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(COVID-19) pandemic has brought a lot of unknowns into the practice of medicine. Doctors are trying to see patients while keeping their patients, themselves, and their staff safe from infection and balancing the threat of being sued for not taking the proper precautions. Stephanie Sheps, vice president of claims at Coverys Specialty Insurance Company, a medical liability insurance provider, shared her thoughts on liability risk in the age of COVID-19 in an interview with 

There are the obvious risks, including transmission of COVID-19, both to patients and to staff. It is a novel issue because we do not fully understand this virus yet, and things continue to evolve daily. Based on patient and provider awareness and precautionary measures taken to mitigate these risks, I believe that the greater liability stems from pandemic-related or contextual realms. Pandemic risks are those that do not involve the diagnosis, transmission, or treatment of COVID-19, but are instead related to the changes in how health care is being delivered or not delivered. These risks include the denial of services to patients because of lack of capacity and lack of 

Medical visits, especially for checkups and management of 

, that are deferred or held virtually present some risk. There is a reason we see our providers in person: they get to put eyes on the patient, they get to take labs, they get to really assess the patient using all of their senses. When that is limited by doing visits through telehealth, I think that could present some greater risk in the future.

Are there oversights that make practices more vulnerable to COVID-related lawsuits?

Yes and no. These are common issues that would have existed before COVID-19, like the failure to document informed consent or informed refusal of treatment. Obviously, there are specific risks related to exposure in the office. The greatest risk right now, however, is that providers are so focused on these COVID-related safety issues that they may overlook traditional typical patient safety and risk mitigation efforts.

Have there been any cases that offer insight into how the courts will look at these COVID-19 issues?

It is a little bit early in the lifecycle to consider potential suits related to COVID-19. Not many have been filed related to COVID-19 that are not just contextual or pandemic-related, as it takes some time for things to wind their way through the court system. There was 1 decision in the federal district court in New York that remanded a case filed in the federal courts, but it was remanded back to the states so that it would not have the protections of the 

Public Readiness and Emergency Preparedness Act

Are there any states or regions where COVID-related actions are more prevalent than others?

Again, it is a little too soon to tell where things are more prevalent because not a lot has been filed in terms of COVID-specific lawsuits. We will likely see more case activity in states that do not have specific immunity for COVID-related countermeasures. Some of those are legislated, some of those are by executive order, but those states will probably see more activity. We will probably see more activity in states without tort reform, or states that do not have caps on noneconomic damages. Finally, states that have had limited or no specific guidance on public health and safety measures like wearing masks, by logical extension, may see more claims activity related to COVID-19 because those states are more likely to have more patients who contract COVID-19. Everything, just like the virus, continues to spread exponentially in the states that have passed legislation to help protect businesses from COVID-related lawsuits.

Do the state legislation protecting businesses from COVID-related suits help medical practices?

Absolutely, they do. The broadest protection comes from the federal extension of the PREP Act, which happened in March of this year. The PREP Act provides immunity to certain individuals, in this case, health care providers, for countermeasures taken to deal with health crises during. Many states have taken the initiative to invoke their own state-related 

, and some of those are even stronger, broader, and more encompassing to protect health care providers than the PREP Act itself. There are good protections out there for health care providers, but like anything else, there are ways around them.

What should practices do to minimize their risk from COVID-related legal action?

One of the things that we have been advocating is to continue traditional risk management and clinical risk management practices, and also employ tactical risk management. Those are things that we need to do now in anticipation of the claims we might have to defend in the future. For tactical risk management, we bucket our recommendations into timeline, record keeping, and memory. We recommend that health care providers, their practices, as well as facilities, keep a very detailed timeline of everything that has transpired related to the pandemic. If cases come up, most will be heard by a jury 3 to 4 years from now. With any luck, this pandemic will be a distant memory by then, and juries will need real reminders of what things were like.

It is important to be proactive about keeping records. We want to memorialize them on a timeline. Note the date that the first COVID-19 case appeared in your practice, the date testing became available, and the dates of any declaration of a state of emergency in your jurisdiction. Note dates when PPE was limited. Any dates relating to staffing shortages, furloughs, or reallocations should also be listed. These dates are critical.

