In the last decade, neurobiological explanations have become available for many of the traits of psychopathy. For example, impulsivity, recklessness/irresponsibility, hostility and aggressiveness may be determined by abnormal levels of neurochemicals including monoamine oxidase (MAO), serotonin (5-HT) and 5-hydroxyindoleacetic acid (5-HIAA), triiodothyronine (T3), free-thyroxine (T4), testosterone, cortisol, adrenocorticotropic hormone (ACTH), and hormones of the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-gonadal axes (W.H.J.M., unpublished data). Other features like sensation-seeking and an incapacity to learn from experiences (Lykken, 1995) might be linked to cortical underarousal (Martens, 2000, 1997; Zuckerman, 1994). Sensation-seeking could also be related to low levels of MAO and cortisol and high concentrations of gonadal hormones, as well as reduced prefrontal grey matter volume (Raine, 1996; Raine et al., 2000; Zuckerman, 1994). Many psychopaths can thus be considered, at least to some degree, victims of neurobiologically determined behavioral abnormalities that, in turn, create a fixed gulf between them and the rest of the world.
It may be possible to diminish traits like sensation-seeking, impulsivity, aggression and related emotional pain with the help of psychotherapeutic, psychopharmacological and/or neurofeedback treatment.
Long-term psychotherapeutic treatment (at least five years) seems effective in some categories of psychopaths, in so far as psychopathic personality traits may diminish (Dolan, 1998; Dolan and Coid, 1993; Sanislow and McGlashan, 1998).
Psychotherapeutic treatment alone may be insufficient to improve symptoms. Psychopharmacological treatment methods may help normalize neurobiological functions and related behavior/personality traits (Martens, in press, 2001, 2000). Lithium(Drug information on lithium) is impressive in treating antisocial, aggressive and assaultive behavior (Bloom and Kupfer, 1994; Sheard et al., 1976; Tupin et al., 1973). Hollander (1999) found that mood stabilizers such as divalproex (Depakote), selective serotonin reuptake inhibitors, monoamine oxidase inhibitors (MAOIs) and neuroleptics have documented efficacy in treating aggression and affective instability in impulsive patients. To date there have been no controlled studies of the psychopharmacological treatment of other core features of psychopathy.
Cortical underarousal and low autonomic activity-reactivity can be substantially reduced with the help of adaptive neurofeedback techniques (Martens, 2001; Raine, 1996).Case Study>
"Norman" was raised by his aunt, as his parents were divorced and neither were capable of or interested in caring for him. As a child and adolescent, he had numerous encounters with law enforcement for joyriding, theft, burglary, fraud, assault and battery. He was sent to reform school twice. When he was 21 years old, he was convicted of armed robbery and served a year and a half in jail. His only close friend was another violent criminal; he had many short-term relationships with girlfriends. At 29, he killed two strangers in a bar who had insulted him and was sentenced to forensic psychiatric treatment. Norman was diagnosed as a psychopath, according to Hare's Psychopathy Checklist (Hare et al., 1990).
Norman showed little improvement over the course of seven years of behavioral psychotherapy and became less and less motivated. The staff of the forensic psychiatric hospital considered him untreatable and intended to stop all treatment attempts. Norman's lawyer arranged for an examination by a forensic neurologist, who subsequently found that Norman suffered from severe cortical underarousal, 5-HT and MAO abnormalities, and concentration problems.
Norman was started on d,l-fenfluramine (Pondimin), a serotonin-releasing drug. (Fenfluramine was voluntarily withdrawn from the U.S. market in 1997 -- Ed.) Acute challenge doses (0.2 mg/kg to 0.4 mg/kg) produced significant dose-dependent decreases in impulsive and aggressive responses. After one month, an MAOI (pargyline [Eutonyl], 10 mg/kg) and psychodynamic psychotherapy were added. Pargyline produced some normalization of his electroencephalogram (EEG) pattern and was titrated up to 20 mg/kg over five months. Neurofeedback was started after two months and continued for 15 months. His EEG pattern gradually normalized, and his capacities for concentration and attention increased.
Norman continued to receive d,l-fenfluramine and psychotherapy for two years, at which point he was discharged from forensic treatment. He voluntarily continued psychotherapy for an additional three years and, in the four years since his release, has not reoffended.Conclusions
It is extremely important to recognize hidden suffering, loneliness and lack of self-esteem as risk factors for violent, criminal behavior in psychopaths. Studying the statements of violent criminal psychopaths sheds light on their striking and specific vulnerability and emotional pain. More experimental psychopharmacological, neurofeedback and combined psychotherapeutic research is needed to prevent and treat psychopathic behavior.
The current picture of the psychopath, which is reflected in the leading diagnostic criteria of psychopathy offered by Cleckley (1982) and Hare et al. (1990), is incomplete because emotional suffering and loneliness are ignored. When these aspects are considered, our conception of the psychopath goes beyond the heartless and becomes more human.