Psychopathy Part II

 

Emotion recognition and empathy

A large body of research suggests that psychopathy is associated with atypical responses to distress cues from other people, more precisely an impaired emotional empathy in the recognition of, and response to, facial expressions, body gestures and vocal tones of fear, sadness, pain and happiness. This impaired recognition and reduced autonomic responsiveness might be partly accounted for by a decreased activation of the fusiform and extra-striate cortical regions. The underlying biological surfaces for processing expressions of happiness are functionally intact in psychopaths, although less responsive than those of controls. The neuroimaging literature is unclear as to whether deficits are specific to particular emotions such as fear. The overall pattern of results across studies indicates that people diagnosed with psychopathy demonstrate reduced MRI, fMRI, aMRI, PET, and SPECT activity in areas of the brain. Research has also shown that an approximate 18% smaller amygdala size contributes to a significantly lower emotional sensation in regards to fear, sadness, amongst other negative emotions, which may likely be the reason as to why psychopathic individuals have lower empathy. Some recent fMRI studies have reported that emotion perception deficits in psychopathy are pervasive across emotions (positives and negatives). Studies on children with psychopathic tendencies have also shown such associations. Meta-analyses have also found evidence of impairments in both vocal and facial emotional recognition for several emotions (i.e., not only fear and sadness) in both adults and children/adolescents.

Moral judgment

Psychopathy has been associated with amorality—an absence of, indifference towards, or disregard for moral beliefs. There are few firm data on patterns of moral judgment. 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 harm would be endorsed in order to achieve the rationally maximum (utilitarian) amount of welfare found no significant differences between subjects high and low in psychopathy. However, a further study using the same tests found that prisoners scoring high on the PCL were more likely to endorse impersonal harm or rule violations than non-psychopathic controls were. The psychopathic offenders who scored low in anxiety were also more willing to endorse personal harm on average.

Assessing accidents, where one person harmed another unintentionally, psychopaths judged such actions to be more morally permissible. This result has been considered a reflection of psychopaths' failure to appreciate the emotional aspect of the victim's harmful experience.

Cause

Behavioral genetic studies have identified potential genetic and non-genetic contributors to psychopathy, including influences on brain function. Proponents of the triarchic model believe that psychopathy results from the interaction of genetic predispositions and an adverse environment. What is adverse may differ depending on the underlying predisposition: for example, it is hypothesized that persons having high boldness may respond poorly to punishment but may respond better to rewards and secure attachments.

Genetic

Genetically informed studies of the personality characteristics typical of individuals with psychopathy have found moderate genetic (as well as non-genetic) influences. On the PPI, fearless dominance and impulsive antisociality were similarly influenced by genetic factors and uncorrelated with each other. Genetic factors may generally influence the development of psychopathy while environmental factors affect the specific expression of the traits that predominate. A study on a large group of children found more than 60% heritability for "callous-unemotional traits" and that conduct disorder among children with these traits has a higher heritability than among children without these traits.

Environment

From accidents such as the one of Phineas Gage, it is known that the prefrontal cortex plays an important role in moral behavior.

A study by Farrington of a sample of London males followed between age 8 and 48 included studying which factors scored 10 or more on the PCL:SV at age 48. The strongest factors included having a convicted parent, being physically neglected, low involvement of the father with the boy, low family income, and coming from a disrupted family. Other significant factors included poor supervision, abuse, harsh discipline, large family size, delinquent sibling, young mother, depressed mother, low social class, and poor housing. There has also been association between psychopathy and detrimental treatment by peers. However, it is difficult to determine the extent of an environmental influence on the development of psychopathy because of evidence of its strong heritability.

Brain injury

Researchers have linked head injuries with psychopathy and violence. Since the 1980s, scientists have associated traumatic brain injury, such as damage to the prefrontal cortex, including the orbitofrontal cortex, with psychopathic behavior and a deficient ability to make morally and socially acceptable decisions, a condition that has been termed "acquired sociopathy", or "pseudo-psychopathy". Individuals with damage to the area of the prefrontal cortex known as the ventromedial prefrontal cortex show remarkable similarities to diagnosed psychopathic individuals, displaying reduced autonomic response to emotional stimuli, deficits in aversive conditioning, similar preferences in moral and economic decision making, and diminished empathy and social emotions like guilt or shame. These emotional and moral impairments may be especially severe when the brain injury occurs at a young age. Children with early damage in the prefrontal cortex may never fully develop social or moral reasoning and become "psychopathic individuals ... characterized by high levels of aggression and antisocial behavior performed without guilt or empathy for their victims". Additionally, damage to the amygdala may impair the ability of the prefrontal cortex to interpret feedback from the limbic system, which could result in uninhibited signals that manifest in violent and aggressive behavior.