In terms of record keeping, make sure that you have 

, including the purchase orders, letters from suppliers, etc. It is also important to have records of patient logs, like when they had visitors, when they left, or dates when the visitation may have been limited or flatly refused.

Document staff training, along with any furloughs and leaves of absence for providers who were concerned about the disease. Maintain a floor plan noting how isolation works for patients that are COVID-19 positive or suspected COVID-19 positive. Also, keep evidence of any reviews of quality assurance or compliance. These tasks contribute to preserving memory.

Memorialize the subject matter experts within your facility, including human resources and office manager personnel. If a deposition is later needed during litigation , you do not want to have to think back to who was working in 2020; you want to have that recorded. If possible, have a video of a day in the life at your facility or practice. It is so important, since memories fade, to get a context and to have a living example of how you functioned during this pandemic to 

 what it was like to deliver health care during a pandemic.

Remember, the strategy behind tactical risk management is that it is never too late to start. It will be more difficult to gather documents in the future. It will benefit the defense to have all of this information in 1 place, starting with your timeline; then connecting to all of your records and documentation; and finally preserving the memories of the actual people who are in charge of those decisions, creating the protocols, and following state federal guidelines with respect to the pandemic.

Does the typical malpractice insurance policy cover COVID-related claims?

Typically, yes, a medical professional liability policy covers what we call professional services, which is insurance company lingo for rendering medical care. However, most policies exclude willful or intentional conduct and many also exclude gross negligence.

 is the vice president of claims at Coverys. She is also a member of the International Association of Defense Counsel, the Professional Liability Underwriters Society, and serves as vice chairperson of the Professional Liability Foundation of Massachusetts

Does the typical malpractice insurance policy cover COVID-related claims? That question and more answered.

Physician Liability During COVID-19: What You Need to Know To Protect Your Practice

 in terms of the harm caused to individuals, the damage caused to property, and the financial implications for individuals and society. Between 2010-2014, an estimated 261,330 intentional fires were reported to US municipal fire departments each year, resulting in 440 deaths, and 1310 injuries, and the economic cost of fire setting was estimated to be as high as $328.5 billion per year.

 In the United States, 1 in 100 adults self-reported a lifetime history of deliberate fire setting; 38% of these fire settings persisted beyond the age of 15 years.

 Although estimations of the number of people who set fires within a population are almost certainly imprecise due to methodological limitations such as variations in study design, definition of fire setting used, data analysis techniques, ungeneralizable samples, and response bias, they do provide insight into the scale of the problem.

Various terminology, with somewhat different meanings, has been used within the literature to describe offending behavior that involves fire (

 are terms used to describe intentional fires set within specific contexts (eg, legal or psychiatric), 

 is the current preferred term in the literature to describe acts of deliberately started fires regardless of their legal or diagnostic status.

Comorbidity is common among adults who set fires. Common diagnoses include personality disorder, psychosis, substance dependence, and mood disorders.

 Reported prevalence rates of pyromania are relatively low, ranging between 0 to 10% of adults who set fires.

 Lower cognitive functioning, intellectual disabilities, and other developmental disorders (eg, autism) are also common, although exact prevalence varies widely depending upon the population sampled (ie, inpatient, community, prison samples).

Despite the development of reliable and valid assessment tools in other areas of offending behavior (eg, sexual offending), the systematic development of tools specific to fire setting has been slower to progress. Nevertheless, several tools have been developed to support the process of systematically collecting and collating clinical information from a range of sources (eg, self and informant reports, behavioral observations, file reviews and clinical assessments) in order to formulate risk and identify treatment needs and intervention plans for individuals who set fires (eg, the Tranah Firesetting Inventory,

 St Andrew’s Fire and Arson Risk Instrument,

 Northgate Firesetter Risk Assessment-2.0,

). These tools do not represent validated risk assessments for fire setting, however, a few fire-specific psychometric measures have been developed to assess fire-related factors (although they lack sufficient evaluation) (

Most recently, the properties of the Fire Interest Rating Scale, Fire Attitudes Scale and the Identification with Fire Questionnaire were analyzed using factor analysis and 4 clinically relevant constructs identified across the 3 scales (ie, the Four Factor Fire Scales): 

However, data collected to validate these measures was limited (eg, ungeneralizable/small samples). Nevertheless, despite fire specific measures not having undergone rigorous reliability and validity evaluations, they can still be used by experienced clinicians as part of a comprehensive assessment.

