PSYCHOPATHY

   

CASE STUDY

 

 

 

 

 

Psychopathy is a psychological construct that describes chronic immoral and antisocial behavior. The term is often used interchangeably with sociopathy. In the ICD-10 diagnosis criteria, the terms antisocial/dissocial personality disorder are used.

The term is used as a definition in law, for example, "psychopathic personality disorder" under the Mental Health Act 1983 of the UK as well as to denote a severe condition often related to antisocial or dissocial personality disorder as defined by the Psychopathy Checklist-Revised (PCL-R). The term "psychopathy" is often confused with psychotic disorders. It is estimated that approximately one percent of the general population are psychopaths.

The psychopath is defined by an uninhibited gratification in criminal, sexual, or aggressive impulses and the inability to learn from past mistakes.Individuals with this disorder gain satisfaction through their antisocial behavior and lack remorse for their actions.

 

In contemporary research, psychopathy has been most frequently operationalized by Dr. Robert D. Hare's Psychopathy Checklist-Revised (PCL-R). The checklist assesses both interpersonal and affective components as well as lifestyle and antisocial deficits. However, the research results cannot be easily extrapolated to the clinical diagnoses of dissocial personality disorder or antisocial personality disorder.

A sample research finding is that between 50 percent and 80 percent of prisoners in England and Wales meet the diagnostic criteria of dissocial personality disorder, but only 15 percent would be predicted to be psychopathic as measured by the PCL-R. Therefore, the findings drawn from psychopathy research have not yet been shown to be relevant as an aid to diagnosis and treatment of dissocial or antisocial personality disorders.

 

Hare's items

The following findings are for research purposes only, and are not used in clinical diagnosis. These items cover the affective, interpersonal, and behavioral features. Each item is rated on a score from zero to two. The sum total determines the extent of a person's psychopathy.[6]

Factor 1: Aggressive narcissism

  1. Glibness/superficial charm
  2. Grandiose sense of self-worth
  3. Pathological lying
  4. Cunning/manipulative
  5. Lack of remorse or guilt
  6. Emotionally shallow
  7. Callous/lack of empathy
  8. Failure to accept responsibility for own actions

Factor 2: Socially deviant lifestyle

  1. Need for stimulation/proneness to boredom
  2. Parasitic lifestyle
  3. Poor behavioral control
  4. Promiscuous sexual behavior
  5. Lack of realistic, long-term goals
  6. Impulsiveness
  7. Irresponsibility
  8. Juvenile delinquency
  9. Early behavioral problems
  10. Revocation of conditional release


Traits not correlated with either factor

  1. Many short-term marital relationships
  2. Criminal versatility

In practice, mental health professionals rarely treat psychopathic personality disorders as they are considered untreatable and no interventions have proved to be effective.[22] In England and Wales the diagnosis of dissocial personality disorder is grounds for detention in secure psychiatric hospitals under the Mental Health Act if they have committed serious crimes, but since such individuals are disruptive for other patients and not responsive to treatment this alternative to prison is not often used.

Because an individual's scores may have important consequences for his or her future, the potential for harm if the test is used or administered incorrectly is considerable. The test can only be considered valid if administered by a suitably qualified and experienced clinician under controlled conditions.

Hare wants the Diagnostic and Statistical Manual of Mental Disorders to list psychopathy as a unique disorder, saying psychopathy has no precise equivalent in either the DSM-IV-TR, where it is most strongly correlated with the diagnosis of antisocial personality disorder, or the ICD-10, which has a partly similar condition called dissocial personality disorder. Both organizations view the terms as synonymous. But only a minority of what Hare and his followers would diagnose as psychopaths who are in institutions are violent offenders.

The manipulative skills of some of the others are valued for providing audacious leadership. It is argued psychopathy is adaptive in a highly competitive environment, because it gets results for both the individual and the corporations or, often small political sects they represent. However, these individuals will often cause long-term harm, both to their co-workers and the organization as a whole, due to their manipulative, deceitful, abusive, and often fraudulent behaviour.

Hare describes people he calls psychopaths as "intraspecies predators who use charm, manipulation, intimidation, sex and violence to control others and to satisfy their own selfish needs. Lacking in conscience and empathy, they take what they want and do as they please, violating social norms and expectations without guilt or remorse". "What is missing, in other words, are the very qualities that allow a human being to live in social harmony

 

PCL-R Factors

Early factor analysis of the PCL-R indicated it consisted of two factors. Factor 1 captures traits dealing with the interpersonal and affective deficits of psychopathy (e.g. shallow affect, superficial charm, manipulativeness, lack of empathy) whereas Factor 2 dealt with symptoms relating to antisocial behaviour (e.g. criminal versatility, impulsiveness, irresponsibility, poor behaviour controls, juvenile delinquency).

The two factors have been found by those following this theory to display different correlates. Factor 1 has been correlated with narcissistic personality disorder, low anxiety, low empathy, low stress reaction and low suicide risk but high scores on scales of achievement and well-being.