Other theories

Evolutionary explanations

Psychopathy is associated with several adverse life outcomes as well as increased risk of disability and death due to factors such as violence, accidents, homicides, and suicides. This, in combination with the evidence for genetic influences, is evolutionarily puzzling and may suggest that there are compensating evolutionary advantages, and researchers within evolutionary psychology have proposed several evolutionary explanations. According to one hypothesis, some traits associated with psychopathy may be socially adaptive, and psychopathy may be a frequency-dependent, socially parasitic strategy, which may work as long as there is a large population of altruistic and trusting individuals, relative to the population of psychopathic individuals, to be exploited. It is also suggested that some traits associated with psychopathy such as early, promiscuous, adulterous, and coercive sexuality may increase reproductive success. Robert Hare has stated that many psychopathic males have a pattern of mating with and quickly abandoning women, and thereby have a high fertility rate, resulting in children that may inherit a predisposition to psychopathy.

Criticism includes that it may be better to look at the contributing personality factors rather than treat psychopathy as a unitary concept due to poor testability. Furthermore, if psychopathy is caused by the combined effects of a very large number of adverse mutations then each mutation may have such a small effect that it escapes natural selection. The personality is thought to be influenced by a very large number of genes and may be disrupted by random mutations, and psychopathy may instead be a product of a high mutation load. Psychopathy has alternatively been suggested to be a spandrel, a byproduct, or side-effect, of the evolution of adaptive traits rather than an adaptation in itself.

Mechanisms

Psychological

Some laboratory research demonstrates correlations between psychopathy and atypical responses to aversive stimuli, including weak conditioning to painful stimuli and poor learning of avoiding responses that cause punishment, as well as low reactivity in the autonomic nervous system as measured with skin conductance while waiting for a painful stimulus but not when the stimulus occurs. While it has been argued that the reward system functions normally, some studies have also found reduced reactivity to pleasurable stimuli. According to the response modulation hypothesis, psychopathic individuals have also had difficulty switching from an ongoing action despite environmental cues signaling a need to do so. This may explain the difficulty responding to punishment, although it is unclear if it can explain findings such as deficient conditioning. There may be methodological issues regarding the research. While establishing a range of idiosyncrasies on average in linguistic and affective processing under certain conditions, this research program has not confirmed a common pathology of psychopathy.

Neurological

Dysfunction of the orbitofrontal cortex, among other areas, is implicated in the mechanism of psychopathy.

Thanks to advancing MRI studies, experts are able to visualize specific brain differences and abnormalities of individuals with psychopathy in areas that control emotions, social interactions, ethics, morality, regret, impulsivity and conscience within the brain. Blair, a researcher who pioneered research into psychopathic tendencies stated, "With regard to psychopathy, we have clear indications regarding why the pathology gives rise to the emotional and behavioral disturbance and important insights into the neural systems implicated in this pathology". Dadds et al., remarks that despite a rapidly advancing neuroscience of empathy, little is known about the developmental underpinnings of the psychopathic disconnect between affective and cognitive empathy.

A 2008 review by Weber et al. suggested that psychopathy is sometimes associated with brain abnormalities in prefrontal-temporo-limbic regions that are involved in emotional and learning processes, among others. Neuroimaging studies have found structural and functional differences between those scoring high and low on the PCL-R in a 2011 review by Skeem et al. stating that they are "most notably in the amygdala, hippocampus and para-hippocampal gyri, anterior and posterior cingulate cortex, striatum, insula, and frontal and temporal cortex".

