Psychopaths: New Trends in Research

By Robert D. Hare (c)1995 The Harvard Mental Health Letter, September 1995
continued from front page

their own selfish needs. Lacking in conscience and in feelings for others, they cold-bloodedly take what they want and do as they please, violating social norms and expectations without the slightest guilt or regret. Although their numbers are small - perhaps 1% of the population - psychopaths account for a large proportion of the serious crime, violence, and social distress in every society. Psychopathic depredations affect people in all races, cultures, and ethnic groups, and at all levels of income and social status. As many as 15% or 20% of prisoners are psychopaths; the disorder is common among drug dealers, spouse and child abusers, swindlers and con men, high-pressure salesmen and stock promoters, gang members, mercenaries, corrupt politicians, unethical lawyers and doctors, terrorists, cult leaders, and black marketeers. In societies undergoing a chaotic breakdown (today, for example, in Rwanda, the former Yugoslavia, and the Soviet Union), psychopaths often emerge as "patriots" and "saviors." Wrapped in the flag, they enrich themselves by callously exploiting cultural or racial tensions and grievances.

Despite many years of debate, our understanding of the disorder is still surprisingly limited, but there are signs that the situation is beginning to change. Researchers are paying increased attention to the diagnosis and measurement of psychopathic traits. The mental health and criminal justice systems are considering new options for evaluating the risk of recidivism and violence, and new approaches to treatment and prevention. Theories and procedures derived from cognitive neuroscience are being adapted to study the causes of psychopathy.

Scientific progress depends heavily on the availability of generally accepted techniques for measuring key variables. Until recently, theory and research on psychopathy were seriously hampered by the lack of such tools. Different clinicians and researchers discussing the subject were often not talking about the same thing in practice. Today three diagnostic systems are commonly used to describe psychopaths: (1) the international classification of diseases (ICD-10) definition of dyssocial personality disorder; (2) the APA's DSM-IV definition of antisocial personality disorder; (3) the Psychopathy Checklist-Revised (PCL-R), a list of symptoms. ICD-10 and the PCL-R define psychopathy with reference to both behavior and inferred personality traits; DSM-IV emphasizes mainly behavior. ICD-10 and DSM-IV employ categorical diagnoses (the disorder is classified as either present or absent); the PCL-R instead provides a numerical score reflecting the degree to which a person's symptoms match the traditional clinical conception of psychopathy. This score can be statistically analyzed into two factors, one covering attitudes and feelings, the other covering socially deviant behavior.

Making a diagnosis

These diagnostic systems sometimes have different theoretical and practical consequences. For example, the DSM-IV diagnosis of antisocial personality disorder, since it reflects mainly behavior, applies to most prison inmates and many offenders with mental disorders. Thus it is not very helpful in distinguishing those who are likely to commit further crimes after release. What differentiates psychopaths from other criminals is their egocentricity, shallow affect, manipulativeness, and lack of empathy or remorse-a point acknowledged in DSM-IV but not explicitly reflected in its diagnostic criteria. Here the PCL-R is useful. Almost two dozen studies have found that offenders with high scores on this rating scale are more than twice as likely as other prisoners to commit further crimes. The PCL-R score is especially useful for predicting violent and sexual offenses. It predicts recidivism and violence well even among young offenders, for whom a diagnosis of antisocial personality disorder is considered inappropriate.

Many criminal justice and mental health personnel know little about psychopathy or have obsolete and inaccurate ideas about it. Some persist in believing that it is a myth, or that all psychiatric categories are useless. Many are as confused and misled by psychopaths as their victims are. How often we have heard, after a violent criminal is released and commits another crime, that "he didn't present as a serious risk," "his therapist said he had made remarkable progress," or "he found religion and turned himself around."

Working the system

Psychopaths are often passed through a variety of treatment programs without success. In one study, for example, they were almost four times more likely to commit a violent crime after release from an intensive therapeutic community program than were other patients. In fact, treated psychopaths were more likely to commit a crime after release than untreated psychopaths who were otherwise similar. They had learned enough psychiatric and psychological jargon to convince therapists, counselors, and parole boards that they were making remarkable progress, but they used that knowledge only to develop new rationalizations for their behavior and better ways to manipulate and deceive. Court-mandated therapy programs for spouse abusers are equally ineffective for the 25% to 35% of their participants who are psychopaths.

Since even a modest improvement would be of great benefit to society we must seek new ways to change psychopaths. There have been some recent developments along these lines. An international panel of experts commissioned by the Canadian government has designed an experimental program for psychopaths and other offenders at high risk for violence. Antisocial and violent acts are conceived as potentially preventable endpoints in a chain of events. The program makes no attempt to train the offenders in empathy, put them in touch with their feelings, or help them develop a conscience. The view that they have simply gone off the track and need re-socialization is rejected. The aim is to make them accept responsibility for their behavior and persuade them that changing it is in their own long-run interest. The program tries to help them use their abilities to satisfy their needs in socially tolerable ways. The criminal activity of psychopaths often falls off with age; efforts are made to speed up that process. Tight control and supervision and clear and certain punishment for transgressions are essential, both during the program and after release from prison.

This kind of program requires continual evaluation to determine what works and what does not for particular individuals; for example, some components of it may be effective for psychopaths but not for other offenders, and vice versa. It is an expensive program and will constantly be in danger of erosion by changing institutional needs, political pressures, and community concerns. The results are likely to be modest. But the alternatives - to bear the enormous cost of keeping psychopaths in prison or run the enormous risk of simply letting them out - are even less attractive.

The psychopathic brain

Recent findings of cognitive neuroscience may throw some light on the causes of psychopathy by establishing a neurophysiological basis for the characteristic lack of empathy or guilt, shallow emotions, and cold-blooded cruelty. In one study, for example, subjects were instructed to determine as quickly and as accurately as possible, by pressing a button, whether a string of letters flashed on a computer screen formed a word. Most people, even non-psychopathic criminals, make these decisions more quickly, with larger and more prolonged recorded brain electrical potentials (brief changes in the EEG), when the words are neutral (e.g., table) than when they are emotionally charged (e.g., cancer). Psychopaths respond to all the words as if they were neutral. Other studies indicate that it is not only the linguistic processes of psychopaths that are devoid of affect. For example, normal people are more likely to blink in response to a startling noise while they are viewing an unpleasant slide than while they are viewing a pleasant slide. In psychopaths there is no difference.

Results of this kind may suggest why psychopaths willingly cause so much pain and suffering. They know how much it hurts only in an abstract intellectual sense; they are apparently unable to construct an "emotional facsimile" of others. A recent brain imaging study suggests a possible neurophysiological basis for failure to appreciate the emotional significance of words and images; the brain mechanisms that normally impart affect to cognitive processes may be inefficient or inoperative in psychopaths. Research in which psychopathology is integrated with cognitive neuroscience offers exciting prospects for improving our understanding of this devastating disorder.

Robert D. Hare, Ph.D., is Professor of Psychology at the University of British Columbia.