A simple word recognition test was used for the affective memory study. They then were shown additional lists of words and asked whether the additional words were on the original memorized list. Different word lists are presented over the course of the study. Some of the words on the lists were negative in affective content words including misery, blood, frown, scar, wreck and some neutral words including gallon, oat, brass, card. It is well established that unimpaired people are better at remembering words that have an emotional content than they are at remembering words with no emotional content.
Researchers have also known for some time that psychopaths remember emotional words just as well as non-psychopaths do, even though it takes psychopaths longer to recognize the emotional content of the words. But this study showed those memories seem to take a very different path in psychopathic brains than they do in non-psychopathic brains.
Prisoner-psychopaths showed greatly reduced activations in the amygdala and posterior cingulate, somewhat reduced activations in the ventral striatum and anterior cingulate, and greatly increased activation in the frontal gyrus. That is, they showed reduced activity in paralimbic regions—amygdala, anterior and posterior cingulate—and increased activity in the lateral frontal cortex, an area typically associated with cognition, not emotion. See Figure 9. The figure shows the rendering of the neural areas in which criminal psychopaths showed significantly less affect-related activity than noncriminal control subjects for the comparison of affective words versus neutral words of an affective memory task.
Also shown are the regions in which criminal psychopaths showed greater affect-related activity than noncriminal control subjects and criminal non-psychopaths bottom panels; depicted in gray scale; see Kiehl et al. These regions include bilateral inferior frontal gyrus. In turns out that the regions of the brain involved in inhibition overlap the paralimbic regions, primarily the anterior and posterior cingulate. Both adults and juveniles high in psychopathic traits exhibited dramatically decreased activity in these inhibitory regions.
Putting these results together begins to paint a picture of the psychopathic brain as being markedly deficient in neural areas critical for three aspects of moral judgment: 1 the ability to recognize moral issues; 2 the ability to inhibit a response pending resolution of the moral issue; and 3 the ability to reach a decision about the moral issue. Along with several other researchers, we have demonstrated that each of these tasks recruits areas in the paralimbic system, and that those precise areas are the ones in which psychopaths have markedly reduced neural activity compared with non-psychopaths.
What does all this mean? First, it suggests that the story of psychopathy is largely limbic and paralimbic rather than prefrontal. He is missing the moral core, a core that appears intimately involved with the paralimbic regions.
If the key to psychopathy lies in these lower regions, then it is no mystery that the psychopath is able to recruit his higher functions to navigate the world. In fact, when he gives a moral response, it seems the psychopath must recruit frontal areas to mimic his dysfunctional paralimbic areas. That is, the psychopath must think about right and wrong while the rest of us feel it. Second, these neurological results should go a long way toward ending the debate about whether psychopathy is just too difficult to diagnose to justify inclusion in the DSM.
Any lingering doubts about the clinical reliability of the Hare instruments disappear now that those instruments have been shown to be robustly predictive of a demonstrable neurological condition. Third, and perhaps more significantly, these imaging techniques may help us identify and then understand the development of psychopathic traits in juveniles.
It is difficult, and controversial, to assess psychopathic traits in young people. No one wants the label psychopath to become self-fulfilling, especially given the hopeful treatment possibilities discussed in Part V. Brain imaging may help us improve our understanding of the developmental trajectories of these traits in ways that might improve treatment. Still, caution is in order. Neuroimaging has its own embedded limitations, making the reliability of conclusions based on imaging data a complex and still developing story.
One also might argue that these results support the position that psychopathy should be an excusing condition. We have known forever that psychopaths are rational yet persistently immoral. The received dogma has been that psychopathy is untreatable, based on study after study that seemed to show that the behaviors of psychopaths could not be improved by any traditional, or even nontraditional, forms of therapy. Nothing seems to have worked—psychoanalysis, group therapy, client-centered therapy, psychodrama, psychosurgery, electroshock therapy or drug therapy —creating a largely unshakable belief among most clinicians and academics, and certainly among lay people, that psychopathy is untreatable, though as we will discuss below few if any of these studies were properly controlled and designed.
Most talking therapies, at least, are aimed at patients who know, at one level or another, that they need help. Psychotherapy normally requires patients to participate actively in their own recovery. But psychopaths are not distressed; they typically do not feel they have any psychological or emotional problems, and are not only generally satisfied with themselves but see themselves as superior beings in a world of inferior ones.