The amygdala and frontal areas have been suggested as particularly important. People scoring 25 or higher in the PCL-R, with an associated history of violent behavior, appear on average to have significantly reduced microstructural integrity between the white matter connecting the amygdala and orbitofrontal cortex (such as the uncinate fasciculus). The evidence suggested that the degree of abnormality was significantly related to the degree of psychopathy and may explain the offending behaviors. Furthermore, changes in the amygdala have been associated with "callous-unemotional" traits in children. However, the amygdala has also been associated with positive emotions, and there have been inconsistent results in the studies in particular areas, which may be due to methodological issues.

Some of these findings are consistent with other research and theories. For example, in a neuroimaging study of how individuals with psychopathy respond to emotional words, widespread differences in activation patterns have been shown across the temporal lobe when psychopathic criminals were compared to "normal" volunteers, which is consistent with views in clinical psychology. Additionally, the notion of psychopathy being characterized by low fear is consistent with findings of abnormalities in the amygdala, since deficits in aversive conditioning and instrumental learning are thought to result from amygdala dysfunction, potentially compounded by orbitofrontal cortex dysfunction, although the specific reasons are unknown.

Considerable research has documented the presence of the two subtypes of primary and secondary psychopathy. Proponents of the primary-secondary psychopathy distinction and triarchic model argue that there are neurological differences between these subgroups of psychopathy which support their views. For instance, the boldness factor in the triarchic model is argued to be associated with reduced activity in the amygdala during fearful or aversive stimuli and reduced startle response, while the disinhibition factor is argued to be associated with impairment of frontal lobe tasks. There is evidence that boldness and disinhibition are genetically distinguishable.

Biochemical

High levels of testosterone combined with low levels of cortisol and/or serotonin have been theorized as contributing factors. Testosterone is "associated with approach-related behavior, reward sensitivity, and fear reduction", and injecting testosterone "shift[s] the balance from punishment to reward sensitivity", decreases fearfulness, and increases "responding to angry faces". Some studies have found that high testosterone levels are associated with antisocial and aggressive behaviors, yet other research suggests that testosterone alone does not cause aggression but increases dominance-seeking. It is unclear from studies if psychopathy correlates with high testosterone levels, but a few studies have found that disruption of serotonin neurotransmission disrupts cortisol reactivity to a stress-inducing speech task. Thus, dysregulation of serotonin in the brain may contribute to the low cortisol levels observed in psychopathy. Cortisol increases withdrawal behavior and sensitivity to punishment and aversive conditioning, which are abnormally low in individuals with psychopathy and may underlie their impaired aversion learning and disinhibited behavior. High testosterone levels combined with low serotonin levels are associated with "impulsive and highly negative reactions", and may increase violent aggression when an individual is provoked or becomes frustrated. Several animal studies note the role of serotonergic functioning in impulsive aggression and antisocial behavior.

However, some studies on animal and human subjects have suggested that the emotional-interpersonal traits and predatory aggression of psychopathy, in contrast to impulsive and reactive aggression, is related to increased serotoninergic functioning. A study by Dolan and Anderson, regarding the relationship between serotonin and psychopathic traits in a sample of personality disordered offenders, found that serotonin functioning as measured by prolactin response, while inversely associated with impulsive and antisocial traits, were positively correlated with arrogant and deceitful traits, and, to a lesser extent, callous and remorseless traits. Bariş Yildirim theorizes that the 5-HTTLPR "long" allele, which is generally regarded as protective against internalizing disorders, may interact with other serotoninergic genes to create a hyper-regulation and dampening of affective processes that result in psychopathy's emotional impairments. Furthermore, the combination of the 5-HTTLPR long allele and high testosterone levels has been found to result in a reduced response to threat as measured by cortisol reactivity, which mirrors the fear deficits found in those with psychopathy.

Studies have suggested other correlations. Psychopathy was associated in two studies with an increased ratio of HVA (a dopamine metabolite) to 5-HIAA (a serotonin metabolite). Studies have found 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 increased impulsivity. 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".

Findings have also shown monoamine oxidase A to affect the predictive ability of the PCL-R. Monoamine oxidases (MAOs) are enzymes that are involved in the breakdown of neurotransmitters such as serotonin and dopamine and are, therefore, capable of influencing feelings, mood, and behavior in individuals. Findings suggest that further research is needed in this area.

