Psychopathy and ASPD Flashcards
General History
Ancient Greece - ‘unscrupulous man’ -> psychopathy
Figures of insanity - always been present
1800’s - madness with the insanity
P’s with an apparent “perversion of the moral faculties”
Lombroso - theories about criminals - facial features
Brain differences? - R and L brain being out of balance?
ASPD - History
- cause is unknown
- inherited traits BUT family life also increases the liklihood of developing the disorder
- abnormalities in nervous system development?
- prenatal exposure - smoking?
- ASPD P’s - require more sensory input for normal brain function
- e.g. serotonin levels of brain regions such as PFC? (linked with impulsively and aggressive behaviour?)
- environment - always plays a big part
- parental influences - ASPF behaviour in themselves influencing the children?
- attachment?
ASPD and Psychopathy links
Closely linked!
- not all ASPD P’s are psychopaths
- all psychopaths tend to have ASPD
- key differences between the two!
Gregory et al (2012) - ASPD without P and ASPD with P
Identified structural GM differences between persistent violent offenders with ASPD + P against those with just ASPD
- using MRI scans
- ASPD + P - significantly reduced GM volumes bilaterally in the anterior rostral PFC and temporal poles relative to offenders with just ASPD and non-offenders
- reductions - not attributable to substance disorders
- reduced GM volume within areas implicated in empathic processing, moral reasoning and processing of prosocial emotions such as guilt and embarrassment may contribute to the profound abnormalities of social behaviour observed in P
- differences between with and without P - it is a distinct phenotype?
DSM-IV and DSM-V definition of Personality Disorder
“an enduring pattern of inner experience and behaviour that devotees markedly from the expectations of the individuals culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment”
DSM-V for PD - changes?
Change from ‘pervasive pattern’ to ‘adaptive failure/impaired sense of self identity / failure to develop effective interpersonal functioning’
What are the 6 types of personality disorders?
Antisocial/Psychopathic Avoidant Borderline Obsessive-Compulsive Narcissistic Schizotypal
Antisocial / Psychopathic PD
- egocentric, non-conforming, unethical, callous, deceitfulness, manipulative, irresponsible, risk-taking
DSM-V ASPD
Impairments in self-funtioning (a or b):
a. IDENTITY - ego-centrism
b. SELF-DIRECTION - goal-setting based on personal gratification, absence of pro-social internal standards associated with failure to confirm ti lawful or culturally normative ethical behaviour
Impairments in interpersonal functioning (a or b)
a. EMPATHY - lack of concern for feelings, needs or suffering of others; lack of remorse after hurting or mistreating others
b. INTIMACY - incapacity for mutually intimate relationships, exploitation is a primary means of relating to others, deceit and coercion, dominance or intimidation used to control others
Pathological personality traits in the following domains:
- ANTAGONISM - manipulativeness, deceitfulness, callousness, hostility
- DISINHIBITION - irresponsibility
DSM-V ASPD
- some explanation
Impairments in personality functioning and the P’s personality trait expression - relatively stable across time and situations
Not better understood as normative for the P’s developmental stage or socio-cultural environment
Not due to direct physiological effects of a substance or a general medical condition
P is at least 18 years old
NICE assessment
Need to conduct a full assessment of:
- antisocial behaviours
- personality functioning, coping strategies, strengths and vulnerabilities
- co-morbid disorders
- the need for treatment, social care and support and occupational rehabilitation or development
- domestic violence or abuse
If in specialist service:
- can check severity using PCL-R or PCL-SV as a part of a structured clinical assessment
Problems with assessing / diagnosing ASPD?
- under-recognised disorder
- when identified, other significant co-morbid disorders are often not detected
- important concerns about assessing risk of violence and risk of harm to self and others
- asking about feelings, behaviours etc - many P’s feel as if nothing is wrong with their behaviour so difficulties here - not chosen to undertake treatment!
- normally referral from court or prison
- therapeutic alliance - KEY - but how do you establish this with someone who does not want treatment?
- what about bringing in family support - PROBLEM - coming from a dysfunctional family, may not be the best thing to do then!
PCL-R - Hare
- psychopahty checklist-revised
- 20 item inventory of perceived personality traits and recorded behaviour
- semi-structured interview along with a review of ‘collateral information’
- each item - different scores - 0, 1 or 2
- score of 30 or above = diagnosis of psychopathy
- variety of questions asked - co-morbidity, relationships, anger and control, family history, school days etc
- extreme end = serial killers
- 40 = absolute maximum score - a prototypical psychopath will achieve this!
Psychopathy - useful?
Is it a disorder or can it be advantageous?
- psychopaths can be very successful
- e.g. business men, CEO’s, surgeons, soldiers etc
- so is it adaptive and advantageous?