Clinicians report that psychopaths go through the therapeutic motions and are incapable of the emotional insights on which most talking therapy depends. No one yet knows how to restore the paralimbic functions that seem so impaired in psychopathy.
Treatment not only seems not to work, there is evidence that some kinds of treatment make matters worse. In a famous study of incarcerated psychopaths about to be released from a therapeutic community, those who received group therapy actually had a higher violent recidivism rate than those who were not treated at all. They teach you how to put the squeeze on people.
But all treatment hope for psychopaths is not lost. Like many mental health treatment efforts, prior efforts to treat psychopaths, as well intentioned and numerous as they have been, have almost never been designed to meet acceptable scientific and methodological standards. Even the better studies typically involved moderate rather than intense treatment, and over relatively short durations.
And of course one of the self-defeating aspects of these studies is that the psychopaths themselves often become disruptive in therapeutic settings not designed to deal with such levels of disruption. The good news about all this bad science is that maybe something does, in fact, work. There may be some room for some thoughtful, targeted, well-designed, and controlled treatment efforts—efforts that might even prove effective, especially with juveniles. In a landmark metastudy focused on the treatment of juveniles with psychopathic tendencies, Mark Lipsey and David Wilson concluded that, although the reported treatment outcomes were not encouraging, pieces of many different studies might be.
Inspired by Lipsey and Wilson, Michael Caldwell and his colleagues at the Mendota Juvenile Treatment Center in Madison, Wisconsin and the University of Wisconsin, reviewed the treatment literature in detail, noticed all of its failings and promises, and decided to design a specific treatment program for psychopathic juvenile offenders. Early results were encouraging.
This pilot study suggested that Lipsey and Wilson might be right—that treatment might work if juvenile psychopaths are treated early enough, intensely enough and for long enough. But of course the numbers, though promising, were extremely small. Caldwell and his colleagues subsequently conducted a larger follow-up study. In the latest published study, Caldwell and his colleagues followed 86 maximum security juvenile offenders in the Mendota center, and again looked at arrest recidivism, this time four years out.
All of these quantitative measures were analyzed and correlated. Caldwell and his group reached several conclusions. The best predictor of reductions in institutional misconduct and recidivism was the length of the decompression treatment. Short-term treatment seemed to have no effect. But long-term treatment, lasting up to and beyond one year, significantly reduced both institutional misconduct and recidivism, at least for the subjects scoring 31 and less on the Hare instruments.
These results are just the first shots across the bow of the conventional wisdom that psychopaths are incorrigible.
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But they are nevertheless very encouraging, not only because of the poor results of past studies but also because psychopathy is such a big problem that even a small and costly improvement is likely to be cost effective. Finally, let us assume, also extraordinarily conservatively, that only half of all incarcerated juvenile psychopaths come to the attention of the authorities or are otherwise able to receive decompression treatment.
Another way to look at this is on an individual incarcerated person basis, even ignoring the cascading effects of recidivism. In their study, Caldwell and his colleagues looked at the treatment costs and benefits of the two treatment modalities, not distinguishing between psychopaths and non-psychopaths.
They then added in the treatment costs and compared those overall costs—of treatment itself and the savings in reduced recidivism—between the two treatment conditions. The results were dramatic, and are summarized in Table 2. Cost Effects of Treatment Because the decompression treatment was so much more effective than traditional treatment, and of course because of the high costs of incarceration, the initially high cost of decompression treatment was more than made up for by its effectiveness.
The critical public policy fact when discussing the admittedly high costs of treating psychopaths, especially with anything like the Caldwell decompression therapy for juveniles, is the even higher cost of not doing so. Even modestly effective and costly treatment will have significant economic benefits. The psychopath has hidden himself since he emerged with the rest of us , years ago. His very disconnectedness is his mask. He has been lost to psychiatry and the law and continues to be lost in a correctional system that is, on the one hand, loath to label juveniles as psychopaths, yet on the other hand seems content to stand by and watch them graduate into adult psychopaths who spin the revolving prison door at up to 25 times the rate of non-psychopaths.