Diagnosis

Tools

Psychopathy Checklist

Psychopathy is most commonly assessed with the Psychopathy Checklist, Revised (PCL-R), created by Robert D. Hare based on Cleckley's criteria from the 1940s, criminological concepts such as those of William and Joan McCord, and his own research on criminals and incarcerated offenders in Canada. The PCL-R is widely used and is referred to by some as the "gold standard" for assessing psychopathy. There are nonetheless numerous criticisms of the PCL-R as a theoretical tool and in real-world usage.

Psychopathic Personality Inventory

Unlike the PCL, the Psychopathic Personality Inventory (PPI) was developed to comprehensively index personality traits without explicitly referring to antisocial or criminal behaviors themselves. It is a self-report scale that was developed originally for 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 and now comprises 154 items organized into eight subscales. The item scores have been found to group into two overarching and largely separate factors (unlike the PCL-R factors), Fearless-Dominance and Impulsive Antisociality, plus a third factor, Cold-heartedness, which is largely dependent on scores on the other two Factor 1 is associated with social efficacy while Factor 2 is associated with maladaptive tendencies. A person may score at different levels on the different factors, but the overall score indicates the extent of psychopathic personality.

Triarchic Psychopathy Measure

The Triarchic Psychopathy Measure, otherwise known as the TriPM, is a 58-item, self-report assessment that measures psychopathy within the three traits identified in the triarchic model: boldness, meanness and disinhibition. Each trait is measured on separate subscales and added up resulting in a total psychopathy score.

The TriPM includes various components of other measures for assessing psychopathy, including meanness and disinhibition patterns within the psychopathic personality. However, there are differing approaches in the measurement of the boldness construct. The boldness construct is used to highlighting the social and interpersonal implications of the psychopathic personality.

DSM and ICD

There are currently two widely established systems for classifying mental disorders—the International Classification of Diseases (ICD) produced by the World Health Organization (WHO) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) 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 first edition of the DSM in 1952 had a section on sociopathic personality disturbances, then a general term that included such things as homosexuality and alcoholism as well as an "antisocial reaction" and "dissocial reaction". The latter two eventually became antisocial personality disorder (ASPD) in the DSM and dissocial personality disorder in the ICD. Both manuals have stated that their diagnoses have been referred to, or include what is referred to, as psychopathy or sociopathy, although neither diagnostic manual has ever included a disorder officially titled as such.

Other tools

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), California Psychological Inventory (Socialization scale), and 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), but in terms of self-report tests, the PPI/PPI-R has become more used than either of these in modern psychopathy research on adults.

Comorbidity

Studies suggest strong comorbidity between psychopathy and antisocial personality disorder. Among numerous studies, positive correlations have also been reported between psychopathy and histrionic, narcissistic, borderline, paranoid, and schizoid personality disorders, panic and obsessive–compulsive disorders, but not neurotic disorders in general, schizophrenia, or depression.

Factor 1 and the boldness scale of psychopathy measurements are associated with narcissism and histrionic personality disorder. This is due to a psychopath's cognitive and affective egocentrism. However, while a narcissistic individual might view themselves as confident, they might seek out validation and attention from others to validate their self-worth, whereas a psychopathic individual usually lacks such ambitions.

Attention deficit hyperactivity disorder (ADHD) is known to be highly comorbid with conduct disorder (a theorized precursor to ASPD), and may also co-occur with psychopathic tendencies. This may be explained in part by deficits in executive function. Anxiety disorders often co-occur with ASPD, and contrary to assumptions, psychopathy can sometimes be marked by anxiety; this appears to be related to items from Factor 2 but not Factor 1 of the PCL-R. Psychopathy is also associated with substance use disorders.

Michael Fitzgerald suggested overlaps between (primary) psychopathy and Asperger Syndrome in terms of fearlessness, planning of acts, empathy deficits, callous behavior, and sometimes superficial charisma. Studies investigating similarities and differences between psychopathy and autism indicate that autism and psychopathy are not part of the same construct. Rather both conditions might co-occur in some individuals. Recent studies indicate that some individuals with an autism diagnosis also show callous and unemotional traits (a risk-factor for developing psychopathy), but are less strongly associated with conduct problems. Likewise, some people with an Asperger Syndrome Diagnosis have shown correlations with the "unemotional" factor and "behavioral dyscontrol" factor of psychopathy, but not the "interpersonal" factor.