Those who engage in fire setting are often complex individuals with a diverse set of treatment or intervention needs warranting a specialist approach that reduces their risk of further offending. Most specialist treatment programs are underpinned by a 

approach, targeting a range of criminogenic needs and factors associated with fire setting, including cognitive distortions, poor problem solving, communication difficulties, self-regulation deficits, and relapse prevention. Treatment often includes a component on fire safety education and the consequences of fire setting, while also address­ing a range of associated interpersonal problems (eg, low self-esteem, social competence difficulties, and poor goal setting). 

 summarizes empirically evaluated treatment programs.

Existing interventions that target fire setting behavior in adults include an adapted version of the Fire Awareness Child Education UP (FACE-UP).

 More recently, a cognitive-behavioral group-based intervention for individuals with developmental disabilities called the Northgate Firesetters Treatment program was developed.

 Investigators reported follow-up data for 24 participants (16 men, 8 women) who completed the Northgate Firesetters Treatment Programme, between 4 years and 12 years, 9 months posttreatment. The majority of participants (n = 17) were living in community settings and only 1 female participant was reported to have set a further fire, although suspicions were raised concerning another 2 participants.

 Despite these positive findings, both of these treatment programs are grounded in theoretical perspectives that predate more recent advancements in the field (ie, Functional Analysis Theory,

). Furthermore, their effectiveness are limited in their comparability to other generic interventions, small sample sizes, and lack of robust evidence in terms of their effectiveness in reducing reoffending.

The Firesetting Intervention Programme for Prisoners (FIPP)

 and the Firesetting Intervention Programme for Mentally Disordered Offenders (FIP-MO)

 are based on the latest comprehensive theory of fire setting: the Multi-Trajectory Theory of Adult Firesetting (M-TTAF).

 The M-TTAF integrates parts of existing psychological theory that are supported by empirical evidence including psychological vulnerabilities, developmental factors, cultural factors, social learning factors, biological factors, and contextual factors related to fire setting into a detailed multifactorial theory.

Following a pilot evaluation of the FIPP, positive findings were reported posttreatment on measures related to fire interest/problematic associations with fire, offence supportive attitudes (ie, fire specific, violent, antisocial), locus of control, and anger regulation, which were stable at 3 month follow-up.

 However, the evaluation of the FIPP was conducted solely with adult males in a prison environment; thus, its effectiveness for women and adults with 

intellectual and developmental disabilities

 has yet to be established. Consequently, the FIP-MO was developed to address fire setting and fire-related risk behaviors for both men and women across secure forensic psychiatric hospitals in the United Kingdom. Significant improvements on self-reported interests, beliefs and attitudes about fire, as well as improvement in anger expression.

It is important to note that due to the paucity of research on fire setting by adults with intellectual and developmental disabilities, the generalizability of the M-TTAF to such groups, and the interventions underpinned by it, has yet to be established. Further, despite evidence suggesting that between 0.4% to 43.6% of adults who set fires have intellectual and developmental disabilities,

 no treatment program to date has been rigorously evaluated for this population. Yet, there is evidence to suggest this small but important group have different characteristics and offence specific treatment needs requiring a 

 Nevertheless, the FIPP and FIP-MO represent the first standardized specialist interventions for individuals who deliberately set fires and have been subject to a multisite research evaluation, with results showing that they are effective in reducing some of the fire setters’ key deficits.

Evidence suggests general recidivism is as high as 60% among adults who set fires; reoffending with fire is much lwer with estimates between 4% and 16%.

 However, the operational definition of recidivism, study methodology, setting and sample populations vary widely. Nevertheless, recidivism has been largely associated with younger age, single relationship status, a diagnosis of personality disorder, a history of criminal offending, an interest in fire, and a number of attributes suggestive of childhood disturbance.