It is time for the criminal justice system to unmask the psychopath. Not necessarily to treat psychopathy as a potentially excusing condition, but rather to recognize the disproportionate psychopathic population in prison and to educate prison and parole officials so they can make better management and release decisions. It is also time to recognize that, contrary to conventional wisdom, psychopathic tendencies in juveniles may be amenable to treatment, at least for some part of the juvenile offender population. The etiological mysteries of psychopathy should not obscure the promise that some portion of this terribly costly population may be treatable.
Psychopaths exist, and they exist in large and disproportionate numbers in prison. Ignoring that fact distorts our penalogical outcome measures and, perhaps more importantly, interferes with the way we should be thinking about and managing non-psychopaths in prison. Yes, caution is in order. The science is still new, the neuroimaging still expensive, cumbersome, and not quite diagnostic, and the mask of psychopathy still a little too opaque.
The precise manner in which legislatures, judges, and prison officials might begin to address the problem of psychopathy is a complex question, implicating many difficult policy issues. But we cannot begin to address any of those difficult issues until we come to grips with the facts that psychopathy is real, it can be reliably diagnosed, and in the near future might even be treatable in some juveniles. National Center for Biotechnology Information , U. Author manuscript; available in PMC Jun Kent A. Morris B. Author information Copyright and License information Disclaimer.
Copyright notice. See other articles in PMC that cite the published article. Abstract The manuscript surveys the history of psychopathic personality, from its origins in psychiatric folklore to its modern assessment in the forensic arena. Table 1 The 20 Items Listed on the Psychopathy Checklist-Revised Hare ; The items corresponding to the early two-factor conceptualization of psychopathy, 89 subsequent three-factor model, 90 and current four-factor model are listed.
Open in a separate window. Psychopathy and Psychiatry Psychopaths have hidden from psychiatry too. Figure 1. Figure 2. Psychopathy and the Law The law has treated psychopathy with the same benign neglect as psychiatry has, and for much longer. Recidivism Once released, psychopaths are much more likely to recidivate than non-psychopaths.
Figure 3. Figure 4.
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Figure 5. Figure 6. The Costs of Recidivism by Psychopaths Many of the following statistics will be familiar to readers steeped in the public policy of crime control; they are visited here in an attempt to tease out the costs associated only with psychopathy. As one neuroscientist writing about psychopathy has said: When we attempt to focus on the psychopath, we find various difficulties.
Figure 7. Figure 8. Figure 9. Figure Table 2 Cost Effects of Treatment References 1. Hare Robert D. See also Coid Jeremy, et al. We will, for now, continue the tradition of focusing on psychopathy as an essentially male condition. Though there are female psychopaths, their incidence in the general population is estimated to be much less than males. Nicholls Tonia L, et al. Recently, there seems to be increased research interest in female psychopathy, and an increasing debate about whether the Hare instruments are properly capturing the female version of the disorder.
Clinical Psychol. Psychopathy in Women: Structural Modeling and Comorbidity. The latest census data show that as of there were approximately Sabol William J, et al. For a discussion of the incidence of psychopathy in prisons, jails, parole, and probation see infra text accompanying notes — Compare Martinson Robert. What Works?
Pub Int. Hofstra L Rev. Sherman et al. The Inevitability of Rehabilitation. See infra text accompanying notes — See, e. J Abnormal Psychol. Psychiatry Res. In: Sinnott-Armstrong Walter. MIT Press; Namely, reduced neuronal activity in the paralimbic regions of the brain. See infra Part IV for a discussion of the neuroimaging findings. See infra Part V for a discussion of treatment findings.
See infra Part I. See infra text accompanying notes 85—88, 92— Such policy questions include, for example, should all parole and even probation decisions be informed by a clinical assessment for psychopathy or a neuroimaging assessment for psychopathy, or both?
Even more broadly, should judges use psychopathy assessments in reaching their sentencing decisions, and if so in what kinds of cases? Should juveniles suspected of being emergent psychopaths be assessed and then treated, either in custody or as a condition of their release? Hartman trans. Millon Theodore, et al. In: Millon, et al. Psychopathy: Antisocial, Criminal and Violent Behavior. One must be careful about this sort of conclusion. The prevalence of psychopaths in our storytelling could be as much about the bad in all of us as is it is about the very bad in just a few of us, and indeed that is often its teaching purpose.
