Journal of Clinical Pharmacy and Therapeutics, 2014, 39, 485–495
doi: 10.1111/jcpt.12182
Review Article
Psychopathy: clinical features, developmental basis and therapeutic challenges D. F. Thompson Pharm D FASHP FCCP, C. L. Ramos PhD RPh and J. K. Willett Pharm D Candidate College of Pharmacy, Southwestern Oklahoma State University, Weatherford, OK, USA
Received 4 November 2013, Accepted 23 April 2014
Keywords: antisocial personality disorder, drug therapy, psychopathy, sociopathy
environmental factors likely contribute to the developmental basis of psychopathy, these factors are poorly understood at present. To date, limited studies with pharmacologic interventions in psychopathy are available and there are insufficient trials to determine efficacy. What is new and conclusion: Psychopathy is a serious personality disorder with profound negative effects on individuals and society. To design rational therapeutic strategies for this disorder, additional research is needed to discover the specific pathological and pathophysiological basis of psychopathy and to further elucidate the genetic and environmental factors responsible for psychopathic development. There is emerging evidence of phenotypic variants in psychopathy, including successful and unsuccessful types. It is important for clinicians to be cognizant of the psychopathic personality.
SUMMARY What is known and objective: Psychopathy is a personality disorder characterized by deficits in personality and behaviour. Personality deficits are marked by interpersonal and affective facets, including pathological lying, grandiose sense of selfworth, lack of remorse and callousness. Behavioural deficits are defined by lifestyle and antisocial deficits, including impulsivity, parasitic lifestyle and poor behavioural controls. The objective of this review is to provide clinicians with (i) an appreciation of the clinical features of psychopathy, (ii) an understanding of the structural and functional derangements and the genetic and environmental factors which serve as the basis for the development of psychopathy and (iii) a summary of published reports of pharmacological approaches to the management of this disorder. Methods: A literature search of MEDLINE/PubMed (1966–present) was conducted using the MeSH search terms psychopathy and antisocial personality disorder alone and in combination with the subheading drug therapy. Additional databases included Web of Science (1945–present) and International Pharmaceutical Abstracts (1970–present) using the text words psychopath and antisocial personality were searched. A search of Amazon books using the search terms psychopathy and sociopathy was also performed. Bibliographies of relevant articles were searched for additional citations. All data sources in English were considered for inclusion. For background information, broad subject headings were searched for review articles first. Human and animal drug therapy articles were evaluated giving preference to those papers using a controlled trial methodology. Results and Discussion: Psychopathy is a personality disorder characterized by a lack of conscience, pathologic lying, manipulative behaviour and often superficial charm. The incidence of psychopathy in the general population is generally considered to be 06–4% with a higher proportion of males to females. Brain imaging studies of psychopaths suggest a smaller and less active amygdala and prefrontal cortex. There also appear to be physiological derangements in psychopathy, including alterations/dysregulation in neurotransmitter homeostasis (dopamine and serotonin), altered endocrine responses (testosterone and cortisol) and altered autonomic responses to emotional stimuli and stressors. Although both genetic and
WHAT IS KNOWN AND OBJECTIVE The Diagnostic and Statistical Manual 5 (DSM-5) is the gold standard reference for classifying mental disorders in the United States1 (Table 1). The DSM-5 outlines personality disorders involving long standing, chronic dysfunctional patterns of activity. There are three clusters under personality disorders: Cluster A, Cluster B and Cluster C, with antisocial personality disorder considered a ‘Cluster B’ disorder. Diagnoses among these three clusters are not considered mutually exclusive. The disorders are generally categorized into these clusters based on clinical similarities rather than an underlying understanding of a specific pathophysiologic mechanism. Psychopathy, sociopathy and antisocial personality disorder have often been used synonymously to describe the same disorder. However, these terms describe distinct disorders and must be differentiated. Antisocial personality disorder is generally diagnosed as a behavioural condition associated with a history of antisocial and criminal behaviour. Psychopathy and sociopathy are dispositional conditions that primarily emphasize personality traits. The DSM-5 has emphasized the observable components of the disorder that a clinician could assess objectively, generally considered factor 2 items, rather than the more subjective personality traits such as lack of empathy, egocentricity and lack of guilt, associated with factor 1 items (Table 2). This has resulted in some confusion in the diagnosis of the syndrome, and the DSM5 term antisocial personality disorder probably casts a wider diagnostic net than the diagnosis of psychopathy. In the DSM-5, an alternative model for personality disorders describes psychopathy as a distinct variant of antisocial personality disorder with characteristics such as lack of fear and a bold interpersonal style. Fortunately, we have the Psychopathy Checklist – Revised
Correspondence: D. F. Thompson, Pharm. D., Dean, College of Pharmacy, Southwestern Oklahoma State University, 100 Campus Drive, Weatherford, OK 73096, USA. Tel.: +1 580 774 3764; fax: +1 580 774 1201; e-mail: [email protected]
