Psychopathy (/saɪˈkɒpəθi/^[1][2] from the Ancient Greek ψυχή "psyche", -soul, mind and πάθος, "pathos" -suffering, disease, condition^[3][4]) is a personality disorder characterized by a pervasive pattern of disregard for the feelings of others and often the rules of society. Psychopaths have a lack of empathy and remorse, and have very shallow emotions. They are generally regarded as callous, selfish, dishonest, arrogant, aggressive, impulsive, irresponsible, and hedonistic. Despite this, psychopaths are often superficially charming and can be highly adept at manipulation. There is at most only a weak association between psychopathy and high IQ.

There is no consensus about the symptom criteria for psychopathy, and no psychiatric or psychological organization has sanctioned a diagnosis of "psychopathy" itself.'^[5]

It should be emphasized that, although there are many behavioral similarities, the terms antisocial personality disorder (ASPD) and psychopathy are not synonymous. ASPD refers to broad behavioral patterns based on clinical observation, whereas psychopathy refers not only to specific behavioral patterns but measurable cognitive, emotional, and neuropsychological differences. In other words, psychopathy assesses character as well as behavior. In addition, ASPD is so broad in its scope that between 50-80% of male inmates qualify as meeting its criteria (Correction Services of Canada, 1990; Hare, 1998; Hare, Forth, & Strachan, 1992). In contrast, only 11-25% of male inmates meet the criteria for psychopathy (Hare, 1996). These data suggest that the construct of psychopathy may be a more precise indicator and a better predictor of violence than the more global construct of antisocial personality disorder.^{[citation needed]}

Psychologist Robert Hare has been a particular champion of the concept of psychopathy, based largely on a characterization introduced by Hervey Cleckley mid 20th century. The Hare Psychopathy Checklist is a standard ratings tool most often used in forensic settings to assess psychopathy. A study by Hare and colleagues suggested that one to two percent of the US population score high enough on a screening version of the scale to be considered potential psychopaths.^[6] The diagnosis of antisocial personality disorder covers two to three times as many prisoners as are rated as psychopaths on Hare's scale.^[7]

According to some, there is little evidence of a cure or effective treatment for psychopathy; no medications can instill empathy, and psychopaths who undergo traditional talk therapy might become more adept at manipulating others and more likely to commit crime.^[8] Others suggest that psychopaths may benefit as much as others from therapy. According to Hare, psychopathy stems from as yet unconfirmed genetic neurological predispositions and as yet unconfirmed social factors in upbringing.^[9] A review published in 2008 indicated multiple causes, and variation in causes between individuals.^[10]

Despite being unused as the main term in diagnostic manuals, the term 'psychopath' is still used by some mental health professionals and by the general public, popular press and in fictional portrayals. Despite the similarity of the names, psychopaths are rarely psychotic. Although psychopathy is associated with and in some cases defined by conduct problems, criminality or violence, most psychopaths are not violent.^[11]

Etymology[link]

The word "psychopathy" is a joining of the Greek words psyche ψυχή (mind, mental) and pathos πάθος (suffering, feeling).^[12] The first documented use is from 1847 in Germany as psychopatisch,^[13] and the noun psychopath has been traced to 1885.^[14]

In medicine, patho- has long had a specific meaning of disease. Thus pathology has meant the study of disease since 1610, and psychopathology the study of mental disorder since 1847. A sense of "worthy to be a subject of pathology, morbid, excessive" is attested from 1845,^[15] including the phrase pathological liar from 1891 in the medical literature.

Psychosis was also used in Germany from 1841, including in a general sense of any mental derangement. The suffix -ωσις (-osis) meant in this case 'abnormal condition'. This term or its adjective psychotic would come to refer specifically to mental states or disorders characterized by hallucinations, delusions or being in some other sense out of touch with reality.^[16]

The term psychopathy initially had a very general meaning too, referring to all sorts of mental disorders. Some medical dictionaries still define it in the narrow and broad sense, for example MedlinePlus from the US National Library of Medicine.^[17] Others, such as Stedman's Medical Dictionary, define it only as an outdated term for an antisocial type of personality disorder.^[18]

The slang psycho has been traced to 1936 as a shortening of the adjective psychopathic, and from 1942 as a shortening of the noun psychopath,^[19] and it can also be short for psychotic.^[20]

The label psychopath has been described as strangely nonspecific but probably persisting because it indicates that the source of behavior lies in the psyche rather than in the situation. The media usually uses the term to designate any criminal whose offenses are particularly abhorrent and unnatural, but that is not its original or general psychiatric meaning.^[21] In the alternative term sociopath, socio has been common in compound words since around 1880, referring to social or society.^[22]

Characteristics[link]

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Psychopathy is defined by a pattern of problems in interpersonal relationships, emotion, and behavior. Hare summarizes the syndrome as a cluster of related symptoms in two broad categories. The Emotional/Interpersonal aspect includes: Glib and superficial; Egocentric and grandiose; Lack of remorse or guilt; Lack of empathy; Deceitful and manipulative; Shallow emotions. The Social Deviance aspect includes: Impulsive; Poor behavior controls; Need for excitement; Lack of responsibility; Early behavior problems; Adult antisocial behavior.^[23]

Hare summarizes the characteristics as: "What is missing, in other words, are the very qualities that allow a human being to live in social harmony". He adds that those who doubt that such individuals exist need only "consider the more dramatic examples of psychopathy that have been increasing in our society in recent years. Dozens of books, movies, and television programs, and hundreds of newspaper articles and headlines, tell the story..."^[9] He also notes that some psychopaths can blend in, undetected, in a variety of surroundings, including corporate environments.^[24] He has described psychopaths as "intraspecies predators".^[25] Simon has also used the word predator to describe psychopaths.^[26] Hare has said that "conceptualizing psychopaths as remorseless predators helped me to make sense of what often appears to be senseless behavior". He details what he sees as aspects of this, such as unempathic manipulation, selfishness, violating social norms, and instrumental violence - meaning cold-blooded and casual.^[27][28]

Personality dimensions[link]

Some studies have linked psychopathy to dimensions of personality. These include antagonism (high), conscientiousness (low) and anxiousness (low, or sometimes high). However, there are different views as to which personality dimensions are more central in regard to psychopathy, and in addition the traits are found throughout the general population in differing combinations.^[29] Some have also linked psychopathy 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.^[30]

Lack of empathy[link]

Psychopaths possess a general lack of empathy. It includes deficiencies in comprehension and appreciation of others’ experiences and motivations, lack of tolerance of differing perspectives and diminished understanding of the effects of own behavior on others.^[31] At an extreme they are simply unable to understand the emotional states of other people, except in a purely detached, intellectual sense. Other people are thus little more than objects for their personal gratification. They are not disturbed by the suffering of others, nor do they take pleasure in making others happy. This callousness extends to everybody, family and strangers alike. They neglect other people's needs and desires and can casually inflict extreme cruelty.

Not only do (primary) psychopaths have a lack of empathy, they also have the failure to admit they are wrong. Primary psychopaths usually do not have genuine empathy, but pick up from normal humans on how they should project empathy.

Shallowness of emotions[link]

Psychopaths do not feel emotions as deeply as an average person. Although they are not totally unemotional, their emotions are so shallow that some clinicians describe them as "proto-emotions: primitive responses to immediate needs."^[32] They live in present to the extreme, and their feelings are immediate, immature and unsophisticated. They are incapable of enduring, real love, and cannot form caring, lasting intimate bonds with others. They feel no fear, and thus take reckless risks and commit crimes with little heed to the consequences. They feel no shame or anguish, thus reprimands and punishments have no effect on their behavior. Their behavior is driven by shallower impulses, such as sexual arousal, frustration, boredom, greed, and irritability.^[33]

Psychopaths are fearless. When exposed to grave danger, they do not experience the normal range of physical and emotional reactions that a normal person would, such as trembling, involuntary urination, or a pounding heart.^[34] They never panic. They frequently engage in criminal acts because they're not afraid of getting caught. They frequently take foolish risks because they are not afraid of getting hurt. This is not to say they are oblivious to the potential consequences of their actions. Rather, the thought of pain and punishment does not provoke an emotional reaction in them and thus has a weak restraining effect.^[35] Their lack of fear also contributes to their often extraordinary talent for lying: people believe the psychopath because he is so unflappable in the face of scrutiny.