 Furthermore, reported length of stay in hospital for adults with intellectual and other developmental 

 and history of fire setting vary from 950 days to 1725 days.

 However, very few studies have included details pertaining to length of stay, which is inevitably effected by many confounding variables, such as mental health, engagement in treatment, previous offending history that are not accounted for within the data.

Whilst there have been significant advancements in our understanding of deliberate fire setting in recent years, further research is urgently needed to understand the etiology of fire setting and to further develop specialist assessment and treatment protocols. In particular, little is known about the relationship between cultural factors and fire misuse, gender-specific factors, or the needs of individuals with intellectual and/or other developmental disabilities. In addition, research on fac­tors that influence the maintenance and desistance process for fire setting will aid the construction of valid and reliable risk assessment tools and ensure individualized treat­ment approaches are taken and practice is evidence based. Focusing on these areas will also ensure that treatment efforts evolve to meet the needs of individuals who have set fires regardless of the treatment setting.

is a postgraduate researcher at the Tizard Centre, School of Social Policy, Sociology and Social Research, University of Kent, UK. 

 is a lecturer in forensic psychology at theSchool of Psychology, Victoria University of Wellington, New Zealand, and Honorary Lecturer in Forensic Psychology at the University of Kent, UK. 

is a chartered psychologist and lecturer in forensic psychology and intellectual and developmental disabilityat the Tizard Centre, School of Social Policy, Sociology and Social Research, University of Kent. Ms Collins and Dr Barnoux have nothing to disclose regarding this article. Dr Tyler is involved in providing training and evaluating the FIPP and FIP-MO programs and has received funding from Fire and Emergency New Zealand to conduct research on their Fire Awareness Intervention Programme (FAIP) for youth.

1. Home Office. Fire statistics data tables. May 14, 2020. Accessed July 23, 2020. 

https://www.gov.uk/government/statistical-data-sets/fire-statistics-data-tables

2. Campbell R. Intentional fires. National Fire Protection Association. July 2017. Accessed July 23, 2020. https://www.nfpa.org/News-and-Research/Data-research-and-tools/US-Fire-Problem/Intentional-fires

Accessed July 23, 2020. http://www.stoparsonuk.org/arson/documents/Arson-Prevention-Forum-Booklet.pdf

4. Zhuang J, Payyappalli VM, Behrendt A, Lukasiewicz K. 

. National Fire Protection Association. October 2017. Accessed July 23, 2020. https://www.nfpa.org/News-and-Research/Data-research-and-tools/US-Fire-Problem/Total-cost-of-fire-in-the-United-States

5. Blanco C, Alegria AA, Petry NM et al. Prevalence and correlates of fire setting in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). 

6. Vaughn M, Fu Q, DeLisi M, et al. Prevalence and correlates of fire setting in the United States: results from the National Epidemiological Survey on Alcohol and Related Conditions. 

Diagnostic and Statistical Manual of Mental Disorders, DSM-V. 

8. Bell R, Doley R, Dawson D. Developmental characteristics of adults who set fires: are recidivist offenders distinctive? 

9. Geller JL, Bertsch G. (1985). Fire-setting behavior in the histories of a state hospital population. 

10. Lindberg N, Holi MM, Tani P, Virkkunen M (2005). Looking for pyromania: characteristics of a consecutive sample of Finnish male criminals with histories of recidivist fire-setting between 1973 and 1993. 

11. Lees-Warley G, Rose J. What does the evidence tell us about adults with low intellectual functioning who deliberately set fires? a systematic review

. International Journal of Developmental Disabilities

12. Tranah T, Nicholas J. Interventions for young people with intellectual disabilities who commit arson. 

13. Taylor JL, Thorne I, Slavkin ML. Treatment of fire-setting behaviour. In: Lindsay WR, Taylor JL,Sturmey , eds.

 Offenders with Developmental Disabilities

14. Long CG, Banyard E, Fulton B, Hollin CR. (2014). Developing an assessment of fire-setting to guide treatment in secure settings: The St Andrew's fire and arson risk instrument (SAFARI). 