It has been suggested that psychopathy may be comorbid with several other conditions than these, 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.

Sex differences

Research on psychopathy has largely been done on men and the PCL-R was developed using mainly male criminal samples, raising the question of how well the results apply to women. Men score higher than women on both the PCL-R and the PPI and on both of their main scales. The differences tend to be somewhat larger on the interpersonal-affective scale than on the antisocial scale. Most but not all studies have found broadly similar factor structure for men and women.

Many associations with other personality traits are similar, although in one study the antisocial factor was more strongly related with impulsivity in men and more strongly related with openness to experience in women. It has been suggested that psychopathy in men manifest more as an antisocial pattern while in women it manifests more as a histrionic pattern. Studies on this have shown mixed results. PCL-R scores may be somewhat less predictive of violence and recidivism in women. On the other hand, psychopathy may have a stronger relationship with suicide and possibly internalizing symptoms in women. A suggestion is that psychopathy manifests more as externalizing behaviors in men and more as internalizing behaviors in women. Furthermore, one study has suggested substantial gender differences were found in the etiology of psychopathy. For girls, 75% of the variance in severe callous and unemotional traits was attributable to environmental factors and just 0% of the variance was attributable to genetic factors. In boys, the link was reversed.

Studies have also found that women in prison score significantly lower on psychopathy than men; with one study reporting only 11 percent of violent females in prison met the psychopathy criteria in comparison to 31 percent of violent males. Other studies have also indicated that high psychopathic females are rare in forensic settings.

Management

Clinical

Psychopathy has often been considered untreatable. Its unique characteristics makes it among the most refractory of personality disorders, a class of mental illnesses that are already traditionally considered difficult to treat. People with psychopathy are generally unmotivated to seek treatment for their condition, and can be uncooperative in therapy. Attempts to treat psychopathy with the current tools available to psychiatry have been disappointing. Harris and Rice's Handbook of Psychopathy says that there is currently little evidence for a cure or effective treatment for psychopathy; as yet, no pharmacological therapies are known to or have been trialed for alleviating the emotional, interpersonal and moral deficits of psychopathy, and patients with psychopathy who undergo psychotherapy might gain the skills to become more adept at the manipulation and deception of others and be more likely to commit crime. Some studies suggest that punishment and behavior modification techniques are ineffective at modifying the behavior of psychopathic individuals as they are insensitive to punishment or threat. These failures have led to a widely pessimistic view on its treatment prospects, a view that is exacerbated by the little research being done into psychopathy compared to the efforts committed to other mental illnesses, which makes it more difficult to gain the understanding of this condition that is necessary to develop effective therapies.

Although the core character deficits of highly psychopathic individuals are likely to be highly incorrigible to the currently available treatment methods, the antisocial and criminal behavior associated with it may be more amenable to management, the management of which being the main aim of therapy programs in correctional settings. It has been suggested that the treatments that may be most likely to be effective at reducing overt antisocial and criminal behavior are those that focus on self-interest, emphasizing the tangible, material value of pro-social behavior, with interventions that develop skills to obtain what the patient wants out of life in pro-social rather than antisocial ways. To this end, various therapies have been tried with the aim of reducing the criminal activity of incarcerated offenders with psychopathy, with mixed success. As psychopathic individuals are insensitive to sanction, reward-based management, in which small privileges are granted in exchange for good behavior, has been suggested and used to manage their behavior in institutional settings.

Psychiatric medications may also alleviate co-occurring conditions sometimes associated with psychopathy or with symptoms such as aggression or impulsivity, including antipsychotic, antidepressant or mood-stabilizing medications, although none have yet been approved by the FDA for this purpose. For example, a study found that the antipsychotic clozapine may be effective in reducing various behavioral dysfunctions in a sample of high-security hospital inpatients with antisocial personality disorder and psychopathic traits. However, research into the pharmacological treatment of psychopathy and the related condition antisocial personality disorder is minimal, with much of the knowledge in this area being extrapolations based on what is known about pharmacology in other mental disorders.