Lilienfeld et al (2012) - Fearless dominance
- some features of a psychopathic personality (e.g. fearlessness, interpersonal dominance) can be adaptive in certain leadership positions!
- tested in 42 US presidents
- FD (boldness associated with psychopathy) was associated with better rated presidential performance, leadership, pervasiveness, crisis management, congressional relations and allied variables
- also associated with several largely or entirely objective indicators of presidential performance, e.g. initiating new projects and being viewed as a world figure
Pegrum and Pearce (2015) - Doctors and psychopathy
Doctors - faced with a range of situations with stress etc
- psychiatric morbidity, long work hours, divorce, surgeon duties, medical lawsuits etc
Some of the traits associated with a psychopathic personality are perhaps selected out in those P’s rising to the top of the medical profession?
- preternatural calmness under pressure
- apparent indifference to human suffering when making life-or-death situations
- calmness needed for intense situations
High pressure situations - is when they become calm!
- so will we find these traits more in medical staff?
Pegrum and Pearce (2015) - Doctors and psychopathy
- method and results
No other studies assessing psychopathic personality traits among doctors in teaching and general hospitals
- 172 doctors using the short form of the Psychopathic Personality Inventory
- overall mean score for doctors = 131
- mean score on general public = 119 (previously tested)
Surgeons and Paediatricians = highest scores!
- surgeons - stress immunity and fearlessness
- paeds - stress immunity, fearlessness and carefree non-playfulness
Stress immunity - overriding personality trait of doctors
> showing that traits associated with psychopathy can be useful for certain situations?!
Sociopathy
More to be a product of the environment that you are in?
Sociopathy - Walsh and Wu (2008)
- appears to be less strongly tied to genotype than psychopathy
- more tied to development in extremely adverse environments rife with abuse, neglect and violence
Numbers:
- fluctuate with changes in socio-culture environments
- particular with the rate of children born into fatherless homes
- these kinds of developmental environments tend to produce a physiology (i.e. a hyporactive ANS) roughly similar to that of psychopaths as well as an intellectually imbalanced profile that is consistently linked to criminal behaviour
Sociopathy - Hare and Babiek (2006)
Acknowledge a clear difference between the two!
Psychopathy =
- the P will have no empathy or sense of morality among a number of other traits
Sociopathy =
- is indicative of having a sense of morality and a well-developed conscience BUT the sense of right and wrong is not that of the parent culture
Sociopathic features
egocentric; callous; impulsive; exaggerated sexuality; detective conscience; boastful; risk taker; not interested in bonding with a mate; antagonistic; can’t resist temptation
Psychopathic features
pathological liar; callous / lacking in empathy; no remorse or guilt superficial charm; parasite; manipulative; shallow affect; lack of control; promiscuous / many ST relationships; impulsive; irresponsible; early behaviour problems; delusions of grandeur / self-worth
Psychopathy…
- something that is there from the start
- don’t experience emotions in the same way we do
- like there is something missing?
- more extreme version of ASPD?
- highly organised
- pathological lying - very strong indicator
- superficial charm
- if they kill - normally do it impulsively, don’t think about it
- seeking power and control over people
- normally very clever individuals
- can’t control impulses
- HARE - they aren’t ill, they know what they are doing
- very big debate!
Distinction between ASPD and Psychopathy
Disinhibition - impulse control problems
Meanness - aggression/disregard for others
Boldness - social dominance/emotional resiliency/ being venturesome
Coid and Ullrich (2010)
- different diagnostic constructs
- didn’t confirm that psychopathy and ASPD are distinct diagnostic entities
- considerable symptom overlap
- did show that the disorders are on a continuum
> well, if both or either was measured using a continuous scale, psychopathy is at the far end of the continuum in terms of symptom severity - not separate diagnostic entities
- BUT psychopathic ASPD is a more severe form than ASPD alone with a greater risk of violence
Veneables et al (2014)
Boldness distinguishes psychopathy from ASPD
Is psychopathy a mental illness?
- lack of treatments for PD’s
- disagreement about the distinction between mental illness and psychopathic disorders
- haven’t agreed whether it is a mental disorder or not
- psychiatrists are not trained in PD’s
Mental Health Act - Treat-ability Clause
- to detain someone, appropriate medical treatment is to be available for him
- new MHA - now ‘any disorder or disability of the mind’
- clause has been taken away - now have to treat the disorder
> can’t just detain the P
now have to make the effort to provide appropriate treatment
DSPD Programme - England and Wales
- government program aimed at treating dangerous P’s with a severe personality disorder
- major aim - to explore under what circumstances people with severe PD’s come to be at high risk of serious violent offending and how that risk can be reduced
Criteria:
- likely to commit offence leading to serious physical or psychological harm ‘from which the victim would find it difficult or impossible to revere from’
- has a severe PD
- link between the disorder and risk of offending
NICE treatment
- group based cognitive and behavioural therapies in order to reduce impulsiveness, anti-social behaviour, interpersonal problems
- can use reasoning and rehabilitation
- drugs - only use if there are co-morbidities
- substance abuse present - programs involved incentives can be used
- may involve multi-agencies, especially if P is an offender or in an institution
- for psychopathy / “dangerous and severe PD”, increase number of session
Treatments
- Therapeutic Community
e. g. Henderson Hospital
- all members involved in the running of the hospital
- community / residential aspects
- learning how to get on with others
- not curing the P’s - claims to help them to hold onto a job, to cope with ordinary life and to keep them out of trouble
- most (in the past) use some psychodynamic / psychoanalytic therapies
Treatments
- Therapeutic Community - Problems?