And in some ways she is the least representative, because psychopathy is substantially more common in men than in women. See sources cited supra note 1 and accompanying text. Female psychopaths seem to appear more frequently in our stories than they do in our real lives, maybe because those stories were told and written mostly by men. Who but a psychopath would order the execution of a series of wives on the mornings after the honeymoons because he has become bored with them?
Only her cliff-hanging stories saved Scheherazade. In the story of The Golden Vase, Ximen is a relentlessly unsavory merchant and social climber, who has become wealthy enough to accumulate a retinue of wives and concubines, one of whom he marries after killing her husband. This is just a tiny sampling of psychopaths who appear in fiction. It is actually difficult to imagine any rich literature in which one or more psychopaths do not appear. He wanted to be one, he wanted to escape the moral ties that bind us all, and his murder of the old woman was a kind of attempted psychopathy.
But the very fact he was exploring the limits of his own horror shows that he had horror, and therefore had a moral core. Perhaps Leopold and Loeb were of this sort. In his seminal study of psychopathy, Cleckley argued that Alcibiades was a psychopath based on historical reports of his impulsiveness, irresponsibility and self-indulgence. Cleckley Hervey. The Mask of Sanity. By way of disclosure, K. Kiehl trained under Hare at the University of British Columbia. Violence and Psychopathy. See infra text accompanying notes 81— Murphy Jane M.
Psychiatric Labeling in Cross-Cultural Perspective. Joyce Richard. The Evolution of Morality. Most psychopaths also have ASPD, but the converse is not true. See infra Figure 1. See infra text accompanying notes 56— Rush Benjamin. Prichard James Cowles. Grob Gerald N, et al. Arno Press; It seems Dr. Prichard coined this term. The Psychopath: Theory, Research, and Practice. Guilford Publications, Inc; Sociopathy as a Human Process. Archives Gen Psychiatry. See infra text accompanying notes 64, 67 for a discussion of ASPD and its relationship to psychopathy.
For example, Robert Kegan has posited, based in part on EEG studies, that psychopathy is caused by an abnormally slow rate of brain development, and that psychopaths, in effect, are frozen in time with the egocentricity, impulsiveness, selfishness, and unwillingness to delay gratification of normal adolescents. Kegan Robert G. In: Reid William H, et al. Though this explanation might be consistent with parts of the paralimbic thesis discussed in Part V below, it is clinically inconsistent with the fact that signs of psychopathy have been detected in very young, preadolescent, children.
Hare, Without Conscience, supra note 40, at — Antisocial Behavior and Social Psychophysiology. In: Wagner Hugh L. Clinical Psychol Rev. The Cycle of Violence. DeVita E, et al. Psychopathy, Family Background, and Early Criminality. But if psychopathy has a genetic component, the failure to bond could be because the parent himself or herself is a psychopath. More subtly, a non-psychopathic parent may not be able to bond normally with a psychopathic child.
The Pathology of Mind. McMillan; Standage Kevin. The Book of Psychiatric Books. Diagnostic and Statistical Manual: Mental Disorders. Psychiatric Times. The Alvor Advanced Study Institute. In: Cooke David J, et al. Psychopathy: Theory, Research and Implications for Society. Antisocial Personality Disorder.
In: John Livesley W, editor. Widiger Thomas A, et al.
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Hare, Psychopathy and Antisocial Personality Disorder , supra note The Psychopathy Checklist. Multi-Health Systems; The Hare Psychopathy Checklist-Revised. Manual for the Hare Psychopathy Checklist-Revised. Hart Stephen D, et al. The Psychopathy Checklist: Screening Version. Forth Adelle E, et al. The Psychopathy Checklist: Youth Version. See infra Part II for a discussion of both the reliability and criticisms of the Hare instruments.
The relationship between ASPD and psychopathy shown in Figure 1 also appears to hold generally in non-incarcerated populations. Levenson Michael R, et al. Assessing Psychopathic Attributes in a Noninstitutionalized Population. Figure 1 depicts the frequency of antisocial personality disorder ASPD and psychopathy among incarcerated populations. Psychopathy and Antisocial Personality Disorder. Current Opinion in Psychiatry.