Legal

The PCL-R, the PCL: SV, and the PCL:YV are highly regarded and widely used in criminal justice settings, particularly in North America. They may be used for risk assessment and for assessing treatment potential and be used as part of the decisions regarding bail, sentence, which prison to use, parole, and regarding whether a youth should be tried as a juvenile or as an adult. There have been several criticisms against its use in legal settings. They include the general criticisms against the PCL-R, the availability of other risk assessment tools which may have advantages, and the excessive pessimism surrounding the prognosis and treatment possibilities of those who are diagnosed with psychopathy.

The interrater reliability of the PCL-R can be high when used carefully in research but tend to be poor in applied settings. In particular Factor 1 items are somewhat subjective. In sexually violent predator cases the PCL-R scores given by prosecution experts were consistently higher than those given by defense experts in one study. The scoring may also be influenced by other differences between raters. In one study it was estimated that of the PCL-R variance, about 45% was due to true offender differences, 20% was due to which side the rater testified for, and 30% was due to other rater differences.

To aid a criminal investigation, certain interrogation approaches may be used to exploit and leverage the personality traits of suspects thought to have psychopathy and make them more likely to divulge information.

United Kingdom

The PCL-R score cut-off for a label of psychopathy is 25 out of 40 in the United Kingdom, instead of 30 as it is in the United States.

In the United Kingdom, "psychopathic disorder" was legally defined in the Mental Health Act (UK), under MHA1983, 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 was intended to reflect the presence of a personality disorder in terms of conditions for detention under the Mental Health Act 1983. Amendments to MHA1983 within the Mental Health Act 2007 abolished the term "psychopathic disorder", with all conditions for detention (e.g. mental illness, personality disorder, etc.) encompassed by 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 to other patients and not responsive to usual treatment methods this alternative to traditional incarceration is often not used.

United States

"Sexual psychopath" laws

Starting in the 1930s, before some modern concepts of psychopathy were developed, "sexual psychopath" laws, the term referring broadly to mental illness, were introduced by some states, and by the mid-1960s more than half of the states had such laws. Sexual offenses were considered to be caused by underlying mental illnesses, and it was thought that sex offenders should be treated, in agreement with the general rehabilitative trends at this time. Courts committed sex offenders to a mental health facility for community protection and treatment.

Starting in 1970, many of these laws were modified or abolished in favor of more traditional responses such as imprisonment due to criticism of the "sexual psychopath" concept as lacking scientific evidence, the treatment being ineffective, and predictions of future offending being dubious. There were also a series of cases where persons treated and released committed new sexual offenses. Starting in the 1990s, several states have passed sexually dangerous person laws, including registration, housing restrictions, public notification, mandatory reporting by health care professionals, and civil commitment, which permits indefinite confinement after a sentence has been completed. Psychopathy measurements may be used in the confinement decision process.

Prognosis

The prognosis for psychopathy in forensic and clinical settings is quite poor, with some studies reporting that treatment may worsen the antisocial aspects of psychopathy as measured by recidivism rates, though it is noted that one of the frequently cited studies finding increased criminal recidivism after treatment, a 2011 retrospective study of a treatment program in the 1960s, had several serious methodological problems and likely would not be approved of today. However, some relatively rigorous quasi-experimental studies using more modern treatment methods have found improvements regarding reducing future violent and other criminal behavior, regardless of PCL-R scores, although none were randomized controlled trials. Various other studies have found improvements in risk factors for crime such as substance abuse. No study has yet examined whether the personality traits that form the core character disturbances of psychopathy could be changed by such treatments.

Frequency

A 2008 study using the PCL: SV found that 1.2% of a US sample scored 13 or more out of 24, indicating "potential psychopathy". The scores correlated significantly with violence, alcohol use, and lower intelligence. A 2009 British study by Coid et al., also using the PCL: SV reported a community prevalence of 0.6% scoring 13 or more. However, if the scoring was adjusted to the recommended 18 or more, this would have left the prevalence closer to 0.1%. The scores correlated with younger age, male gender, suicide attempts, violence, imprisonment, homelessness, drug dependence, personality disorders (histrionic, borderline and antisocial), and panic and obsessive–compulsive disorders.