Prison does not make any deep impression on the psychopath and thus does little to discourage future criminality (there are anecdotes of psychopaths reacting nonchalantly to being sentenced to life in prison.^[36]). Public exposure as a crook does not leave them feeling devastated or ashamed. In short, no sort of setback can break their morale or alter their character.

Because their own emotional life is so shallow, psychopaths often have difficulty predicting the emotional reactions of others and are often clumsy with emotional language. Sometimes, they may fail to appreciate the emotional meaning of certain words and use them in odd or inappropriate fashion. For instance, one person thought to be a psychopath regularly beat his wife, eventually battering her to death. He was afterwards quoted as saying: "I loved her so deeply. I miss her so much. What happened was a tragedy. I lost my best lover and my best friend. [...] Why doesn't anybody understand what I've been going through?"^[37] One might expect that a man who genuinely loved his wife would not have battered her to death and would feel terrible anguish if he did. This might suggest that his description of his own emotions was inaccurate or deceptive. Psychopaths can be very skilled at figuring out and manipulating people's emotions, but only so long as they can read their reactions for cues. Hare cites the example of a psychopath who once described dispassionately his murders to an interviewer. Eventually, the interviewer could no longer maintain her poker face and expressed her disgust. The psychopath immediately shifted gears and feigned remorse and horror. Because of his sparse emotional life, he did not realize that his description should horrify his listener. It took the interviewer's loss of composure to make him realize this.^[38]

Sweeping generalizations about emotions in psychopathy are contradicted by complexity and individual differences found in research. Lack of fear and anxiety has been the most consistent claim, but while studies show some reduced responsiveness in specific contexts, for example to forewarned aversive stimuli or film imagery, most studies do not report significant differences in resting physiological activity or in reactions such as the startle response. It is also possible that some emotions are suppressed so as not to show weakness or vulnerability. Anger, sadness or happiness may be present though denied, concealed or linked to motivational states of impulsivity or antisocial behaviors. Guilt, shame and interpersonal affection are complex states that relate to socialization and morals as well as particular emotional experiences.^[39]

Lying and manipulation[link]

Psychopaths can be pathological liars. Their relationships with other people are practically defined by manipulation and exploitation. The psychopath sees no reason why he should be honest or caring towards other people. They typically become very good at lying, sometimes fooling experienced interrogators. Because they are incapable of shame or fear, their body language and tone of voice never display the typical signs that often betray liars. They are completely unafraid of being caught in a lie. When they are confronted, they will, without pause, simply rework their story to fit the facts and appear consistent. This utterly confident presentation is what often sways people's doubts. Another reason they are great manipulators is because they practice harder. They are aggressive and domineering, often relishing the game of control for its own sake if not the rewards they can finagle. They have fewer social inhibitions, and are usually more confident. They are not afraid of causing offense, being rejected, or being put down. When these things do happen, they tend to dismiss them and are not discouraged from trying again.

Although psychopaths are mentally very different from normal people, through their skill at deception they often succeed in convincing others that they are normal, caring, and law-abiding. A psychopath will readily lie about his past to cover up past errors and exaggerate his skills and virtues, all to create the impression that he is in fact the most wonderful kind of person imaginable. Although the psychopath possesses shallow emotions, he will often claim to possess the normal range of human emotions. They tend to make good first impressions and can appear quite likable. There is thus no easy way to detect psychopaths.

Psychopaths are not perfect liars. The speech of psychopaths is often riddled with wild inconsistencies and contradictions. While this is often due to their usually improvisational method and poor emotional understanding, there is also a cognitive deficit at play. Robert Hare argues that psychopaths have difficulty integrating the components of their thought processes and thus fail to notice the absurdities in their speech. They simply toss ideas at their listener without putting much thought into coherence. Cleckley called this phenomenon "semantic aphasia".^[40] For instance, one psychopath told Hare: "I had to steal sometimes to get out of town, yeah, but I'm not a fucking criminal."^[41] Another psychopath was once asked if she ever committed a violent crime, and responded: "No, but once I had to kill someone."

Semantic processes[link]

Hervey Cleckley suggested from 1941 that psychopaths lack an ability to be aware of what life really means - the common emotion or purpose that gives rise to the various personal and social goals and responsibilities that normal people have. In addition to editing out his statement in the first edition of 'The Mask of Sanity' that psychopaths are 'frankly and unquestionably psychotic' (p. 257),^[42] and not being able to account for their problems in terms of obvious intellectual impairment, Cleckley speculated that it was due to a core deficit in the personality functioning of the person. To explain this, he described the condition as a semantic (meaning) disorder. He made an analogy to concepts being advanced with regard to neurological language problems, namely the work of Henry Head on semantic aphasia or semantic dementia. This showed for Cleckley that the basic production of speech and grammatical language could appear largely intact, while the underlying inner speech and sense of meaning and intention was impaired. However, Cleckley acknowledged that this was not evidence that this was occurring in his cases, but rather he was using it as a general analogy or a way of restating the concept of psychopathy, regarding superficial versus deeper levels of personality.^[43] The specific analogy has not generally been maintained in discussion of psychopathy.

Impulsivity, irresponsibility, low tolerance for boredom[link]

Psychopaths can be impulsive and have little self-control. They often act on their immediate desires with little planning or thought for the consequences. Their crimes tend to be spur-of-the-moment affairs. Psychopaths do not think hard about the future and they change their plans frequently. They often abandon relationships and quit jobs on a whim. Their lifestyles often reveal a pattern of bouncing from one job to another, one city to another, and in and out of prison.

Psychopaths care nothing for rules and obligations. At work, they regularly shirk duties and break promises, leading to erratic performance records. They spend their money recklessly and often have terrible credit histories. They neglect their children.

Psychopaths have an excessive need for stimulation. They will often abuse drugs or perform reckless acts, including criminal ones, simply for the thrill. At work, they regularly neglect tasks that they find boring.

Parasitic lifestyle[link]

Due to their frequent lack of qualifications, concern only for their own welfare, irresponsibility, and disinterest in boring work, it is unlikely that psychopaths will be productive family members or workers. They tend to live parasitically, draining resources but contributing little.^[44] They have no qualms about draining the money of friends and family to satisfy their desires or bail them out of trouble. Some psychopaths specifically adopt a lifestyle of seducing men or women in order to obtain money and sex from them for as long as they can.

Lack of remorse[link]

Psychopaths show a profound inability to feel remorse. Whatever the crime, whoever the victim, a psychopath simply does not accept responsibility for the consequences of his actions. They know the difference between right and wrong but do not care. In some cases, psychopaths are completely forthright about their attitude: they acknowledge the pain they caused but are not sorry. In other cases they may rationalize what happened, perhaps by minimizing the seriousness of the incident, or blaming the victim in some way. They may deny any harm was done. They may even be proud of having successfully swindled, deceived, or ruined the lives of other people, seeing it as a testament to their cunning and power.

Though psychopaths do not feel remorse, they may feign contrition in order to elicit leniency and forgiveness.

Grandiosity[link]

Psychopaths see themselves as superior beings, with an exaggerated sense of entitlement. They often appear arrogant, opinionated, domineering, and cocky. They believe they are more talented than anyone else and that they can become anything they want to be. They see themselves as smarter than everyone else and have little regard for the opinions of others. It is not uncommon for psychopaths who have defrauded people to describe them as weak, inferior beings who deserved to be taken advantage of.^[45] They resent authority and being in a position of inferiority.^[46] With their exaggerated sense of entitlement, psychopaths often expect large rewards for mediocre efforts.^[47] They will apply for important jobs despite lacking qualifications, demand authority and privileges above their rank, and show no gratitude for favors granted them. They are shameless and relentless self-promoters, exaggerating or fabricating their talents and dismissing their failings. In this respect, they resemble narcissists, and indeed the two disorders are sometimes hard to distinguish.

Most psychopaths tend to be underachievers due to a lack of interest in education and lack of self-discipline. However, some more intelligent psychopaths can force themselves to exercise discipline, and may have successful careers. However, they are unashamed and dismissive of the legal, financial, career, or personal problems in their lives. They blame everyone and everything but themselves for their failures - bad luck, an unfair system, unsupportive colleagues, etc. - or they might dismiss their old projects as wastes of time that they were right to abandon. They may even portray their bad qualities as virtues: many psychopaths brag about their criminal versatility, the number of crimes they got away with, and their talent for deception.