In contrast, Factor 2 was found to be related to antisocial personality disorder, social deviance, sensation seeking, low socio-economic status and high risk of suicide.The two factors are nonetheless highly correlated and there are strong indications they do result from a single underlying disorder.However, research has failed to replicate the two-factor model in female samples.

Recent statistical analysis using confirmatory factor analysis by Cooke and Michie indicated a three-factor structure, with those items from factor 2 strictly relating to antisocial behaviour (criminal versatility, juvenile delinquency, revocation of conditional release, early behavioural problems and poor behavioural controls) removed from the final model. The remaining items are divided into three factors: Arrogant and Deceitful Interpersonal Style, Deficient Affective Experience and Impulsive and Irresponsible Behavioural Style.

In the most recent edition of the PCL-R, Hare adds a fourth antisocial behaviour factor, consisting of those Factor 2 items excluded in the previous model. Again, these models are presumed to be hierarchical with a single unified psychopathy disorder underlying the distinct but correlated factors.

The Cooke & Michie hierarchical ‘three’-factor model has severe statistical problems—i.e., it actually contains ten factors and results in impossible parameters (negative variances)—as well as conceptual problems. Hare and colleagues have published detailed critiques of the Cooke & Michie model. New evidence, across a range of samples and diverse measures, now supports a four-factor model of the psychopathy construct, which represents the Interpersonal, Affective, Lifestyle, and overt Antisocial features of the personality disorder.

 

Diagnostic criteria and PCL-R assessment

Psychopathy is most commonly assessed with the PCL-R, which is a clinical rating scale with 20 items. Each of the items in the PCL-R is scored on a three-point (0, 1, 2) scale according to two factors. PCL-R Factor 2 is associated with reactive anger, anxiety, increased risk of suicide, criminality, and impulsive violence.

PCL-R Factor 1, in contrast, is associated with extroversion and positive affect. Factor 1, the so-called core personality traits of psychopathy, may even be beneficial for the psychopath (in terms of nondeviant social functioning). A psychopath will score high on both factors, whereas someone with APD will score high only on Factor 2.[51]

Both case history and a semi-structured interview are used in the analysis.

 

Symptoms

Common characteristics of those with psychopathy are:

 

Legal definition (sexual predators)

Psychopathy has quite separate legal and judicial definitions that should not be confused with the medical definition. The American Psychiatric Association is vigorously opposing any non-medical or legal definition of what purports to be a medical condition "without regard for scientific and clinical knowledge".Various states and nations have at various times enacted laws specific to dealing with psychopaths.

In the United States approximately twenty states currently have provisions for the involuntary civil commitment for sex offenders or sexual predators, under Sexually violent predator acts, avoiding the use of the term "psychopath". These statutes and provisions are controversial and are being reviewed by the U.S. Supreme Court as a violation of a person's Fourteenth Amendment rights.

 

The Primary–Secondary distinction

Primary psychopathy was defined by those following this theory as the root disorder in patients diagnosed with it, whereas secondary psychopathy was defined as an aspect of another psychiatric disorder or social circumstances. Today, primary psychopaths are considered to have mostly Factor 1 traits from the PCL-R (arrogance, callousness, manipulativeness, lying) whereas secondary psychopaths have a majority of Factor 2 traits (impulsivity, boredom proneness, irresponsibility, lack of long-term goals).

Secondary psychopaths show normal to above-normal physiological responses to (perceived) potential threats. Their crimes tend to be unplanned and impulsive with little thought of the consequences. According to those using this theory, this type have hot tempers and are prone to reactive aggression. They experience normal to above-normal levels of anxiety but are nevertheless highly stimulus-seeking and have trouble tolerating boredom. Their lifestyle may lead to depression and even suicide.

Mealey uses the term "primary psychopathy" to differentiate between psychopathy that is biological in origin and "secondary psychopathy" that results from a combination of genetic and environmental influences.Lykken prefers sociopathy to describe the latter.

Sellbom and Ben-Porath (2005) describe the distinction:

Some people who engage in violent behavior possess psychopathic personality traits, such as callousness, grandiosity, and fearlessness, and presumably engage in such conduct because they care little about others. Others are impulsive and experience considerable anger, anxiety, and distress and may commit violent acts as a reaction to negative emotions, which are sometimes referred to as "crimes of passion." Indeed, the distinction between primary and secondary psychopathy (including so-called neurotic psychopathy) has long been noted in the psychopathy literature (Karpman, 1947; Lykken, 1995).

This distinction closely resembles the distinction between instrumental and impulsive/reactive crime/violence in the field of criminology.

Joseph P. Newman et al., who use this concept of psychopathy, have validated David T. Lykken's conceptualization of psychopathy subtypes in relation to Gray's behavioral activation system and behavioral inhibition system.Newman et al. found measures of primary psychopathy to be negatively correlated with Gray's behavioral inhibition system, a construct intended to measure behavioral inhibition from cues of punishment or nonreward. In contrast, measures of secondary psychopathy to be positively correlated with Gray's behavioral activation system, a construct intended to measure sensitivity to cues of behavioral approach.

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