In the past 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 and 5-hydroxyindoleacetic acid, triiodothyronine, free thyroxine, testosterone, cortisol, adrenocorticotropic hormone, and hormones of the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-gonadal axes.8
Other features, such as sensation-seeking and an incapacity to learn from experiences, might be linked to cortical underarousal.4 Sensation-seeking could also be related to low levels of MAO and cortisol and high concentrations of gonadal hormones, as well as reduced prefrontal gray matter volume.9 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 such as sensation-seeking, impulsivity, aggression, and related emotional pain with the help of psychotherapy, psychopharmacotherapy, and/or neurofeedback. Long-term psychotherapy (at least 5 years) seems effective in some categories of psychopaths, in so far as psychopathic personality traits may diminish.10-12
Psychotherapy alone may be insufficient to improve symptoms. Psychopharmacotherapy may help normalize neurobiological functions and related behavior/personality traits.13 Lithium is impressive in treating antisocial, aggressive, and assaultive behavior.14 Hollander15 found that mood stabilizers, such as divalproex, SSRIs, MAOIs, and neuroleptics, have documented efficacy in treating aggression and affective instability in impulsive patients. There have been no controlled studies of psychopharmacotherapy for other core features of psychopathy.
Cortical underarousal and low autonomic activity-reactivity can be substantially reduced with the help of adaptive neurofeedback techniques.16,17
CASE VIGNETTE
Norman was raised by his aunt; his parents were divorced and neither was 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, and assault and battery. He was sent to reform school twice. When he was 21, he was convicted of armed robbery and served 1½ years 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. The diagnosis was psychopathy, according to Hare’s psychopathy checklist.2
Norman showed little improvement over the course of 7 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, serotonin and MAO abnormalities, and concentration problems.
Treatment with D,L-fenfluramine, a serotonin-releasing drug, was started. (Fenfluramine was voluntarily withdrawn from the US market in 1997.) Acute challenge doses (0.2 mg/kg to 0.4 mg/kg) produced significant dose-dependent decreases in impulsive and aggressive responses. After 1 month, an MAOI (pargyline, 10 mg/kg) and psychodynamic psychotherapy were added. Pargyline produced some normalization of his EEG pattern and was titrated to 20 mg/kg over 5 months. Neurofeedback was started after 2 months and continued for 15 months. His EEG pattern gradually normalized, and his capacity for concentration and attention increased.
Norman continued to receive D,L-fenfluramine and psychotherapy for 2 years, at which point he was discharged from forensic treatment. He voluntarily continued psychotherapy for an additional 3 years and, in the 4 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 psychopharmacotherapy, neurofeedback, and combined psychotherapy research is needed to prevent and treat psychopathic behavior.
The current picture of the psychopath 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.
Note to readers- This article was originally published in Psychiatric Times and posted on PsychiatricTimes.com in 2006. Ever since, it has remained one of the best-read articles. We re-publish it here with updates from Dr Martens.
Disclosures:
Dr Martens is Chair of the W. Kahn Institute of Theoretical Psychiatry and Neuroscience. He is also Psychiatry Advisor of the European Commission (Leonardo da Vinci) and a member of the Royal College of Psychiatrists.
References
1. Cleckley HM. Mask of Sanity: An Attempt to Clarify Some Issues About the So-Called Psychopathic Personality. 6th ed. St Louis: CV Mosby Co; 1982.
2. Hare RD, Harpur TJ, Hakstian AR, et al. The revised psychopathy checklist: descriptive statistics, reliability, and factor structure. Psychol Assess. 1990;2:338-341.
3. Martens W. Hidden suffering of the psychopath: new insight on basis of self-reports of psychopaths; 2013. Accessed September 15, 2014. https://www.smashwords.com/books/view/304901
4. Martens WHJ. Antisocial and psychopathic personality disorders: causes, course and remission: a review article. Int J Offender Ther Comp Criminol. 2000;44:406-430.
5. Martens WH, Palermo GB. Loneliness and associated violent antisocial behavior: analysis of the case reports of Jeffrey Dahmer and Dennis Nilsen. Int J Offender Ther Comp Criminol. 2005;49:298-307.
6. Martens WH. Sadism linked to loneliness: psychodynamic dimensions of the sadistic serial killer Jeffrey Dahmer. Psychoanal Rev. 2011;98:493-514.
7. Black DW, Baumgard CH, Bell SE, Kao C. Death rates in 71 men with antisocial personality disorder: a comparison with general population mortality. Psychosomatics. 1996;37:131-136.
8. Martens WHJ. A new multidimensional model of antisocial personality disorder. Am J Forensic Psychiatry. 2005;25:59-73.
9. Raine A, Lencz T, Bihrle S, et al. Reduced prefrontal gray matter volume and reduced autonomic activity in antisocial personality disorder. Arch Gen Psychiatry. 2000;57:119-127.
10. Dolan B, Coid J. Psychopathic and Antisocial Personality Disorders: Treatment and Research Issues. London: Gaskell; 1993.
11. Dolan B. Therapeutic community treatment for severe personality disorders. In: Millon T, Simonsen E, Birket-Smith M, Davis RD, eds. Psychopathy: Antisocial, Criminal, and Violent Behaviors. New York: Guilford Press; 1998:407-438.
12. Sanislow CA, McGlashan TH. Treatment outcome of personality disorders. Can J Psychiatry. 1998;43:237-250.
13. Martens WH. Criminality and moral dysfunctions: neurologic, biochemical and genetic dimensions. Int J Offender Ther Comp Criminol. 2002;46:170-182.
14. Bloom FE, Kupfer DJ, eds. Psychopharmacology: The Fourth Generation of Progress. New York: Raven Press; 1994.
15. Hollander E. Managing aggressive behavior in patients with obsessive-compulsive disorder and borderline personality disorder. J Clin Psychiatry. 1999;60(suppl 15):38-44.
16. Martens WH. Effects of antisocial or social attitudes on neurobiological functions. Med Hypotheses. 2001;56:664-671.
17. Raine A. Autonomic nervous system factors underlying disinhibited, antisocial, and violent behavior. Biosocial perspectives and treatment implications. Ann N Y Acad Sci. 1996;794:46-59.