Unrealistic long-term goals[link]

Closely related to the psychopath's grandiosity is a lack of realistic planning. They often have grandiose, self-centered goals, and they believe that they can become anything they want to be. However, they often fail to appreciate the talent, dedication, and effort it would take to achieve such goals. Since they are focused on the present, they have no capability to self-sacrifice to achieve their goals, give up quickly and easily, lack patience and instead focus on instant gratification.^[41]

High recidivism[link]

It is impossible to correct a psychopath's behavior through punishment. Psychopaths reoffend at a much higher rate than non-psychopathic offenders, especially when it comes to violent crime. As much as 80% of psychopathic inmates will be convicted of something within five years of their release, compared to less than half of other inmates.^[48][49] Psychopaths frequently violate parole conditions, ending up back in prison soon after release.

There is currently no reliable means by which to reform a psychopath. In the past, special therapies for psychopathic inmates were designed to teach them sensitivity, but these backfired and instead made them even more likely to reoffend.^[50] It is believed that the programs instead made them more adept manipulators and thus opened up more opportunities for them to exploit people.

Juvenile delinquency[link]

Background checks on psychopaths typically reveal that their antisocial behavior began in childhood. Researchers noticed common misbehaviors including:

• frequent unauthorized absences from school and home
• defiance of parents, teachers, and rules
• petty theft from other children and parents
• non-responsiveness to reprimands and punishment
• animal abuse
• early promiscuity
• vandalism and arson
• persistent bullying and fighting

What has struck researchers is that many psychopaths come from apparently stable backgrounds. Popular wisdom holds that antisocial tendencies are the result of abusive and neglectful parenting, yet some psychopaths had caring parents who did their best to socialize their child properly.^[51]

"There are some individuals who come from fantastic home backgrounds—dedicated parents, all the advantages in the world—and yet they grew up to become psychopathic violent monsters later in life, and you ask the question: 'how the heck did they get there?'"

—Adrian Raine^[51]

Robert Hare argues that parents cannot be held to fault for their offspring becoming psychopaths, for no amount of good parenting can fix the basic condition, which has genetic causes.^[52] Though upbringing cannot cure psychopathy, it can alter its expression. Hare found that psychopaths from unstable families were more likely to be violent.^[53]

Current medical practice forbids diagnosing children as psychopaths.^[51] Nonetheless, Robert Hare has developed checklists that can identify psychopathic tendencies in juveniles. The Psychopathy Checklist: Youth Version (PCL:YV) is used for clinical research,^[54] while the Antisocial Process Screening Device (APSD) is used to identify problem children for therapeutic intervention.^[55]

Moral judgment[link]

Psychopaths have been considered notoriously amoral – an absence of, indifference towards, or disregard for moral beliefs. There are little firm data on patterns of moral judgment, however. Studies of developmental level (sophistication) of moral reasoning found all possible results – lower, higher or the same as non-psychopaths. Studies that compared judgments of personal moral transgressions versus judgments of breaking conventional rules or laws, found that psychopaths rated them as equally severe, whereas non-psychopaths rated the rule-breaking as less severe. A study comparing judgments of whether personal or impersonal harms would be endorsed in order to achieve the rationally maximum (utilitarian) amount of welfare, found no significant differences between psychopaths and non-psychopaths. However, a further study using the same tests found that psychopaths (prisoners scoring high on the psychopathy checklist) were more likely to endorse impersonal harms or rule violations than non-psychopaths. Psychopaths who scored low in anxiety were also more willing to endorse personal harms on average.^[56] Assessing accidents, where one person harmed another unintentionally, psychopaths judged such actions more morally permissible. This result is perhaps a reflection of psychopaths' failure to appreciate the emotional aspect of the victim's harmful experience, and furnishes direct evidence of abnormal moral judgment in psychopathy.^[57]

Perceptual/emotional recognition deficits[link]

Facial affect recognition[link]

In a 2002 study, David Kosson and Yana Suchy, et al.[Who] asked psychopathic inmates to name the emotion expressed on each of 30 faces. Compared to the control group, psychopaths had a significantly lower rate of accuracy in recognizing disgusted facial affect but a higher rate of accuracy in recognizing anger. Additionally, when "conditions designed to minimize the involvement of right-hemispheric mechanisms" (i.e., sadness) were used, psychopaths had more difficulty accurately identifying emotions. This study did not replicate Blair's et al. (1997) findings that psychopaths are specifically less sensitive to nonverbal cues of fear or distress.^[58]

One study indicated that in children antisocial behaviour is associated with perceiving hostility from others, while callous-unemotional traits appear related to not recognising fear in others. Those showing the latter trait tended to pay less attention to the eye region of faces. Although deficits in these areas have been linked to the amygdala in patients with brain damage, a recent meta-analysis suggested the deficits are not always found in adult psychopathy and tend to show more on tasks requiring verbal processing (e.g. a verbal response to a questioner) at the same time as visual processing.^[59][60]

Vocal affect recognition[link]

In a 2002 experiment, Blair, Mitchell, et al. used the Vocal Affect Recognition Test to measure psychopaths' recognition of the emotional intonation given to connotative neutral words. Psychopaths tended to make more recognition errors than controls with a particularly high rate of error for sad and fearful vocal affect.^[61]

Stroop tasks[link]

A study on Stroop tasks found that there is "a circumscribed attentional deficit in psychopathy that hinders the use of unattended information that is (a) not integrated with deliberately attended information and (b) not compatible with current goal-directed behavior."^[62]

Psychopathy and intelligence[link]

Psychopathy was for some time popularly associated with higher than average intelligence, but Hare and Neumann (2008) state that a large literature shows that there is at most only a weak association between psychopathy and IQ. They consider that the early pioneer Cleckley included high IQ in his checklist due to selection bias since many of his patients were "well educated and from middle- or upper-class backgrounds" and state that "there is no obvious theoretical reason why the disorder described by Cleckley or other clinicians should be related to intelligence; some psychopaths are bright, others less so."^[42]

In addition, studies indicate that different aspects of the definition of psychopathy (e.g. interpersonal, affective (emotion), behavioral and lifestyle components) can show different links to intelligence, and it can also depend on the type of 'intelligence' assessment (e.g. verbal IQ, creative, practical, analytical). Those scoring high on psychopathy measures may tend to score lower on verbal IQ.^[63]

Non-western cultures[link]

Skeem et al. in review (2011) wrote "Does psychopathy exist in at least some non-Western cultures? The answer appears to be an unqualified “Yes.”" They continued "Murphy (1976) reported clear evidence for the existence of conditions similar (albeit not identical) to Western psychopathy. For example, she found that the Inuits had a term—kunlangeta (meaning “his mind knows what to do but he does not do it”)—that they used to describe “a man who . . . repeatedly lies and cheats and steals things and . . . takes sexual advantage of many women—someone who does not pay attention to reprimands and who is always being brought to the elders for punishment” (p. 1026), a description that bears a striking resemblance to the Western concept of psychopathy. In addition, Murphy reported that the Yorubas had a term arankan, “which means a person who always goes his own way regardless of others, who is uncooperative, full of malice, and bullheaded” (p. 1026)."^[5] However, the Murphy study was simply a brief field report noting broad resemblances in some antisocial behaviors; it did not report any assessment of the specific psychological traits or behavioral patterns said to define psychopathy according to, for example, the Hare checklist.^[64] In addition, Skeem et al. indicated that there had been no studies comparing prevalence of assessed psychopathy in non-western nations.