Psychopathy has a much higher prevalence in the convicted and incarcerated population, where it is thought that an estimated 15–25% of prisoners qualify for the diagnosis. A study on a sample of inmates in the UK found that 7.7% of the inmates interviewed met the PCL-R cut-off of 30 for a diagnosis of psychopathy. A study on a sample of inmates in Iran using the PCL: SV found a prevalence of 23% scoring 18 or more. A study by Nathan Brooks from Bond University found that around one in five corporate bosses display clinically significant psychopathic traits - a proportion similar to that among prisoners.

Society and culture

In the workplace

There is limited research on psychopathy in the general work populace, in part because the PCL-R includes antisocial behavior as a significant core factor (obtaining a PCL-R score above the threshold is unlikely without having significant scores on the antisocial-lifestyle factor) and does not include positive adjustment characteristics, and most researchers have studied psychopathy in incarcerated criminals, a relatively accessible population of research subjects.

However, psychologists Fritzon and Board, in their study comparing the incidence of personality disorders in business executives against criminals detained in a mental hospital, found that the profiles of some senior business managers contained significant elements of personality disorders, including those referred to as the "emotional components", or interpersonal-affective traits, of psychopathy. Factors such as boldness, disinhibition, and meanness as defined in the triarchic model, in combination with other advantages such as a favorable upbringing and high intelligence, are thought to correlate with stress immunity and stability, and may contribute to this particular expression. Such individuals are sometimes referred to as "successful psychopaths" or "corporate psychopaths" and they may not always have extensive histories of traditional criminal or antisocial behavior characteristic of the traditional conceptualization of psychopathy. Robert Hare claims that the prevalence of psychopathic traits is higher in the business world than in the general population, reporting that while about 1% of the general population meets the clinical criteria for psychopathy, figures of around 3–4% have been cited for more senior positions in business. Hare considers newspaper tycoon Robert Maxwell to have been a strong candidate as a "corporate psychopath".

Academics on this subject believe that although psychopathy is manifested in only a small percentage of workplace staff, it is more common at higher levels of corporate organizations, and its negative effects (for example, increased bullying, conflict, stress, staff turnover, absenteeism, reduction in productivity) often causes a ripple effect throughout an organization, setting the tone for an entire corporate culture. Employees with the disorder are self-serving opportunists, and may disadvantage their own organizations to further their own interests. They may be charming to staff above their level in the workplace hierarchy, aiding their ascent through the organization, but abusive to staff below their level, and can do enormous damage when they are positioned in senior management roles. Psychopathy as measured by the PCL-R is associated with lower performance appraisals among corporate professionals. The psychologist Oliver James identifies psychopathy as one of the dark triadic traits in the workplace, the others being narcissism and Machiavellianism, which, like psychopathy, can have negative consequences.

According to a study from the University of Notre Dame published in the Journal of Business Ethics, psychopaths have a natural advantage in workplaces overrun by abusive supervision, and are more likely to thrive under abusive bosses, being more resistant to stress, including interpersonal abuse, and having less of a need for positive relationships than others.

In fiction

Characters with psychopathy or sociopathy are some of the most notorious characters in film and literature, but their characterizations may only vaguely or partly relate to the concept of psychopathy as it is defined in psychiatry, criminology, and research. The character may be identified as having psychopathy within the fictional work itself, by its creators, or from the opinions of audiences and critics, and may be based on undefined popular stereotypes of psychopathy. Characters with psychopathic traits have appeared in Greek and Roman mythology, Bible stories, and some of Shakespeare's works.

Such characters are often portrayed in an exaggerated fashion and typically in the role of a villain or antihero, where the general characteristics and stereotypes associated with psychopathy are useful to facilitate conflict and danger. Because the definitions, criteria, and popular conceptions throughout its history have varied over the years and continue to change even now, many of the characters characterized as psychopathic in notable works at the time of publication may no longer fit the current definition and conception of psychopathy. There are several archetypal images of psychopathy in both lay and professional accounts which only partly overlap and can involve contradictory traits: the charming con artist, the deranged serial killer and mass murderer, the callous and scheming businessperson, and the chronic low-level offender and juvenile delinquent. The public concept reflects some combination of fear of a mythical bogeyman, the disgust and intrigue surrounding evil, and fascination and sometimes perhaps envy of people who might appear to go through life without attachments and unencumbered by guilt, anguish or insecurity.