© 2014 John Wiley & Sons Ltd
485
D. F. Thompson et al.
Psychopathy review Table 1. Diagnostic and statistical manual 5 (DSM 5)1: [645] personality disorders
acquired, affective disturbances resulting from early socialization forces. Secondary psychopaths are often characterized as being withdrawn, hostile and having comorbid emotional problems.2,7 Obviously, there is not a clear distinction in the origin of these disorders and the true aetiology probably lies somewhere in a complex interaction of genetic and environmental forces.8 The other major distinction between these two variants is the level of anxiety experienced by these individuals.2,7 Primary psychopaths have a low level of anxiety in contrast to sociopaths who may present with a relatively high level of anxiety. These distinctions can also be reflected in the PCL-R scores, where primary psychopaths tend to score higher on factor 1 attributes and lower on factor 2 attributes relative to sociopaths, who score lower on factor 1 and higher on factor 2.2,7 Because the terminology in the field can be confusing, we will use the term ‘psychopath’ or ‘psychopathy’ throughout this paper to refer primarily to the classic construct of primary psychopathy. It is likely that further variants of the psychopath construct will emerge as further work continues in this area. The purpose of this paper is to review the current literature on the personality disorder of psychopathy. Background on this disorder along with structural and functional brain deficit studies, current and potential pharmacotherapy and the likely implications of this mental disorder for clinicians are reviewed and discussed. Psychopaths are ubiquitous. They have existed throughout history and across all socio-economic, racial, ethnic, gender and cultural divisions. Native Alaskan peoples call individuals with psychopathic traits ‘kunlangeta.’ When asked how kunlangeta are dealt with in their culture, they reply, ‘Somebody would have pushed them off the ice when nobody else was looking.’9 Because of the high incidence of psychopathy in the general population, the charming and charismatic nature of these individuals, and the ‘masks’ that they wear, many people are taken in by psychopaths. It is difficult to explain how a psychopath sees the world. Because they lack a conscience, their understanding of the world is radically different from normal individuals. These individuals have a shallow, superficial understanding of emotions, yet at the same time, they can mimic emotions masterfully thereby fooling people into thinking they are caring and emotionally normal. It may be similar to a colour-blind person looking at a traffic light. They know the top light is red and act accordingly, but they have no understanding of what the colour ‘red’ really is.10 Author Martha Stout, PhD., has captured the essence of psychopathy in the following excerpt from her book The Sociopath Next Door: The Ruthless vs. the Rest of Us.10 ‘Imagine, if you can, not having a conscience, none at all, no feelings of guilt or remorse no matter what you do, no limiting sense of concern of the well-being of strangers, friends, or even family members. Imagine no struggles with shame, not a single one in your whole life, no matter what kind of selfish, lazy, harmful, or immoral action you had taken. And pretend that the concept of responsibility is unknown to you, except as a burden others seem to accept without question, like gullible fools. Now add to this strange fantasy the ability to conceal from other people that your psychological makeup is radically different from theirs. Since everyone simply assumes that conscience is universal among human beings, hiding the fact that you are conscience-free is nearly effortless. You are not held back from any of your desires by guilt or shame, and you are never confronted by others for your coldbloodedness. The ice water in your veins is so bizarre, so completely outside of their personal experience that they seldom even guess at your condition.