Offending[link]

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A 2002 literature review of studies on mental disorders in prisoners stated that 47% of male prisoners and 21% of female prisoners had anti-social personality disorder.^[65] According to an unsourced article in popular science magazine Scientific American, studies indicate that about 25% of prison inmates meet diagnostic criteria for psychopathy.^[11] A 2009 study of British prisoners found a prevalence for "categorically diagnosed psychopathy" of 7.7% in men and 1.9% in women.^[66]

The personalities of people who engage in criminal behavior are varied and psychopathy cannot be said to be the underlying type. In addition, there is individual variation within the type that might be labeled as psychopathic.^[5]

Criminals who are assessed as psychopathic are more likely than other criminals to commit crime again in future, on average. However, this link appears to be due largely to the scale items that assess impulsive behaviors and past criminal history, which are well-established but very general risk factors. The aspects of core personality held to be distinctively psychopathic, generally show little or no predictive link to crime by themselves.^[5][67] Some clinicians suggest that assessment of the construct of psychopathy does not necessarily add value to violence risk assessment.^[68]

Although psychopathy is associated on average with an increased risk of violence, it is difficult to know how to manage the risk.^[69] One study concluded that psychopathy is associated with a greater average rate of violence due not to a neurodevelopmental disorder but the result of a person adapting to their life.^[70]

Regarding types of crimes committed, links have sometimes been suggested to more 'instrumental' (used to get something) violence rather than 'reactive' (emotional, personal) violence. One conclusion in this regard was made by a 2002 study of homicide offenders, which reported that the homicides committed by psychopaths were almost always (93.3%) primarily instrumental, while about half (48.4%) of those committed by non-psychopaths were.^[71] However, contrary to the equating of this to mean "in cold blood", more than a third of the homicides by psychopaths involved emotional reactivity as well. In addition, the non-psychopaths still accounted for most of the instrumental homicides, because most of these murderers were not psychopaths. In any case, FBI profilers indicate that serious victim injury is generally an emotional offense, and some research supports this at least with regard to sexual offending. Some studies have found more serious offending by non-psychopaths on average than by psychopaths (e.g. more homicides versus more armed robbery and property offenses).^[5]

Terrorists are sometimes called psychopaths and comparisons can be drawn with traits such as antisocial violence, a selfish worldview that precludes welfare for others, lack of remorse or guilt, and blaming external events. However, such comparisons could also then be drawn more widely, for example to soldiers in wars. In addition, it has been noted that coordinated terrorist activity requires organization, loyalty and ideology; traits such as self-centeredness, unreliability, poor behavioral controls, and unusual behaviors may be disadvantages.^[72] Recently Häkkänen-Nyholm and Nyholm (2012) have discussed the possibility of psychopathy being associated with organised crime, economical crime and war crimes. ^[73]

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. Despite "their extensive criminal histories and high recidivism rate", psychopaths showed "a great proficiency in persuading parole boards to release them into the community." "High-psychopathy offenders (both sexual and non-sexual offenders) were about 2.5 times more likely to be granted conditional release than non-psychopathic offenders."^[74]

Some studies have found only weak associations between psychopathy and sexual offending overall. The association is more certain for sexual violence. Psychopaths have higher sexual arousal to depictions of rape than non-psychopaths. Rapists, especially sadistic rapists, and sexual homicide offenders have a high rate of psychopathy. Some researchers have argued that psychopaths have a preference for violent sexual behavior.^[75]

One study examined the correlation between psychopathy scores and types of aggression expressed in a sample of 38 sexual murderers. 85% of the sample scored in the moderate to high range of psychopathy. About half the sample were below the cut-off for psychopathy, and about half scored above the cut-off for psychopathy. 82% of those above the cut-off had engaged in sadistic violence (defined as enjoyment indicated by self-report or evidence) as compared to 53% of those below the cut-off. It was also found that psychopathy scores correlated with gratuitous violence and sadism.^[76]

In considering the challenging issue of possible reunification of some sex offenders in to homes with a non-offending parent and child(ren), it has been advised that any sex offender with a significant criminal history should be assessed on the Psychopathy Checklist Revised, and if they score 18 or higher they should be excluded from any consideration of being placed in a home with children under any circumstances.^[77]

Childhood precursors[link]

Psychopathic tendencies can sometimes be recognized in childhood or early adolescence. If recognized, a diagnosis of Conduct Disorder, or possibly the related Oppositional Defiant Disorder, may be given. However, while these childhood signs have been found in a significantly higher proportion of psychopaths than in the general population, it must be stressed that not all the subjects of such childhood diagnoses turn out to be psychopaths as adults, or even disordered at all. Therefore, psychopathy is not normally diagnosed in children or adolescents, and some jurisdictions explicitly forbid diagnosing minors with psychopathy and similar personality disorders. This is because such a diagnosis "fails to capture the emotional, cognitive, and interpersonality traits — egocentricity and lack of remorse, empathy, or guilt - that are so important in the diagnosis of psychopathy."^[78]

Children showing strong psychopathic precursors often appear immune to punishment; nothing seems to modify their undesirable behavior. Consequently parents usually give up, and the behavior worsens.^[79]

Three behaviors — bedwetting, cruelty to animals and firestarting, known as the Macdonald triad — were first described by J.M. MacDonald as possible indicators, if occurring together over time during childhood, of future episodic aggressive behavior.^[80] However, subsequent research has found that bedwetting is not a significant factor^[81] and the triad as a particular profile has been called an urban legend.^[82] Questions remain about a connection between animal cruelty and later violence, though it has been included in the DSM as a possible factor in conduct disorder and later antisocial behavior.^[83]

The question of whether young children with early indicators of psychopathy respond poorly to intervention, compared to conduct-disordered children without these traits, has only recently been examined in controlled clinical research. The empirical findings from this research have been consistent with broader anecdotal evidence, pointing to poor treatment outcomes.^[84] Many of the above characteristics can be paralleled in bullying at school and elsewhere.

Causes and pathophysiology[link]

Evolutionary explanations[link]

Researchers within evolutionary psychology have proposed several evolutionary explanations for psychopathy. One is that psychopathy represents a frequency-dependent, socially parasitic strategy. This may work as long as there are few other psychopaths in the community since more psychopaths means increasing the risk of encountering another psychopath as well as non-psychopaths likely adapting more countermeasures against cheaters.^[85][86]

Genetics[link]

One approach to studying the role of genetics for a trait is to calculate the heritability coefficient. It describes the proportion of the variance that is due to genetic factors for some characteristic that differs between individuals. The heritability for psychopathy is around 50%.^[85]

Genetic factors may generally influence the development of psychopathy while environmental factors affect the specific traits that predominate.^[42]

A 2005 twin study found that children with antisocial behavior can be classified into two groups: those who also had high "callous-unemotional traits" were "under extremely strong genetic influence and no influence of shared environment" while those who were ranked low of those traits were under both "moderate genetic and shared environmental influence."^[87]

The psychologist Robert Hare in his book, "Without Conscience: The Disturbing World of Psychopaths Among Us", argues that psychopathy has a genetic predisposition. He goes on to state that many (male) psychopaths have a pattern of mating with, and quickly abandoning women, and as a result, have a high fertility rate. These children may inherit a predisposition to psychopathy. Hare describes the implications as chilling.^[88]

Neuroscience[link]

"The amygdala is crucial for stimulus-reinforcement learning and responding to emotional expressions, particularly fearful expressions that, as reinforcers, are important initiators of stimulus-reinforcement learning. Moreover, the amygdala is involved in the formation of both stimulus-punishment and stimulus-reward associations. Individuals with psychopathy show impairment in stimulus-reinforcement learning (whether punishment- or reward-based) and responding to fearful and sad expressions. It is argued that this impairment drives much of the syndrome of psychopathy (Blair, 2008).^[89]

People scoring ≥25 in the Psychopathy Checklist Revised, with an associated history of violent behavior, appear to have significantly reduced microstructural integrity in their uncinate fasciculus — white matter connecting the amygdala and orbitofrontal cortex. The more extreme the psychopathy, the greater the abnormality.^[90]

Recent studies have triggered theories on determining whether there is a biological relationship between the brain and psychopathy. One theory suggests that psychopathy is associated with both the amygdala, which is associated with emotional reactions and emotional learning, and the prefrontal cortex, associated with impulse control, decision-making, emotional learning and behavioral adaptation.^[91] Some studies have shown there is less "gray matter" in these areas in psychopaths than in non-psychopaths.