15. Taylor JL, Thorne I. Northgate firesetter risk assessment. Unpublished manual. Northgate and Prudhoe NHS Trust; 2005.

16. Taylor JL, Thorne I, Robertson A, Avery G. (2002). Evaluation of a group intervention for convicted arsonists with mild and borderline intellectual disabilities. 

17. Murphy G, Clare I. Analysis of motivation in people with mild learning disabilities (mental handicap) who set fires. 

Firesetting: Addressing Offending Behavior.

 Redcar and Cleveland Psychological Service; 1997.

19. Gannon TA, Ó Ciardha C, Barnoux MFL. The Identification with Fire Questionnaire. CORE-FP, School of Psychology, University of Kent; 2011.

20. Gannon TA, Barrowcliffe E. Firesetting in the general population: The development and validation of the Fire Setting and Fire Proclivity Scales. 

21. Ó Ciardha C, Tyler N, Gannon TA. (2015). A practical guide to assessing adult fire setters’ fire-specific treatment needs using the Four Factor Fire Scales. 

22. Hayes A. Climbing the ladder of reform. 

23. Taylor JL, Robertson A, Thorne I, Belshaw T, Watson A. Responses of female fire‐setters with mild and borderline intellectual disabilities to a group intervention. 

Journal of Applied Research in Intellectual Disabilities. 

24. Taylor JL. Roots, referrals, risks and remedies for offenders with intellectual disabilities. Paper presented at: A Risky Business, BPS conference. October 2014. University of Manchester, UK.

25. Jackson H, Glass C, Hope S. (1987). A functional analysis of recidivistic arson. 

26. Fineman KR. Firesetting in childhood and adolescence. 

27. Fineman KR. A model for the qualitative analysis of child and adult deviant behavior. 

The Firesetting Intervention Programme for Prisoners (FIPP). 

Firesetting Intervention Programme for Mentally Disordered Offenders (FIP-MO) Version 2.0.

 CORE-FP. University of Kent and Kent Forensic Psychiatry Services, NHS; 2014.

30. Gannon TA, Ó Ciardha C, Doley RM, Alleyne E. The Multi-Trajectory Theory of Adult Firesetting (M-TTAF). 

31. Gannon TA, Alleyne E, Butler H, et al. Specialist group therapy for psychological factors associated with fire setting: Evidence of a treatment effect from a non-randomized trial with male prisoners. 

32. Tyler N, Gannon TA, Lockerbie L, Ó Ciardha C. An evaluation of a specialist fire setting treatment programmed for male and female mentally disordered offenders (the FIP-MO). 

33. Ritchie EC, Huff TG. Psychiatric aspects of arsonists. 

34. Dickens G, Sugarman P, Ahmad F, Edgar S, Hofberg, K, Tewari S. Characteristics of low IQ arsonists at psychiatric assessment. 

35. Alexander RT, Chester V, Green FN, Gunaratna I, Hoare S. Arson or fire setting in offenders with intellectual disability: clinical characteristics, forensic histories, and treatment outcomes. 

Journal of Intellectual and Developmental Disability

36. Rice ME, Harris GT. Firesetters admitted to a maximum security psychiatric institution: Offenders and offenses. 

37. Ducat L, McEwan TE, Ogloff JR. An investigation of fire setting recidivism: factors related to repeat offending. 

The development of an actuarial model for arson recidivism

39. Dickens G, Sugarman P, Edgar S, Hofberg K, Tewari S, Ahmad F. Recidivism and dangerousness in arsonists. 

The Journal of Forensic Psychiatry & Psychology

Gunaratna I, Hoare S. Arson or fire setting in offenders with intellectual disability: clinical characteristics, forensic histories, and treatment outcomes

Journal of Intellectual and Developmental Disability.

41. Edwards MJ, Grace RC. The development of an actuarial model for arson recidivism. 

42. Dickens G, Sugarman P, Edgar S, et al. Recidivism and dangerousness in arsonists. 

The Journal of Forensic psychiatry & Psychology

43. Alexander RT, Chester V, Green FN, et al. Arson or fire setting in offenders with intellectual disability: clinical characteristics, forensic histories, and treatment out-comes. 