Cluster A: Paranoid, Schizoid and Schizotypal Cluster B: Histrionic, Narcissistic, Antisocial and Borderline Cluster C: Avoidant, Dependent and Obsessive-Compulsive
Table 2. Items in the revised psychopathy checklist (PCL-R)16 and arranged by factor, facets and items Glibness/Superficial Charm Grandiose sense of self-worth Need for stimulation/Proneness to boredom Pathological lying Conning/Manipulative Lack of remorse or guilt Shallow affect Callous/Lack of empathy Parasitic lifestyle Poor behavioural controls Promiscuous sexual behaviour Early behavioural problems Lack of realistic, long-term goals Impulsivity Irresponsibility Failure to accept responsibility for own actions Many short-term marital relationships Juvenile delinquency Revocation of conditional release Criminal versatility Factor 1: Interpersonal-affective scale Interpersonal facet (Facet 1) Glibness/Superficial charm Grandiose sense of self-worth Pathological lying Conning/Manipulative Affective facet (Facet 2) Lack of remorse or guilt Shallow affect Callous/Lack of empathy Failure to accept responsibility for own actions Factor 2: Antisocial scale Lifestyle facet (Facet 3) Need for stimulation/Proneness to boredom Impulsivity Irresponsibility Parasitic lifestyle Lack of realistic, long-term goals Antisocial facet (Facet 4) Early behavioural problems Poor behavioural controls Juvenile delinquency Revocation of conditional release Criminal versatility
(PCL-R), discussed later in the paper, that provides a valid, reliable instrument to identify psychopathy. Although psychopathy is often treated as a single construct, there are a number of variants emerging with the growing body of research and theory.2–4 The classic distinction has been made between primary and secondary psychopaths.5,6 Primary psychopaths are characterized as having an inheritable, biologically acquired, affective deficit. These individuals tend to be confident, dominant and free from negative emotions. Secondary psychopaths, often referred to as sociopaths, are conceptualized as having
© 2014 John Wiley & Sons Ltd
Journal of Clinical Pharmacy and Therapeutics, 2014, 39, 485–495 486
D. F. Thompson et al.
Psychopathy review
pain and anguish. Psychopaths are often impulsive and exhibit poor behaviour control. A typical response from a psychopath is ‘I did it because I felt like it.’ However, this impulsivity may not be a central construct in psychopathy. Poythress and Hall17 have questioned the universality of impulsivity in psychopathy and provide evidence that many ‘successful psychopaths’ may be able to control much of their underlying impulsive traits. More data will be needed to clearly understand all the reproducible features of this complex construct. As a result of many of these traits, most psychopaths often voice specific goals they want to achieve but have little understanding of how to achieve them and they end up with failed marriages, incomplete educations and poor work records. Implicit within the PCL-R is a history of antisocial behaviour from an early age; however, psychopathy should never be diagnosed in individuals
doi: 10.1111/jcpt.12182
Review Article
Psychopathy: clinical features, developmental basis and therapeutic challenges D. F. Thompson Pharm D FASHP FCCP, C. L. Ramos PhD RPh and J. K. Willett Pharm D Candidate College of Pharmacy, Southwestern Oklahoma State University, Weatherford, OK, USA
Received 4 November 2013, Accepted 23 April 2014
Keywords: antisocial personality disorder, drug therapy, psychopathy, sociopathy
environmental factors likely contribute to the developmental basis of psychopathy, these factors are poorly understood at present. To date, limited studies with pharmacologic interventions in psychopathy are available and there are insufficient trials to determine efficacy. What is new and conclusion: Psychopathy is a serious personality disorder with profound negative effects on individuals and society. To design rational therapeutic strategies for this disorder, additional research is needed to discover the specific pathological and pathophysiological basis of psychopathy and to further elucidate the genetic and environmental factors responsible for psychopathic development. There is emerging evidence of phenotypic variants in psychopathy, including successful and unsuccessful types. It is important for clinicians to be cognizant of the psychopathic personality.