Researchers have conducted brain scans on psychopaths while exposing them to emotionally charged words such as "rape", "murder", and "love". In a normal person, these words will provoke activity in the limbic system, which governs emotions. Psychopaths showed no such activity. They react to emotionally charged words as if they were neutral words (e.g. "tree", "chair", "spoon"). They do, however, show activity in the brain areas associated with language processing, suggesting that their response is more cognitive than emotional.^{[92][verification needed]}

There is DT-MRI evidence of breakdowns in the white matter connections between these two important areas in a small British study of nine criminal psychopaths. This evidence suggests that the degree of abnormality was significantly related to the degree of psychopathy and may explain the offending behaviors.^[93][94]

A 2008 review found various abnormalities (based on group differences from average) reported in the literature, centered on a prefrontal-temporo-limbic circuit — regions that are involved in emotional and learning processes, as well as many other processes. However, the authors report that the people classed as "psychopathic" cannot in fact be seen as a homogeneous group (i.e. as all having the same characteristics), and that the associations between structural changes and psychopathic characteristics do not enable causal conclusions to be drawn. They conclude that psychopathic characteristics involve multifactorial processes including neurobiological, genetic, epidemiological, and sociobiographical (the person's life in society) factors.^[10]

Psychopaths do have an elevated probability of being left-handed.^[95]

Neurotransmitters and hormones[link]

High levels of testosterone combined with low levels of cortisol have been theorized as contributing factors. Testosterone is "associated with approach-related behavior, reward sensitivity, and fear reduction". Cortisol increases "the state of fear, sensitivity to punishment, and withdrawal behavior". Injecting testosterone "shift[s] the balance from punishment to reward sensitivity", decreases fearfulness, and increases "responding to angry faces". Some studies have found that antisocial and aggressive behaviors are associated with high testosterone levels but it is unclear if psychopaths have high testosterone levels. A few studies have found psychopathy to be linked to low cortisol levels.^[96]

High testosterone levels combined with low serotonin levels may increase violent aggression. Some research suggests that testosterone alone does not cause aggression but increases dominance-seeking behaviors. Low serotonin is associated with "impulsive and highly negative reactions" which, if combined with high testosterone, may cause aggression if an individual becomes frustrated.^[96]

Psychopathy was also associated in two studies with an increased ratio of HVA (a dopamine metabolite) to 5-HIAA (a serotonin metabolite).^[96]

Several animal studies note the role of serotonergic functioning in impulsive aggression and antisocial behavior.^{[97][98][99][100]}

Studies have indicated that individuals with the traits meeting criteria for psychopathy show a greater dopamine response to potential 'rewards' such as monetary promises or taking drugs such as amphetamines. This has been theoretically linked to an increased impulsivity.^[101]

A 2010 British study found that a large 2D:4D digit ratio, an indication of high prenatal estrogen exposure, was a "positive correlate of psychopathy in females, and a positive correlate of callous affect (psychopathy sub-scale) in males".^[102]

Diagnosis[link]

Assessment measures[link]

Hare Psychopathy Checklist[link]

Psychopathy in forensic settings is most commonly assessed with the PCL-R. Each of the items in the PCL-R is scored on a three-point scale, with a rating of 0 if it does not apply at all, 1 if there is a partial match or mixed information, and 2 if there is a reasonably good match to the offender. This is said to be ideally done through a face-to-face interview together with supporting information on lifetime behavior (e.g. from case files), but is also done based only on file information. It can take up to three hours to collect and review the information. The PCL-R is referred to by some as the "gold standard" for assessing psychopathy. It was developed with and for criminal samples, based on Cleckley's original characterization but with positive-adjustment indicators omitted. 30 out of a maximum score of 40 is recommended as the cut-off for the label of psychopathy (Hare, 2003), although there is little or no scientific support for this as a particular break point. For research purposes a cut-off score of 25 is sometimes used.^[5] In fact, the UK has used a cut-off of 25 rather than the 30 used in the US.^[103]

The PCL-R items were designed to be split in two. Factor 2 involves either impulsive-irresponsible behaviors or antisocial behaviors. Factor 1 involves interpersonal or affective (emotion) personality traits. The two factors correlate with each other to some extent. In addition, Factor 2 is associated with a maladaptive lifestyle including criminality, while Factor 1 is associated with narcissism and low empathy as well as social dominance and less fear or depression.^[5]

Because an individual's scores may have important consequences for his or her future, the potential for harm if the test is used or administered incorrectly is considerable. The test can only be considered valid if administered by a suitably qualified and experienced clinician under controlled conditions.^[28][104]

There is also a shorter version of the PCL-R, known as a screening version (PCL-SC), developed for quicker assessments of larger numbers or groups without criminal records. It has only 12 items but correlates strongly with the main PCL-R. The corresponding cut-off score is 18.

PCL-R items[link]

There are 20 items in the PCL-R, conventionally divided into two factors. Each factor is sometimes further subdivided in two - interpersonal vs affect items for Factor 1, and lifestyle vs antisocial behavior items for Factor 2. Two items, 'Promiscuous sexual behavior' and 'Many short-term marital relationships', have sometimes been left out in such divisions (Hare, 2003):

One issue related to the assessment of individuals who may exhibit affective, interpersonal, and behavioral features associated with psychopathy is the ability to overcome gender myths when the psychopathy features are present in females.^[105] The Hare Psychopathy Checklist-Revised has both percentiles and T-score tables for male and female offenders.

Three-factor model[link]

Recent statistical analysis using confirmatory factor analysis by Cooke and Michie^[106] indicated a three-factor structure, with those items from factor 2 strictly relating to antisocial behaviour (criminal versatility, juvenile delinquency, revocation of conditional release, early behavioural problems, and poor behavioural controls) removed from the final model. The remaining items are divided into three factors: Arrogant and Deceitful Interpersonal Style, Deficient Affective Experience, and Impulsive and Irresponsible Behavioural Style.^[106]

Hare and colleagues have published detailed critiques of the Cooke & Michie hierarchical ‘three’-factor model, citing severe statistical problems. Hare and colleagues note that the Cooke & Michie model actually contains ten factors, and results in impossible parameters (negative variances). Hare and colleagues also note conceptual problems with this model.^[107]

Discrete vs. continuous[link]

An early and influential taxonometric analysis from Harris and colleagues indicated a discrete category may underlie PCL-R psychopathy, but this was only found for the behavioural Factor 2 items, indicating this analysis may be related to Antisocial Personality Disorder rather than psychopathy per se.^[108] Marcus, John, and Edens more recently performed a series of statistical analysis on PPI scores and concluded psychopathy may best be conceptualized as having a "dimensional latent structure" like depression.^[109]

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 (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 call some people 'psychopaths'. The Hare checklist 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 this constellation of traits.^[110]

Psychopathic Personality Inventory[link]

Unlike the PCL, the Psychopathic Personality Inventory (PPI) was developed to comprehensively index personality traits without explicitly referring to anti-social or criminal behaviors themselves.^[5] It is a self-report scale that was developed in non-clinical samples (e.g. university students) rather than prisoners, though may be used with the latter. It was revised in 2005 to become the PPI-R (Lilienfeld & Widows) and now comprises 154 items organized into eight subscales. The item scores have been found to group into two over-arching and largely separate factors, plus a third factor which is mainly dependent on scores on the other two:

I: Fearless dominance. Involving social influence, fearlessness, stress immunity.

II: Impulsive antisociality/selfishness. Involving 'Machiavellian' egocentricity, Rebellious nonconformity, Blame externalization, Carefree lack of planning.

III: Coldheartedness.

A person may score at different levels on the different factors, but the overall score indicates the extent of psychopathic personality. Higher scores on factor I are actually associated with emotional stability and social efficacy, as well as reduced empathy. Scores on factor II are more associated with maladaptive tendencies — including aggressiveness, substance use problems, negative feelings and suicidal ideation.

Other[link]

There are some traditional personality tests that contain subscales relating to psychopathy, though they assess relatively non-specific tendencies towards antisocial or criminal behavior. These include the Minnesota Multiphasic Personality Inventory (Psychopathic Deviate scale); the California Psychological Inventory (Socialization scale); and the Millon Clinical Multiaxial Inventory (Antisocial Personality Disorder scale). There is also the Levenson Self-Report Psychopathy Scale (LSRP) and the Hare Self-Report Psychopathy Scale (HSRP). However, in terms of self-report tests, the PPI/PPI-R has become the most used in modern psychopathy research on adults.^[5]

DSM and ICD[link]

There are currently two widely established systems for classifying mental disorders — Chapter V of the International Classification of Diseases (ICD-10) produced by the World Health Organization (WHO) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) produced by the American Psychiatric Association (APA). Both list categories of disorders thought to be distinct types, and have deliberately converged their codes in recent revisions so that the manuals are often broadly comparable, although significant differences remain.

The DSM has never listed psychopathy as the official term for a personality disorder, but states that its diagnosis of antisocial personality disorder means more or less the same thing. It is defined as a '...a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood.' and requires three out of seven specific factors to be present. The ICD's conceptually similar diagnosis is called Dissocial personality disorder, 'usually coming to attention because of a gross disparity between behaviour and the prevailing social norms, and characterized by' 3 of 6 specific issues. Antisocial personality disorder is defined in terms of behavior, while psychopathy is defined more in terms of character. A much larger proportion of convicts qualify for ASPD, whilst only a minority are psychopaths.

