Psychopathy

# Overview
Psychopathy is a  psychological construct that describes chronic immoral and antisocial behavior.    The term is often used interchangeably with sociopathy. Psychopathy has been the most studied of any personality disorder. Today the term can legitimately be used in two ways. One is in the legal sense, "psychopathic personality disorder" under the  Mental Health Act 1983 of the UK. The other use is as a severe form of the antisocial or dissocial personality disorder as exclusively 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.  They are overrepresented in prison systems, politics, law enforcement agencies, law firms, and in the media.
The psychopath is defined by a continual seeking of instant gratification in criminal, sexual, or aggressive impulses.  It is frequently co-morbid with other psychological disorders (particularly narcissistic personality disorder).  The psychopath differs slightly from the sociopath, and even more so from an individual with antisocial personality disorder.  Nevertheless, the three are frequently used interchangeably.  While nearly all psychopaths have antisocial personality disorder, only some individuals with antisocial personality disorder are psychopaths.  Many psychologists believe that psychopathy falls on a spectrum of disorders ranging from narcissistic personality disorder on the low end, malignant narcissism in the middle, and psychopathy on the high end.  An almost all-pervasive misconception is that psychopaths are doomed to a life of violence and crime.  It is possible for psychopaths to become successful in many lines of work, while many also become lazy underachievers.  Psychopathy is frequently mistaken with other similar personality disorders, such as dissocial personality disorder, narcissistic personality disorder, and schizoid personality disorder (as well as others).

# History
Interest in the psychopathic personality pattern goes back to colonial times. In those times, a person with a mental illness such as psychopathy would be reasoned as a subject of demonic possession. It also goes back to Theophrastus . In 1801, Philippe Pinel described patients who were mentally unimpaired but nonetheless engaged in impulsive and self-defeating acts. He saw them as la folie raisonnante ("insane without delirium")  meaning that they fully understood the irrationality of their behavior but continued with it anyway. Pinel was one of the last to study psychopathic personalities without including a moral judgment in his diagnosis.  By the turn of the century, Henry Maudsley had begun writing about the moral imbecile, and was arguing that such individuals could not be rehabilitated by the correctional system.
Maudsley included the psychopath's immunity to the reformational effects of punishment, owing to their refusal to anticipate further failure, and punishment.  In 1904, Emil Kraepelin described four types of personalities similar to the antisocial personality disorder. By 1915 he had identified them as defective in either effect or volition, dividing the types further into categories only some of which correspond to the current descriptions of antisocial.
The Mask of Sanity by Hervey Cleckley, M.D., first published in 1941,  is considered a seminal work and the most influential clinical description of psychopathy in the 20th century. The basic elements of psychopathy outlined by Cleckley are still relevant today. The title refers to the normal "mask" that conceals the mental disorder of the psychopathic person in Cleckley's conceptualization.
Otto Kernberg believed that psychopathy should fall under a spectrum of pathological narcissism, that ranged from narcissitic personality on the low end, malignant narcissism in the middle, and psychopathy at the high end. Because of the psychopaths inability to internalize superego precursors, they are unable to learn from past mistakes, and are completely devoid of a conscience.  This trait in conjunction with an inability to control criminal, sexual and aggressive desires, leads to the psychopath to constantly engage in antisocial behaviors.  Psychopathy (in its extreme form) does not necessarily lead itself to criminal and violent behavior (although such tendencies are likely).  Instead, psychopaths high in social cognition may be able to redirect their aggressive and sexual desires in a more positive manner.  Psychopaths (and others on the pathological narcissism scale) low in social cognition are more prone to violence against others, failure in occupational settings, and problems maintaining relationships.  All psychopaths differ in their impulse control abilities, and overall desires.  Psychopaths high in the pathological narcissism scale are more equipped to succeed, but pathological narcissism does not in any way guarantee success.  Those that fall into the category of psychopath are vulnerable to a life of crime, poverty, and extremely poor interpersonal relationships.
Psychopathy in its extreme form offers very few benefits.  Such benefits include lack of anxiety/nervousness, the ability to lead and control others without concerns of failure, and the ability to stay calm in extremely difficult situations.  These benefits mixed in with pathological narcissism and high levels of social cognition may lead to the psychopath becoming an extremely effective leader.  Again, this occurs only in rare circumstances.