44. Taylor JL, Thorne I, Robertson A, Avery G. Evaluation of a group intervention for convicted arsonists with mild and borderline intellectual disabilities. 

Fire setting is the current preferred term in the literature to describe acts of deliberately started fires regardless of their legal or diagnostic status.

Understanding Adult Fire Setting, Pyromania, and Arson

American Academy of Psychiatry and the Law

 (APPL) recently presented James L. Knoll IV, MD, with the Seymour Pollack Award, for notable achievements in the education and teaching of forensic psychiatry. The award was presented at the 

Knoll, director of Forensic Psychiatry and professor of Psychiatry at 

State University of New York (SUNY) Upstate Medical University

 in Syracuse, NY, said he was honored and humbled to receive the award. He added that it was the support of AAPL, SUNY Upstate, and New York State’s Office of Mental Health that has allowed him the opportunity to pursue his passion for teaching, writing, and forensic investigation. He added that the award further inspires him to explore the interface between psychiatry and the law, as well as train the next generation of forensic psychiatrists.

 (2010 to 2014), is a nationally recognized expert in forensic psychiatry who has made significant contributions to the research on mass murder and violence. He is chair of the Threat Assessment Subcommittee of the Syracuse School Safety Task Force and has spoken nationally and consulted with law enforcement, including the Department of Justice, National Institute of Justice, and the Federal Bureau of Investigation (FBI).

Knoll is one of only a handful of psychiatrists in the country to be accepted as an associate fellow of the 

International Criminal Investigative Analysis Fellowship

; the fellowship meets regularly at the FBI National Academy in Quantico, VA. Before moving to New York, he was the director of Psychiatric Treatment Services for the New Hampshire State Prison system, where he was responsible for the oversight of New Hampshire’s insanity acquitee patient population. Knoll has served as an expert witness in cases of national prominence, such as the “Cleveland Strangler” serial murder case of Anthony Sowell, and the “137 shots” Cleveland Police shooting case. He has served as a stalking risk assessment consultant for law enforcement and victims of stalking for more than 20 years.

A prodigious writer, Knoll’s works include:

; and the series “Tales from the New Asylums” can be found 

 (where he served as co-editor and contributing editor).

• Textbooks of forensic psychiatry, such as: 

Principles & Practice of Forensic Psychiatry

The Oxford Textbook of Correctional Psychiatry

Clinical Assessment of Malingering and Deception.

• A vast compendium of articles on the Jonestown mass murder-suicide (

1. 2020 AAPL Annual Meeting Livestream Program. October 7-18 & 24-25, 2020. Accessed November 6, 202. https://www.aapl.org/docs/pdf/20200930131518616.pdf

Editor in chief emeritus of Psychiatric Times, James L. Knoll IV, MD, was recently recognized for notable achievements in the education and teaching of forensic psychiatry. 

National Leader in Forensic Psychiatry Receives Prestigious Award

SPECIAL REPORT: FORENSIC PSYCHIATRY, PART II

-Special Report Chair: James L. Knoll IV, MD

Psychopathy is a personality disorder characterized by lack of empathy, grandiosity, shallow affect, deceitfulness, impulsivity, irresponsibility, and disregard for the well-being or rights of others. Few syndromes in medicine have carved as deep of a niche in human cultural thought as the one occupied by psychopathy. The mythos of the psychopath is born of both in extremis of its infamous case examples and of past deficiencies in the empirical research. However, the scientific landscape for psychopathy has expanded significantly over recent decades, and discourse around treatment has become more optimistic.

, sociopath, and antisocial are often used interchangeably by clinicians, they are not equal. Psychopathy and sociopathy both describe the same personality syndrome. However, many experts identify them as separate but overlapping entities with distinct etiological mechanisms.

 Psychopathy remains empirically the better described of the 2 and is the term most often used to denote the cluster of personality traits in question.