The DSM-V working party is recommending a revision of antisocial personality disorder to be called antisocial/dyssocial personality disorder.^[111] There is also a suggestion to include a subtype "Antisocial/Psychopathic Type".^[112]

Disagreements[link]

Antisocial personality disorder is diagnosed mainly via behavior and socially deviant behaviors, whereas a diagnosis of psychopathy also includes affective and interpersonal personality factors. Thus, PCL-R psychopathy defines a different and smaller group of people than those who meet criteria for ASPD.^[103] Some who meet criteria for ASPD may only score high on Factor 2 of the PLC-R.^[113]

Proponents claim that the Hare Psychopathy Checklist is better able to predict future criminality, violence, and recidivism than the diagnosis of ASPD. Hare writes that there are also differences between PLC psychopaths and others on "processing and use of linguistic and emotional information", while such differences are small between those diagnosed with ASPD and not.^[114][115] However, the Hare Psychopathy Checklist requires the use of a rather long interview and availability of considerable additional information^[115] as well as depending in part on judgments of character rather than observed behavior.

Hare wrote that the field trials for the DSM-IV found personality traits judgments to be as reliable as those diagnostic criteria relying only on behavior, but that the personality traits criteria were dropped in part because it was feared that the average clinician would not use them correctly. Hare criticizes the instead used DSM-IV criteria for being poorly empirically tested. In addition, the introductory text description describes the personality characteristics typical of psychopathy, which Hare argues make the manual confusing and actually containing two different sets of criteria. He has also argued that confusion regarding how to diagnose ASPD, confusion regarding the difference between ASPD and psychopathy, as well as the differing future prognoses regarding recidivism and treatability, may have serious consequences in settings such as court cases where psychopathy is often seen as aggravating the crime.^[114]

However, Hare's concept and checklist have also been criticized. In 2010 there was controversy after it emerged Hare had threatened legal action that stopped publication of a peer-reviewed article on the PCL-R. Hare alleged the article quoted or paraphrased him incorrectly. The article eventually appeared three years later. It alleged that the checklist is wrongly viewed by many as the basic definition of psychopathy, yet it leaves out key factors, while also making criminality too central to the concept. The authors claimed this leads to problems in overdiagnosis and in the use of the checklist to secure convictions. Hare has clarified that he receives less than $35,000 a year from royalties associated with the checklist and its derivatives.^[116]

In addition, Hare's concept of psychopathy has been criticised as being only weakly applicable to real-world settings and tending towards tautology. It is also said to be vulnerable to 'labeling effects'; to be over-simplistic; reductionistic; to embody the fundamental attribution error; and to not pay enough attention to context and the dynamic nature of human behavior.^[117] Some research suggests that ratings made using this system depend on the personality of the person doing the rating, including how empathic they themselves are. One forensic researcher has suggested that future studies need to examine the class background, race and philosophical beliefs of raters because they may not be aware of enacting biased judgments of people whose section of society or individual lives they have no understanding of or empathy for.^[118][119]

Cleckley checklist[link]

In his book Mask of Sanity, Hervey M. Cleckley described 16 'common qualities' that he thought were characteristic of the individuals he termed psychopaths:^[120] Cleckley checklist formed the basis for Hare's more current PCL-R checklist (see above).

Cleckley also suggested there were milder forms. He ended his survey by saying "If we consider, in addition to these patients (nearly all of whom have records of the utmost folly and misery and idleness over many years and who have had to enter a psychiatric hospital), the vast number of similar people in every community who show the same behavior pattern in milder form but who are sufficiently protected and supported by relatives to remain at large, the prevalence of this disorder is seen to be appalling."^[121]

Other diagnostic considerations[link]

Primary-secondary distinction[link]

Primary psychopathy was defined by those following this theory as the root disorder in patients diagnosed with it, whereas secondary psychopathy was defined as an aspect of another psychiatric disorder or social circumstances.^[122]

The primary psychopath is said to engage in antisocial behavior as a result of a genetic-biological predisposition directed by particular psychodynamic forces that occur in infancy. The secondary psychopath's antisocial behavior is said to result from strictly environmental forces (e.g., membership in a deviant group) that occur at developmental stages beyond infancy. The fundamental distinction between the two is the ability to attach emotionally to others and to experience the natural anxiety associated with human attachment. The primary psychopath forms no attachments as a result of early developmental obstruction, and thus is capable of harming others with little or no anxiety. The secondary psychopath forms human attachments, possibly to deviant subgroups, or not. However, whether or not the secondary psychopath appears to be attached to others, emotional connection to other human beings is present.^[123]

Secondary psychopaths show normal to above-normal physiological responses to (perceived) potential threats; their crimes tend to be unplanned and impulsive with little thought of the consequences.^[124] According to those using this theory, this type have hot tempers and are prone to reactive aggression. They experience normal to above-normal levels of anxiety but are nevertheless highly stimulus-seeking and have trouble tolerating boredom. Their lifestyle may lead to depression and even suicide.

Lykken has linked primary psychopathy to mostly Factor 1 traits from the PCL-R (arrogance, callousness, manipulativeness, lying) and secondary psychopathy to a majority of Factor 2 traits (impulsivity, boredom proneness, irresponsibility, lack of long-term goals).^[21]

Mealey uses the term "primary psychopathy" to differentiate between psychopathy that is biological in origin and "secondary psychopathy" that results from a combination of genetic and environmental influences.^[125] Lykken prefers sociopathy to describe the latter.

Sellbom and Ben-Porath (2005) describe the distinction as "Some people who engage in violent behavior possess psychopathic personality traits, such as callousness, grandiosity, and fearlessness, and presumably engage in such conduct because they care little about others. Others are impulsive and experience considerable anger, anxiety, and distress and may commit violent acts as a reaction to negative emotions, which are sometimes referred to as "crimes of passion." Indeed, the distinction between primary and secondary psychopathy (including so-called neurotic psychopathy) has long been noted in the psychopathy literature (Karpman, 1947; Lykken, 1995)."^[126]}}

This distinction closely resembles the distinction between instrumental and impulsive/reactive crime/violence in the field of criminology.^{[citation needed]}

Joseph P. Newman et al., who use this concept of psychopathy, have validated David T. Lykken's conceptualization of psychopathy subtypes in relation to Gray's behavioral activation system and behavioral inhibition system.^[127] Newman et al. found measures of primary psychopathy to be negatively correlated with Gray's behavioral inhibition system, a construct intended to measure behavioral inhibition from cues of punishment or nonreward.^[127] In contrast, measures of secondary psychopathy to be positively correlated with Gray's behavioral activation system, a construct intended to measure sensitivity to cues of behavioral approach.^[127]

Psychopathy vs. sociopathy[link]

Hare writes that the difference between sociopathy and psychopathy may "reflect the user's views on the origins and determinates of the disorder." The term sociopathy may be preferred by sociologists that see the causes as due to social factors. The term psychopathy may be preferred by psychologists who see the causes as due to a combination of psychological, genetic, and environmental factors.^[128]

David T. Lykken proposes psychopathy and sociopathy as two distinct kinds of antisocial personality disorder. He believes psychopaths are born with temperamental differences such as impulsivity, cortical underarousal, and fearlessness that lead them to risk-seeking behavior and an inability to internalize social norms. On the other hand, he claims sociopaths have relatively normal temperaments; their personality disorder being more an effect of negative sociological factors like parental neglect, delinquent peers, poverty, and extremely low or extremely high intelligence. Both personality disorders are the result of an interaction between genetic predispositions and environmental factors, but psychopathy leans towards the hereditary whereas sociopathy tends towards the environmental.^[21]

Miscellaneous[link]

Famous individuals are sometimes diagnosed, perhaps at a distance, as psychopaths. Adolf Hitler was so diagnosed by psychoanalysts before, during and after the second world war. One recent writer, however, argues that he shows examples of not always being egocentric, callously disregarding of feelings, lacking impulse control, or not learning from mistakes. Instead four trends charactericistic of criminality are identified - irresponsibility, self-indulgence, interpersonal intrusiveness, and social rule-breaking.^[129]

A crucial issue regarding the concept of psychopathy is whether it identifies a distinct condition that can be separated from other conditions and 'normal' personality types, or whether it is simply a combination of scores on various dimensions of personality found throughout the population in varying combinations.