SUMMARY What is known and objective: Psychopathy is a personality disorder characterized by deficits in personality and behaviour. Personality deficits are marked by interpersonal and affective facets, including pathological lying, grandiose sense of selfworth, lack of remorse and callousness. Behavioural deficits are defined by lifestyle and antisocial deficits, including impulsivity, parasitic lifestyle and poor behavioural controls. The objective of this review is to provide clinicians with (i) an appreciation of the clinical features of psychopathy, (ii) an understanding of the structural and functional derangements and the genetic and environmental factors which serve as the basis for the development of psychopathy and (iii) a summary of published reports of pharmacological approaches to the management of this disorder. Methods: A literature search of MEDLINE/PubMed (1966–present) was conducted using the MeSH search terms psychopathy and antisocial personality disorder alone and in combination with the subheading drug therapy. Additional databases included Web of Science (1945–present) and International Pharmaceutical Abstracts (1970–present) using the text words psychopath and antisocial personality were searched. A search of Amazon books using the search terms psychopathy and sociopathy was also performed. Bibliographies of relevant articles were searched for additional citations. All data sources in English were considered for inclusion. For background information, broad subject headings were searched for review articles first. Human and animal drug therapy articles were evaluated giving preference to those papers using a controlled trial methodology. Results and Discussion: Psychopathy is a personality disorder characterized by a lack of conscience, pathologic lying, manipulative behaviour and often superficial charm. The incidence of psychopathy in the general population is generally considered to be 06–4% with a higher proportion of males to females. Brain imaging studies of psychopaths suggest a smaller and less active amygdala and prefrontal cortex. There also appear to be physiological derangements in psychopathy, including alterations/dysregulation in neurotransmitter homeostasis (dopamine and serotonin), altered endocrine responses (testosterone and cortisol) and altered autonomic responses to emotional stimuli and stressors. Although both genetic and
WHAT IS KNOWN AND OBJECTIVE The Diagnostic and Statistical Manual 5 (DSM-5) is the gold standard reference for classifying mental disorders in the United States1 (Table 1). The DSM-5 outlines personality disorders involving long standing, chronic dysfunctional patterns of activity. There are three clusters under personality disorders: Cluster A, Cluster B and Cluster C, with antisocial personality disorder considered a ‘Cluster B’ disorder. Diagnoses among these three clusters are not considered mutually exclusive. The disorders are generally categorized into these clusters based on clinical similarities rather than an underlying understanding of a specific pathophysiologic mechanism. Psychopathy, sociopathy and antisocial personality disorder have often been used synonymously to describe the same disorder. However, these terms describe distinct disorders and must be differentiated. Antisocial personality disorder is generally diagnosed as a behavioural condition associated with a history of antisocial and criminal behaviour. Psychopathy and sociopathy are dispositional conditions that primarily emphasize personality traits. The DSM-5 has emphasized the observable components of the disorder that a clinician could assess objectively, generally considered factor 2 items, rather than the more subjective personality traits such as lack of empathy, egocentricity and lack of guilt, associated with factor 1 items (Table 2). This has resulted in some confusion in the diagnosis of the syndrome, and the DSM5 term antisocial personality disorder probably casts a wider diagnostic net than the diagnosis of psychopathy. In the DSM-5, an alternative model for personality disorders describes psychopathy as a distinct variant of antisocial personality disorder with characteristics such as lack of fear and a bold interpersonal style. Fortunately, we have the Psychopathy Checklist – Revised
Correspondence: D. F. Thompson, Pharm. D., Dean, College of Pharmacy, Southwestern Oklahoma State University, 100 Campus Drive, Weatherford, OK 73096, USA. Tel.: +1 580 774 3764; fax: +1 580 774 1201; e-mail: [email protected]
© 2014 John Wiley & Sons Ltd
485
D. F. Thompson et al.
Psychopathy review Table 1. Diagnostic and statistical manual 5 (DSM 5)1: [645] personality disorders
acquired, affective disturbances resulting from early socialization forces. Secondary psychopaths are often characterized as being withdrawn, hostile and having comorbid emotional problems.2,7 Obviously, there is not a clear distinction in the origin of these disorders and the true aetiology probably lies somewhere in a complex interaction of genetic and environmental forces.8 The other major distinction between these two variants is the level of anxiety experienced by these individuals.2,7 Primary psychopaths have a low level of anxiety in contrast to sociopaths who may present with a relatively high level of anxiety. These distinctions can also be reflected in the PCL-R scores, where primary psychopaths tend to score higher on factor 1 attributes and lower on factor 2 attributes relative to sociopaths, who score lower on factor 1 and higher on factor 2.2,7 Because the terminology in the field can be confusing, we will use the term ‘psychopath’ or ‘psychopathy’ throughout this paper to refer primarily to the classic construct of primary psychopathy. It is likely that further variants of the psychopath construct will emerge as further work continues in this area. The purpose of this paper is to review the current literature on the personality disorder of psychopathy. Background on this disorder along with structural and functional brain deficit studies, current and potential pharmacotherapy and the likely implications of this mental disorder for clinicians are reviewed and discussed. Psychopaths are ubiquitous. They have existed throughout history and across all socio-economic, racial, ethnic, gender and cultural divisions. Native Alaskan peoples call individuals with psychopathic traits ‘kunlangeta.’ When asked how kunlangeta are dealt with in their culture, they reply, ‘Somebody would have pushed them off the ice when nobody else was looking.’9 Because of the high incidence of psychopathy in the general population, the charming and charismatic nature of these individuals, and the ‘masks’ that they wear, many people are taken in by psychopaths. It is difficult to explain how a psychopath sees the world. Because they lack a conscience, their understanding of the world is radically different from normal individuals. These individuals have a shallow, superficial understanding of emotions, yet at the same time, they can mimic emotions masterfully thereby fooling people into thinking they are caring and emotionally normal. It may be similar to a colour-blind person looking at a traffic light. They know the top light is red and act accordingly, but they have no understanding of what the colour ‘red’ really is.10 Author Martha Stout, PhD., has captured the essence of psychopathy in the following excerpt from her book The Sociopath Next Door: The Ruthless vs. the Rest of Us.10 ‘Imagine, if you can, not having a conscience, none at all, no feelings of guilt or remorse no matter what you do, no limiting sense of concern of the well-being of strangers, friends, or even family members. Imagine no struggles with shame, not a single one in your whole life, no matter what kind of selfish, lazy, harmful, or immoral action you had taken. And pretend that the concept of responsibility is unknown to you, except as a burden others seem to accept without question, like gullible fools. Now add to this strange fantasy the ability to conceal from other people that your psychological makeup is radically different from theirs. Since everyone simply assumes that conscience is universal among human beings, hiding the fact that you are conscience-free is nearly effortless. You are not held back from any of your desires by guilt or shame, and you are never confronted by others for your coldbloodedness. The ice water in your veins is so bizarre, so completely outside of their personal experience that they seldom even guess at your condition.
Cluster A: Paranoid, Schizoid and Schizotypal Cluster B: Histrionic, Narcissistic, Antisocial and Borderline Cluster C: Avoidant, Dependent and Obsessive-Compulsive
Table 2. Items in the revised psychopathy checklist (PCL-R)16 and arranged by factor, facets and items Glibness/Superficial Charm Grandiose sense of self-worth Need for stimulation/Proneness to boredom Pathological lying Conning/Manipulative Lack of remorse or guilt Shallow affect Callous/Lack of empathy Parasitic lifestyle Poor behavioural controls Promiscuous sexual behaviour Early behavioural problems Lack of realistic, long-term goals Impulsivity Irresponsibility Failure to accept responsibility for own actions Many short-term marital relationships Juvenile delinquency Revocation of conditional release Criminal versatility Factor 1: Interpersonal-affective scale Interpersonal facet (Facet 1) Glibness/Superficial charm Grandiose sense of self-worth Pathological lying Conning/Manipulative Affective facet (Facet 2) Lack of remorse or guilt Shallow affect Callous/Lack of empathy Failure to accept responsibility for own actions Factor 2: Antisocial scale Lifestyle facet (Facet 3) Need for stimulation/Proneness to boredom Impulsivity Irresponsibility Parasitic lifestyle Lack of realistic, long-term goals Antisocial facet (Facet 4) Early behavioural problems Poor behavioural controls Juvenile delinquency Revocation of conditional release Criminal versatility
(PCL-R), discussed later in the paper, that provides a valid, reliable instrument to identify psychopathy. Although psychopathy is often treated as a single construct, there are a number of variants emerging with the growing body of research and theory.2–4 The classic distinction has been made between primary and secondary psychopaths.5,6 Primary psychopaths are characterized as having an inheritable, biologically acquired, affective deficit. These individuals tend to be confident, dominant and free from negative emotions. Secondary psychopaths, often referred to as sociopaths, are conceptualized as having
© 2014 John Wiley & Sons Ltd
Journal of Clinical Pharmacy and Therapeutics, 2014, 39, 485–495 486
D. F. Thompson et al.
Psychopathy review
pain and anguish. Psychopaths are often impulsive and exhibit poor behaviour control. A typical response from a psychopath is ‘I did it because I felt like it.’ However, this impulsivity may not be a central construct in psychopathy. Poythress and Hall17 have questioned the universality of impulsivity in psychopathy and provide evidence that many ‘successful psychopaths’ may be able to control much of their underlying impulsive traits. More data will be needed to clearly understand all the reproducible features of this complex construct. As a result of many of these traits, most psychopaths often voice specific goals they want to achieve but have little understanding of how to achieve them and they end up with failed marriages, incomplete educations and poor work records. Implicit within the PCL-R is a history of antisocial behaviour from an early age; however, psychopathy should never be diagnosed in individuals