Figure 2 depicts the comorbidity of substance abuse and psychopathy among incarcerated populations. Psychopaths with drug problems make up slightly less than half of all incarcerated psychopaths. The figure was adapted using information from Hemphill James F, et al. Psychopathy and Substance Abuse. J Personality Disorders. Compare Gacono Carl B. Gacono Carl B. Psychopathic Personality: The Scope of the Problem. In: Patrick Christopher J. Handbook of Psychopathy. Sproat JH. The Care of Idiots and Imbeciles.
J Mental Sci. I Modern American Law. The caveat paragraph was not without its contemporary psychiatric critics. John Hopkins Press; An example of a state incorporating the caveat paragraph by case law via pattern jury instructions is Idaho. Powers, P. Compare United States v.
Frazier, F. United States, F. Leister, F. Freeman, F. Currens, F. Smith, F. It is an affirmative defense to a prosecution under any Federal statute that, at the time of the commission of the acts constituting the offense, the defendant, as a result of a severe mental disease or defect, was unable to appreciate the nature and quality or the wrongfulness of his acts. Mental disease or defect does not otherwise constitute a defense. See supra text accompanying notes 27—32; see infra Part IV.
See Wolf Susan. Freedom Within Reason. Rutgers LJ. Psychopathy and Criminal Responsibility. This is the famous, and rather silly, example from the Model Penal Code. These realities, plus the fact that mental disorders simply do not work in this way, makes this example silly. Still, keeping mens rea separate from excuse is a useful, if sometimes difficult, conceptual undertaking.
Fradella Henry F. In a nutshell, this is the difference between insanity and duress, or more generally, between excuse and justification. Morse Stephen J. Uncontrollable Urges and Irrational People. Va L Rev. Criminal Justice Act, , c. Mental Health Act, , c. Hoffman, author Nov. Care Info. Davey Monica, Goodnough Abby. NY Times. But see discussion of treatment infra Part V. See Table 1 for the various models and their respective item loadings. Harpur Timothy J, et al. Factor Structure of the Psychopathy Checklist.
Cooke David J, Michie Christine. Psychol Assessment. Hare, Manual for the Hare Psychopathy Checklist, supra note 60, at 71 fig. See Edens John F. Psychopathic Disorder: A Category Mistake? J Med Ethics. Leistico Anne-Marie R, et al. See Rice Marnie E, et al. This estimate represents 8. Cornell Dewey G, et al.
Psychopathy in Instrumental and Reactive Violent Offenders. See Hart Stephen D, et al. Violence and Psychopathy, supra note 28, at 1—2. Violence and Psychopathy [ Google Scholar ] , supra note 28, at 5, 10— Hare, Manual for the Hare Psychopathy Checklist, supra note 60, at 53, 55, tbl. Porter Stephen, et al. Medical News Today. Hart et al. Figure 3 depicts the recidivism rate of Canadians for the three years of their release. They were divided into low, moderate, and high categories of psychopathy based on their PCL-R score.
Adapted from Hart et al. Figure reproduced by permission of the American Psychological Association. Unauthorized use not permitted. Figure 4 tracks released sex offenders for 20 years after their release date. Figure 5 depicts survival curves for rates of reconvictions for new sexually violent crimes in convicted sex offenders following release from prison. The interaction between psychopathy high-low and deviant sexual response to violence deviant-nondeviant identifies a group of individuals with extremely high risk to reoffend in a ten-year period.
This data demonstrates psychopathy is a significant predictor of sexually violent recidivism. Vincent Gina M, et al. Other physical details online resource.
Agostinelli: Sul problema delle aurore boreali e il moto di un corpuscolo elettrizzato in presenza di un dipolo magnetico -- G. Shapiro: Radar astronomy, general relativity, and celestial mechanics -- V. Szebehely: Applications of the restricted problem of three bodies in space research -- G. Wilkins: The analysis of the observation of the satellites of Mars. Summary, etc C. Agostinelli: Sul problema delle aurore boreali e il moto di un corpuscolo elettrizzato in presenza di un dipolo magnetico.
Shapiro: Radar astronomy, general relativity, and celestial mechanics. Szebehely: Applications of the restricted problem of three bodies in space research.