Otto Kernberg, from a particular psychoanalytic perspective, believes 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.^[130] However, narcissism as generally defined is only one aspect of psychopathy as generally defined.

Co-occurrence[link]

Psychopaths may have various other mental conditions.^[131] It is difficult to consider psychopathy 'comorbid' with clinical diagnoses when it is not itself a clinical diagnosis, unless considered to mean antisocial personality disorder. The constellation of traits in psychopathy assessments overlaps considerably with ASPD criteria and also with Histrionic personality disorder and Narcissistic personality disorder criteria.^[132]

Psychopathy is associated with substance use disorders. This appears to be linked more closely to anti-social/criminal lifestyle, as measured by Factor 2 of the PCL-R, than the interpersonal-emotional traits assessed by Factor I of the PCL-R.^{[131][133][134]}

Attention deficit hyperactivity disorder (ADHD) is known to be highly comorbid with conduct disorder, and may also co-occur with psychopathic tendencies. This may be explained in part by deficits in executive function.^[131]

Anxiety disorders often co-occur with antisocial personality disorder, and contrary to assumptions psychopathy can sometimes be marked by anxiety; however, this appears to be due to the antisocial aspect (factor 2 of the PCL), and anxiety may be inversely associated with the interpersonal-emotional traits (Factor I of the PCL-R). Depression appears to be inversely associated with psychopathy. There is little evidence for a link between psychopathy and schizophrenia.^[131]

It has been suggested that psychopathy may be comorbid with several other diagnoses than these,^[134] but limited work on comorbidity has been carried out. This may be partly due to difficulties in using inpatient groups from certain institutions to assess comorbidity, owing to the likelihood of some bias in sample selection.^[131]

Comorbidity may be more reflective of poor discriminant validity of categories in the DSM-IV than reflective of actually separate conditions.

Epidemiology[link]

Research by Hare using scores on a questionnaire estimated that approximately one to two percent of the general population score 12 or more which indicates 'potential psychopathy'.^[6]

A 2009 British study reported a community prevalence of psychopathy-related traits of 0.6%, consistent with the estimate given by the screening version of the psychopathy checklist.^[135]

Management[link]

Clinical management[link]

In practice, mental health professionals rarely treat psychopathic personality disorders as they are often considered untreatable and no interventions have proved to be effective.^[136] However, some of the difficulty has been attributed to the lack of clarity about the concept and diagnosis of psychopathy; the threat of danger to staff, or deceit or poor motivation from patients; and a lack of follow-up to test effectiveness. Despite pessimism, as of 1999, treatment of patients still takes place in a variety of psychiatric hospitals and secure units, and the research has indicated that some individuals do show some improvements when the right treatment is identified, and that longer periods of therapy often produce better results.^[137]

It has been shown in some studies that punishment and behavior modification techniques may not improve the behavior of psychopaths. Furthermore, it has been suggested that traditional therapeutic approaches can actually make psychopaths more adept at manipulating others and concealing their behavior. They are considered by some to be not only incurable but also untreatable.^[138]

However, some researchers suggest that psychopaths can benefit as much as others from psychological treatment, at least in terms of criminal behaviours even if not on the central personality traits.^[11] For example, one therapeutic approach to juveniles reports reduced re-offending over a two year period compared to usual care.^[139]

Losel concluded in a review in 1997 that specific therapeutic modalities for psychopathy showed little evidence of impact. He suggested that therapeutic communities might do better when highly structured with clear rules and regulations, however.^[140]

Legal response[link]

United Kingdom[link]

In the United Kingdom, "Psychopathic Disorder" was legally defined in the Mental Health Act (UK)^[141] as, "a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned." This term, which did not equate to psychopathy, was intended to reflect the presence of a personality disorder, in terms of conditions for detention under the Mental Health Act 1983. With the subsequent amendments to the Mental Health Act 1983 within the Mental Health Act 2007, the term 'psychopathic disorder' has been abolished, with all conditions for detention (e.g. mental illness, personality disorder, etc.) now being contained within the generic term of 'mental disorder'.

In England and Wales, the diagnosis of dissocial personality disorder is grounds for detention in secure psychiatric hospitals under the Mental Health Act if they have committed serious crimes, but since such individuals are disruptive for other patients and not responsive to treatment this alternative to prison is not often used.^[142]

United States[link]

Psychopathy has quite separate legal and judicial definitions that should not be confused with the medical definition. The American Psychiatric Association is vigorously opposing any non-medical or legal definition of what purports to be a medical condition "without regard for scientific and clinical knowledge." ^[143] Various states and nations have at various times enacted laws specific to dealing with psychopaths.

In the United States, approximately 20 states currently have provisions for the involuntary civil commitment for sex offenders or sexual predators, under Sexually violent predator acts, avoiding the use of the term "psychopath." These statutes and provisions are controversial and are being reviewed by the U.S. Supreme Court as a violation of a person's Fourteenth Amendment rights,^[144] such as in Foucha v. Louisiana.^[145])

Washington

Washington State Legislature ^[146] defines a "Psychopathic personality" to mean "the existence in any person of such hereditary, congenital or acquired condition affecting the emotional or volitional rather than the intellectual field and manifested by anomalies of such character as to render satisfactory social adjustment of such person difficult or impossible."^[144] The same statute defines the "sexual psychopath" as "any person who is affected in a form of psychoneurosis or in a form of psychopathic personality, which form predisposes such person to the commission of sexual offenses in a degree constituting him a menace to the health or safety of others" for prison sentencing purposes in the Sentencing Reform Act of 1981.^[146]

California

California enacted a psychopathic offender law in 1939, since greatly outmoded and revised,^[147] that defined a psychopath solely in terms of offenders with a predisposition "to the commission of sexual offenses against children." A 1941 law^[148] attempted to further clarify this to the point where anyone examined and found to be psychopathic was to be committed to a state hospital and anyone else was to be sentenced by the courts. However, these laws were enacted years before the American Psychiatric Association began publishing the Diagnostic and Statistical Manual of Mental Disorders which is used today for diagnosis and does not include "psychopathic offender". Hence, these laws are of historical interest only.

History[link]

In very general terms, behaviors related to a modern concept of "antisocial personality" have been informally noted in a brief vignette by Theophrastus in Ancient Greece, whose The Unscrupulous Man "will go and borrow more money from a creditor he has never paid ... When marketing he reminds the butcher of some service he has rendered him and, standing near the scales, throws in some meat, if he can, and a soup-bone. If he succeeds, so much the better; if not, he will snatch a piece of tripe and go off laughing".^[149] Figures of insanity (e.g. vagabonds, libertines, the "mad") have often, at least since the 18th century, represented an image of darkness and threat to society, as would later "the psychopath", a mixture of concepts of dangerousness, evil and illness.^[150]

Clinical concepts that might in some aspects be related to theories of psychopathy today are thought to have emerged in the early 19th century. In 1801, Philippe Pinel described, without moral judgment, patients who appeared mentally unimpaired but who nonetheless engaged in impulsive and self-defeating acts. He described this as Manie sans délire (insanity without confusion or delusion) or la folie raisonnante (rational insanity), and his anecdotes generally described people carried away by instincte fureur (instinctive fury). Benjamin Rush wrote in 1812 about individuals with an apparent "perversion of the moral faculties" which he saw as a sign of innate defective organization. He also saw such people as objects of compassion whose mental alienation could be helped, even if that needed to be in prisons or what he referred to as the "christian system of criminal jurisprudence".^[151] In 1835 James Cowles Prichard developed a broad diagnostic category called moral insanity, referring to "madness" of emotional or moral dispositions without significant delusions or hallucinations. Prichard generally referred more to eccentric behaviour than out of control passions, though his diagnosis became widely used. None of these concepts are directly comparable to later diagnostic categories of psychopathy in the specific sense, or even to personality disorders. Moreover, "moral" did not necessarily refer at that time to morality, it could just mean psychological or emotional.^[152]

The (pseudo) scientific study of individuals thought to lack a conscience flourished in the latter half of the 19th century. Notably, Cesare Lombroso rejected the view that criminality could occur in anyone and sought to identify particular "born criminals" whom he thought showed certain physical signs, such as proportionately long arms or a low and narrow forehead.^[153][154] Towards the turn of the 20th century, Henry Maudsley had begun writing about the "moral imbecile", "moral insanity" and "criminal psychosis". He saw these as genetic disorders for which individuals could be neither punished nor reformed by the correctional system, and applied the concepts to what he saw as a lower class of chronic offenders who he described in various negative ways by comparison to "the higher industrial classes".^[151][155]

