be seen as a precursor to ASPD. Some researchers have speculated that two subtypes of conduct disorder mark dual developmental pathways to adult psy­chopa­thy. The DSM allows differentiating between childhood onset before age 10 and adolescent onset at age 10 and later. Childhood-onset is argued to be more due to a personality disorder caused by neurological deficits interacting with an adverse environment. For many, but not all, childhood onset is associated with what Terrie Moffitt's developmental theory of crime refers to as "life-course-persistent" antisocial behavior as well as poorer health and economic status. Adolescent onset is argued to more typically be associated with short-term antisocial behavior.

It has been suggested that the combination of early-onset conduct disorder and ADHD may be associated with life-course-persistent antisocial behaviors as well as psychopathy. There is evidence that this combination is more aggressive and antisocial than those with conduct disorder alone. However, it is not a particularly distinct group since the vast majority of young children with conduct disorder also have ADHD. Some evidence indicates that this group has deficits in behavioral inhibition, similar to those of adults with psychopathy. They may not be more likely than those with conduct disorder alone to have the interpersonal/affective features and the deficits in emotional processing characteristic of adults with psychopathy. Proponents of different types/dimensions of psychopathy have seen this type as possibly corresponding to adult secondary psychopathy and increased disinhibition in the triarchic model.

The DSM-5 includes a specifier for those with conduct disorder who also display a callous, unemotional interpersonal style across multiple settings and relationships. The specifier is based on research that suggests that those with conduct disorder who also meet the criteria for the specifier tend to have a more severe form of the disorder with an earlier onset, as well as a different response to treatment. Proponents of different types/dimensions of psychopathy have seen this as possibly corresponding to adult primary psychopathy and increased boldness or meanness in the triarchic model.

Mental traits

Cognition

Dysfunctions in the prefrontal cortex and amygdala regions of the brain have been associated with specific learning impairments in psychopathy. Damage to the ventromedial prefrontal cortex, which regulates the acti