CONCERN
- ultimate dreams for psychopaths
- allowed to run the whole show - can make you worse?
Expensive?
Difficult to run?
Not a huge amount of evidence to back up?
Treatments
- Pharmacological
- not used as a treatment per say
- more used alongside another form of treatment to treat co-morbid disorders?
- antipsychotics, antidepressants, mood stabilisers
Treatments
- Therapies
CBT Schema Focussed therapy Transference focussed therapy Cognitive analytical Dynamic / Dialectical behaviour therapy
Treatments
- Reasoning and Rehabilitation
Widely accepted/accredited, evidence-based, multi-faceted C-B program for teaching cognitive skills, social skills and values that are required for prosocial competence
- teaches cognitive and behavioural skills, social skills, lateral thinking, assertiveness training, critical thinking, interpersonal skills etc
- 36 x 2 hour sessions, in groups of 6-12
- challenging / taking away P’s from egocentric thinking using learning exercises and other activities
- reframing thoughts and altering behaviours. social skills etc
- can be effective for some aspects but not everything
Tong and Farrington (2006) - meta-analysis showed 14% reduction in recidivism
Treatments
- Dialectical Behaviour Therapy
- adapted DBT for use with psychopathy
- addresses problems such as abstract thinking and problem solving which normal DBT would not have been able to solve
- range of emotions need to be addressed NOT just anger and hostility
- staged treatment - need a pre-treatment where commitment to change and agreed goals are set
- then have to gather information about violence / criminal behaviour plus BHA (behavioural chain analysis)
- then develop a hierarchy of treatment
- weekly sessions / skills groups
- may need other treatment alongside if, e.g. substance abuse
- some success but not for all
Questions to ask about psychopaths
- why is it difficult to treat psychopaths?
- are they insane, or do they know what they are doing?
- are they born with different brains?
- are they controlling their behaviour?
- why do some kill and some do not?
Brain or other abnormality?
- brain abnormality - e.g. frontal lobes, amygdala
- differences in early life - can children be diagnosed as psychopaths?
- can these abnormalities change / be changed?
- chemical involvement?
> oxytocin - problems - can be a possibility
> lack of it - need some form of balance?
Brain and Psychopathy
Hare - MRI / SPECT studies
- DR-MRI study of incinate fascicles (UF) and orbitofrontal cortex (PFC)
Meffert et al
- fMRI study using video of emotional hand interactions
Brain and Psychopathy
- de Oliveria-Souza et al (2008)
Investigating whether P is related to GM reduction in regions of the brain that underlie moral conduct and whether the severity of psychopathy is related to the degree of structural abnormality
- optimised voxel-based morphometry and the screening version of the Psychopathy checklist
- 15 community psychiatric P’s with high PCl:SV scores and 15 healthy controls
Brain and Psychopathy
- de Oliveria-Souza et al (2008) - results
GM reductions were observed in the frontopolar, orbitofrontal and anterior temporal cortices, superior temporal sulcus region and insula of the P’s
Degree of structural abnormalities - significantly related to the interpersonal / affective dimension of psychopathy
Pattern of GM reductions in P’s with high psychopathy scores comprised a distributed fronto-temporal network which plays a critical role in moral sensibility and behaviour
Psychopathy and Children - Conduct Disorder
- cannot diagnose a PD in anyone under 18!
- use conduct disorder instead!
- red flags that may lead to psychopathy….
Psychopathy and Children
- Raine
Can see differences in children in early years
BUT we cannot diagnose psychopathy!
Psychopathy and Children
- Fontaine
- callous, unemotional beahviorus
- more at risk of psychopathy
- unless they grow out of this behaviour, they will grow up to be full-blown psychopaths
Psychopathy and Children
- adolescent brain
Under developed PFC?
- this obviously doesn’t help the situation?!
Psychopathy and Children
- Viding
- conduct disorder and callous unemotional trait
- found brain differences in this group
Final point to note about psychopaths
They interpret and process in the same way as us
- just understand things differently
- patterns of activation - just different?