In 1891 Julius Ludwig August Koch formally introduced the concept of "psychopathic inferiority" (psychopathischen minderwertigkeiten). This also referred to diverse kinds of dysfunction or strange conduct in the absence of obvious mental illness or retardation. Koch was a Christian and influenced by the degeneration theory popular at the time, though he referred to both congenital and acquired types. Habitual criminality was only a small part of his concept, but the public soon used the shortened version "inferiors" to refer to anyone supposedly suffering from an inherent disposition toward crime.^[156][157]

20th century[link]

Emil Kraepelin included a section on moral insanity in his psychiatric classification scheme but by 1904 was referring to psychopathic conditions. Also influenced by degeneration theory, Kraepelin eventually included several categories involving antisocial or criminal behavior, as well as a dissocial type, including: born criminals (inborn delinquents), liars and swindlers, querulous persons, and driven persons (including vagabonds, spendthrifts, and dipsomaniacs).^[158] After World War I psychiatrists dropped the term "inferiors" (minderwertigkeiten) and used psychopathisch instead, and its derivatives psychopathie and psychopathen. This was an attempt to avoid assumptions of inferiority and degeneracy, and to be neutral and scientific, and referred not just to antisocial behaviors but a wide range of issues.^[157] Kurt Schneider and Karl Birnbaum were also influential in attempting a more scientific classification of psychopathy, defined broadly in terms of abnormal personalities. Schneider proposed a "compassionless" type and a "willenlos" (weak-willed) type; Birnbaum an "amoral" type and a "haltlos" (lacking resilience or stability) type. Birnbaum also used the term "sociopathic", which would become influential from the late 1920s in America.

Nevertheless, in the first decades of the 20th century, "constitutional psychopathic inferiority" became a commonly used term in the US, implying the issue was inherent to the genetics or makeup of the person, an organic disease.^[159] As a category it was used to target any and all dysfunctional or antisocial behavior, and in psychiatric categorization it labeled a broad range of alleged mental deviances, including homosexuality.^[160] Some courts began to develop "psychopathic laboratories" for the classification and treatment of offenders; the term psychopathic was chosen to avoid the social stigma of "lunacy" or "insanity", while emphasizing variance from normality rather than simply a mental hygiene issue.^[161] Nevertheless, at least one such laboratory issued a report on eugenic sterilization initiatives.^[162] From the 1930s, "sexual psychopath" laws (a term going back to Richard von Krafft-Ebing) started to be implemented in many US states, allowing for the indeterminate psychiatric commitment of sex offenders.^[163]

George Partridge, while narrowing the definition of psychopathy to antisocial personality, emphasized that at least some types appeared to be about social maladjustment due to social learning, and argued that the term sociopath should be used.^[164] David Henderson published in 1939 a theory of "psychopathic states" which, although he described different types and unusually suggested that psychopaths might not all be criminals, included a violently antisocial type which ended up contributing to that being the popular meaning of the term.^[159][165] In the 1940s a diagnosis of autistic psychopathy was introduced, later coming to wider notice and renamed Asperger syndrome to avoid the stigma of the term psychopathy.^[166]

The Mask of Sanity by Hervey M. Cleckley, M.D., first published in 1941, is considered a seminal work which provided a vivid series of case studies of individuals described as psychopaths. Cleckley proposed 16 characteristics of psychopathy, derived mainly from his work with male psychiatric patients in a locked institution. The title refers to the "mask" of normal functioning that Cleckley thought concealed the disorganization, amorality and disorder of the psychopathic personality.^[167] This marked the start in America of the current clinical and popularist conception of psychopathy as a particular type of antisocial, emotionless and criminal character.^[168] Cleckley would produce five editions of the book over subsequent decades, including a substantial revision in 1950, expanding his case studies and theories to more non-prisoners and non-criminals.^[43]

The first version of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders in 1952 did not use the term psychopath, but instead "sociopathic personality disturbance", although it included many of Cleckley's criteria. The diagnosis had antisocial or dyssocial subtypes, though the latter was deleted in the DSM-II. The diagnosis was only one within a broader category that would be termed personality disorders.

Cleckley's concept of psychopathy, particularly in the sense of a conscience-less man beneath a mask of normality, caught the public imagination. However, the book fell out of favor, and when he died in 1984 Cleckley was better remembered for a vivid case study of a female patient published in 1956, turned into a movie The Three Faces of Eve in 1957, which had (re)popularized in America another controversial diagnosis, Multiple Personality Disorder.^[169]

A distinction was proposed by psychoanalyst Benjamin Karpman from the 1940s between psychopathy due to psychological problems (e.g. psychotic, hysterical or neurotic conditions) and idiopathic psychopathy where there was no obvious psychological cause. He concluded that the former could not be attributed to a psychopathic personality and that the latter appeared so absent of any redeeming features that it couldn't be seen as a personality issue either, but must be a constitutional "anethopathy" (amorality or antipathy).^[170][122] Various theories of distinctions between primary and secondary psychopathy remain to this day. Meanwhile, criminologist sociologists William and Joan McCord were influential in narrowing the definition of psychopathy to an antisocial lack of the guilt emotion and reactive aggression.^[171][172] On the other hand, various analysts purported to identify "successful" psychopaths in society, some even suggesting it was but an adaption to the social or economic mores of the age, others noting they could be hard to spot either because they were so good at hiding their lack of conscience, or because many people showed the traits to some degree.^[173]

However, there remained no international clinical agreement on the diagnosis of psychopathy. A 1977 study found little relationship with the characteristics commonly attributed to psychopaths and concluded that the concept was being used too widely and loosely.^[174] Robert D. Hare had published a book in 1970 summarizing research on psychopathy, and was subsequently at the forefront of psychopathy research. Frustrated by a lack of agreed definitions or rating systems for psychopathy, including at a ten-day international North Atlantic Treaty Organization conference in 1975, Hare began developing his Psychopathy Checklist. Produced in 1980, it was based partly on the list of traits advanced by Cleckley and partly on the theories of other authors and on his own experiences with clients in prisons. Meanwhile, also in the wake of the NATO conference, a DSM-III task force instead developed the diagnosis of antisocial personality disorder, published in the DSM in 1980.^[175] This was based on some of the criteria put forward by Cleckley but operationalized in behavioral rather than personality terms, more specifically related to conduct. APA was most concerned to demonstrate inter-rater reliability rather than necessarily validity.

Nevertheless, one author referred to the concept of psychopathy in 1987 as an "infinitely elastic, catch-all category".^[176] In 1988, Blackburn wrote in the British Journal of Psychiatry that as commonly used in psychiatry it is little more than a moral judgment masquerading as a clinical diagnosis, and argued that it should be scrapped.^[177] Ellard argued similarly in the same year in the Australian and New Zealand Journal of Psychiatry, describing the concept as 'a reflection of the customs and prejudices of a particular social group. Most psychiatrists are from that group and therefore fail to see the incongruity.'^[178] By the 1970s and 80s the sexual psychopath laws were falling out of favor in many states; the Group for the Advancement of Psychiatry called them a failure based on a confusing label mixing law and psychiatry.^[179]

Hare revised his checklist (PCL-R) as a draft in 1985 (removing two items) and then finalised it as the first edition in 1991. Meanwhile, following some criticism over the lack of psychological criteria in the DSM, further studies were conducted leading up the DSM-IV in 1994 and some personality criteria were included as "associated features" which were outlined in the text.^[180] The World Health Organization's ICD incorporated a similar diagnosis of Dissocial Personality Disorder. Both state that psychopathy (or sociopathy) may be considered synonyms of their diagnosis.

Hare updated the PCL-R with extra data in a 2nd edition in 2003. He has also written two bestsellers on psychopathy, "Without Conscience" in 1993 and "Snakes in Suits" in 2006. Cleckley had described psychopathic patients as "carr[ying] disaster lightly in each hand" and "not deeply vicious", but Hare presented a far more malevolent picture, and the "mask of sanity" acquired a more sinister and Machiavellian meaning.^[181][182]

See also[link]

• Empathy
• Evil
• Fictional portrayals of psychopaths
• Hedonism
• Immorality
• The Mask of Sanity

References[link]