The term antisocial is often clinically used as a short-hand reference to the DSM-V diagnosis of antisocial personality disorder (ASPD), which is based almost entirely on behaviors. A lack of empathy and disregard for the safety of others are neither necessary nor sufficient for the diagnosis. In contrast, psychopathy is a set of personality traits which may or may not be associated with obvious misconduct. It must not be assumed that an individual who meets diagnostic criteria for ASPD also has psychopathic/sociopathic personality traits, because this is often not the case.

Psychopathy seems to have some degree of hereditability, although genetic and epigenetic factors are not entirely sufficient to account for disorder. A prevalence of between 15% to 25% has been described in incarcerated populations, and approximately 1% in the general population, with a male to female ratio of about 3:1.

 One study found 4% of corporate managers exhibited significant psychopathic traits.

Psychopathy has been associated with deficits in multiple cognitive domains, including attention, judgement of risk and reward, and the emotional processing.

 The brains of individuals with psychopathy have identifiable structural and functional differences from the brains of those without, which appear to account for some of the cognitive and behavioral manifestations of the disorder. Reduced gray matter volumes in the amygdala and multiple areas of the prefrontal cortex have been described. On fMRI, psychopathic brains have exhibited dysfunctional activity in the default mode network, including limbic and paralimbic structures.7 People with psychopathy have also been found to exhibit impaired communication between the visual prefrontal cortex and the amygdala.8 Increased activity in the ventral striatum in the context of reward expectancy has also been described in association with criminal activity among those with psychopathy.

Unsurprisingly, psychopathic personalities are identified more frequently in forensic than community settings. The odds of encountering a patient with psychopathy in the general outpatient setting, however, are significant. As with other personality syndromes, these patients often present to a psychiatrist seeking treatment for a comorbid condition, and only through careful assessment does the character pathology become apparent to the clinician. Psychopathy is most often associated with substance use disorders and with other Cluster B personality syndromes, such as narcissistic personality disorder.

The impairment caused by this condition should not be underestimated. In the forensic setting, this is usually evident. In the community, however, impairment may be less conspicuous. Deficits in attention and risk-reward assessment may result in harmful financial decisions, poor judgement at work, gambling, and other impulsive behaviors. Callousness, deceitfulness, and grandiosity may lead to brief and combustive relationships. One may encounter a patient who cannot seem to maintain employment despite ability and qualification; instrumentally engages socially with others and is undisturbed when relationships fall apart; and exhibits a pattern of poor decision making accompanied by a psychological scotoma for personal responsibility. Psychopathic personality traits may also present adaptively in one domain of life, such as a boardroom

, and maladaptively in another, such as marriage.

The gold standard instrument for assessing psychopathy is the 

In the forensic setting, performance of the PCL-R is accompanied by extensive collateral investigation, psychiatric interview, and review of the individual’s medical, social, and criminal history. There is also a screening version of the PCL-R, the PCL-SV, which can be performed outside of the specialized forensic setting (

 good interrater reliability and can potentially be useful when leveraged by objective and ethical evaluators who are trained to interpret the instruments and to provide honest and impartial professional opinions. However, concerns have been raised about the susceptibility of the tests to bias when performed by individuals who lack this expertise.

 These tools have also exhibited wide variability in their ability to predict future violence and their use in the assessment of risk must be approached with caution. There are significant ethical concerns regarding the potential misuse of these tests in legal and clinical decision making when the fate of an individual’s liberty or the safety of others is at stake.

 While the items in the PCL-R and PCL-SV may help guide formulation, the diagnosis of psychopathy in the general outpatient setting must be made carefully and only with substantial amounts of data gathered through the physician-patient relationship over time.

The differential diagnosis for psychopathy includes a personality disturbance due to another mental illness or physical condition. For example, individuals with frontotemporal dementia may present with impulsive behavior and an apparent lack of regard for others. Autism spectrum disorders may also present with impaired mentalization and apparent lack of empathy. Psychotic illnesses may produce a flattened affect with the appearance of shallow or blunted emotional responses. Patients who are dependent on a substance may exhibit manipulativeness and recklessness when their disorder is decompensated, and then improve when receiving appropriate treatment.

