What Is Psychopathy?

By Dr. Osman Shabir, PhDReviewed by Dr. Jennifer Logan, MD, MPH

Psychopathy refers to the neurological and anti-social manifestations that occur in a person with an anti-social personality disorder.

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This disorder is primarily characterised by impairments to empathy and remorse, coupled with antisocial behaviour, in addition to disinhibition. Within the general population, the prevalence of psychopathy is estimated to be between 0.1%-1.2% whereas the proportion of incarcerated individuals with psychopathy is thought to be 15-25%.

Characteristics & Diagnosis of Psychopathy

Psychopathy can simply be defined as a chronic (long-term) mental disorder comprised of abnormal and violent social behaviours with little or no remorse or guilt. As such, individuals displaying these behaviours are commonly referred to as ‘psychopaths’.

The psychopathy checklist (PCL) & psychopathic personality inventory (PPI) are two of the main diagnostic tools used to assess psychopathy in legal settings. In the UK, 25 out of 40 is considered a cut-off for psychopathy whereas in the US it is 30 for the PCL. Clinically, the DSM and ICD class psychopathy as an antisocial personality disorder (ASPD) and dissocial personality disorder (DPD) respectively. In the UK, DPD is basis alone for detention in secure psychiatric hospitals under the Mental Health Act 2007.

The three key elements that they assess are:

1. Disinhibition – poor impulse control and lack of urge control
2. Meanness – lack of empathy and close attachments, defiance of authority and destructive excitement seeking
3. Boldness – toleration of danger, high self-confidence and social assertiveness

Taken together, these individuals have manipulative self-serving behaviours with an almost total disregard for others, as such have repeated occurrences of crime and violence. Typically, these behaviours manifest from childhood that persists or worsens into adulthood, suggesting a developmental nature to psychopathy.

Emotional characteristics include:

• Reduced recognition of emotional expressions (fear, sadness and happiness)
• Recognition of anger and disgust is not typically impaired
• Less likely to respond to the pain and distress of others
• Impaired moral judgment (reduced responsiveness to ‘care-based’ transgressions)
• Impairments to stimulus-reinforcement learning or associating a reward or punishment value with a situation or stimulus

Causes & Neurobiology of Psychopathy

Psychopathy can be classed as a developmental disorder as common characteristics are present from childhood. Thus, genes may predispose individuals to psychopathy, though additional environmental factors may be important. However, other factors such as brain injuries may also be associated with the development of psychopathy.

Neuroimaging studies have started to shed light into differences within particular brain regions between healthy controls and psychopaths. Particularly, there are brain abnormalities within the prefrontal-temporo-limbic regions involved in emotional regulation and learning.

Within the prefrontal-temporo-limbic regions, the amygdala, hippocampus, insula and striatum are heavily structurally altered, in addition to reduced structural function within the right orbitofrontal cortex, right anterior cingulate cortex and the left dorsolateral prefrontal cortex.

Of all these affected brain areas that are involved in emotional regulation and learning/reward processing, the amygdala and orbitofrontal cortex are particularly associated with psychopathy and violence.

Individuals scoring highly on the psychopathy scale (PCL) who also have a history of violence have reduced structural integrity between the white matter tracts connecting the amygdala to the orbitofrontal cortex. As such, reduced function and crosstalk between the amygdala and orbitofrontal cortex leads to reduced fear and boldness.

Management of Psychopathy

Psychopathy is very difficult to treat or manage. Furthermore, individuals with psychopathy are often unwilling or unmotivated to seek treatment and may be uncooperative. Also, traditional punishments (incarceration or community service) are ineffective as individuals are insensitive to punishment and threat.

Often with psychopathy, there may be numerous comorbidities such as antisocial personality disorder, narcissistic, borderline, paranoid and schizoid personality disorder, obsessive-compulsive disorders and ADHD. Treatments for these comorbidities including antipsychotic, antidepressant and mood stabilising medicines may be used, though none will work effectively for psychopathy per se.