The concept of psychopathy in pediatric patients is complex and controversial. Psychopathy is similar to other personality disorders in that it is not diagnosed prior to adulthood, due to the fluidity of personality traits during early development and the inability to predict which children will go on to develop a disorder and which will not. Furthermore, multiple items in the adult diagnostic criteria are predicated on the patient having had sufficient years of life to fulfill them (such as parasitic lifestyle or multiple short-term marital relationships). Any assessment of psychopathic traits in a child or adolescent patient must be approached with extreme caution.

A perilous belief once persisted in the scientific community that psychopathy was not only untreatable, but that attempting to treat a 

 While incarceration is the definitive “treatment” for some, psychopathy exists on a spectrum like any other mental disorder; more recent research suggests the condition is capable of responding to treatment. Although data are still limited, the treatment of psychopathy has begun to gain traction as a target for clinical research. The substantial evidence supporting the existence of cognitive and emotional processing deficits in people with psychopathy suggests that these are potential treatment targets. Indeed, cognitive behavioral and cognitive remediation 

Some have also suggested that the interpersonal and affective symptoms of psychopathy may be amenable to modified dialectical behavioral therapy techniques.

Data are limited regarding the use of medication to target psychopathic personality traits. The best approach to pharmacotherapy is to target and treat comorbid psychiatric disorders.

Although it may be daunting to encounter a patient with psychopathy in the general practice setting, this syndrome is well defined and can be approached clinically in a manner similar to other personality disorders. Essential elements include examination of the history and patient’s motivation for care, assessment and treatment of comorbid conditions, and collaboration with family members and other treatment providers. Psychopathy is associated with an increased risk of violence; however, this relationship is more complex than it appears and remains the subject of ongoing research.

 As neurological and psychological investigations continue, the future appears more promising than previously thought.

is a child & adolescent and forensic psychiatrist. He is the director of the Sexual Violence Prevention & Risk Management Program at Beth Israel Deaconess Medical Center, and a Harvard Medical School faculty. His forensic practice focuses on criminal and civil cases including sex offender, threat, competency, and criminal responsibility assessments. 

is fourth year psychiatry resident at Beth Israel Deaconess Medical Center in Boston, MA. She will be matriculating to the forensic psychiatry fellowship program at the University of Massachusetts Medical School.

1. Walsh A, Wu H-H. Differentiating antisocial personality disorder, psychopathy, and sociopathy: evolutionary, genetic, neurological, and sociological considerations. 

2. Werner, KB, Few, LR., Bucholz, KK. Epidemiology, comorbidity, and behavioral genetics of antisocial personality disorder and psychopathy. 

3. Hart, SD, Storey, JE. Clinical and forensic issues in the assessment of psychopathy. In: Weiner, IB, eds. 

4. Babiak, P, Neumann, CS, Hare, RD. Corporate psychopathy: Talking the walk. 

5. Anderson, NE, Steele, VR, Maurer, JM, Rao, V, Koenigs, MR, Decety, J, Kosson, DS, Calhoun, VD, Kiehl, KA. 2017. Differentiating emotional processing and attention in psychopathy with functional neuroimaging. . 

6. Baskin-Sommers AR, Curtin JJ, Newman JP. Altering the Cognitive-Affective Dysfunctions of Psychopathic and Externalizing Offender Subtypes with Cognitive Remediation. 

7. Johanson M, Vaurio O, Tiihonen J, Lähteenvuo M. A Systematic Literature Review of Neuroimaging of Psychopathic Traits. 

8. Contreras-Rodríguez O, Pujol J, Batalla I, et al. Disrupted neural processing of emotional faces in psychopathy. 

9. Geurts DE, von Borries K, Volman I, Bulten BH, Cools R, Verkes RJ. Neural connectivity during reward expectation dissociates psychopathic criminals from non-criminal individuals with high impulsive/antisocial psychopathic traits. 

10. Steinert SW, Lishner DA, Vitacco MJ, Hong PY. Conceptualizing successful psychopathy: An elaboration of the moderated-expression model.

The Psychopathy Checklist–Revised, 2nd ed. 

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While incarceration is the definitive “treatment” for some, psychopathy exists on a spectrum like any other mental disorder; more recent research suggests the condition is capable of responding to treatment. 

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