# Hare and psychopathy
In contemporary research, psychopathy has been most frequently operationalized by Dr. Robert D. Hares 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.
Factor1: Aggressive narcissism
- Glibness / superficial charm
- Grandiose sense of self-worth
- Pathological lying
- Cunning / manipulative
- Lack of remorse or guilt
- Shallow
- Callous / lack of empathy
- Failure to accept responsibility for own actions
Factor2: Socially deviant lifestyle
- Need for stimulation / proneness to boredom
- Parasitic lifestyle
- Poor behavioral control
- Lack of realistic, long-term goals
- Impulsivity
- Irresponsibility
- Juvenile delinquency
- Early behavior problems
- Revocation of conditional release
Traits not correlated with either factor
- Many short-term marital relationships
- Promiscuous sexual behavior
- Criminal versatility
In practice, mental health professional rarely treat psychopathic personality disorders as they are considered untreatable and no interventions have proved to be effective.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 should 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 that 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 organisations 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 that psychopathy is adaptive in a highly competitive environment, because it gets results for both the individual and the corporations or, often small political sects that they represent. However, these individuals will often cause long-term harm, both to their co-workers and the organization as a whole, due 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 that it consisted of two factors.  Factor 1 capture 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 that 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 remain items 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.

### Diagnostic criteria and PCL-R assessment
Hare's PCL-R has allowed for a differentiation between individuals with psychopathy and antisocial personality disorder (APD).
In contemporary research and clinical psychiatric practice, the American Psychiatric Association use the DSM and European doctors use the ICD-10 and will use the term antisocial personality disorder.  Psychopathy is most commonly assessed by those who subscribe to a separate idea of psychopathy 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.
Both case history and a semi-structured interview are used in the analysis.

# 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. (See Foucha v. Louisiana for an example.)
- Washington State Legislature  defines a "Psychopathic personality" to mean "the existence in any person of such hereditary, congenital or acquired condition affecting the emotional or volitional rather than the intellectual field and manifested by anomalies of such character as to render satisfactory social adjustment of such person difficult or impossible". The same statute defines the "sexual psychopath" as "any person who is affected in a form of psychoneurosis or in a form of psychopathic personality, which form predisposes such person to the commission of sexual offenses in a degree constituting him a menace to the health or safety of others" for prison sentencing purposes in the Sentencing Reform Act of 1981.
- California enacted a psychopathic offender law in 1939, since greatly outmodeled and revised.  that defined a psychopath solely in terms of offenders with a predisposition "to the commission of sexual offenses against children." A 1941 law attempted to further clarify this to the point where anyone examined and found to be psychopathic was to be committed to a state hospital and anyone else was to be sentenced by the courts. However, these laws were enacted years before the American Psychiatric Association began publishing the Diagnostic and Statistical Manual of Mental Disorders which is used today for diagnosis and does not include "psychopathic offender". Hence, these laws are of historical interest only.
- In the United Kingdom, "Psychopathic Disorder" is legally defined in the Mental Health Act (UK) as, "a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned."
According to Jay Ziskin any diagnosis that does not appear in DSM III is not a formal diagnoses for legal uses, as shown in a quote from Coping with Psychiatric and Psychological Testimony Vol II by Jay Ziskin which is a book for attorneys to shoot down psychiatric testimony in the United States.
One should note whether the report contains a formal diagnosis......Those that do not are weakened......One can usually spot a formal diagnosis by the presence of a code number, usually a three-digit number, sometimes with additional digits ... although in some cases, psychiatrists will state what turns out to be a formal diagnosis without using the code numbers. Where there is a formal diagnosis, one should check to see if it is one of those listed in the diagnostic and statistical manual (DSM-III). .......the lawyer ... should check the manual for the elements required for making that diagnosis and then check to see if the report describes those elements.....If there is a diagnosis, but it is not from DSM-III, this is a matter to be questioned as there is only one official diagnositic classification system and it is DSM-III.

# Subtypes of psychopathy

## The PrimarySecondary 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. Including 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:
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.

# Relationship to other terms

## Relationship to sociopathy
The difference between sociopathy and psychopathy, according to Hare, may "reflect the user's views on the origins and determinates of the disorder."
David T. Lykken proposes that psychopathy and sociopathy are two distinct kinds of antisocial personality disorder. He holds that psychopaths are born with temperamental differences such as impulsivity, cortical underarousal, and fearlessness that lead them to risk-seeking behavior and an inability to internalize social norms. Sociopaths, on the other hand, he believes to have relatively normal temperaments; their personality disorder being more an effect of negative sociological factors like parental neglect, delinquent peers, poverty, and extremely low or extremely high intelligence. Both personality disorders are, of course, the result of an interaction between genetic predispositions and environmental factors, but psychopathy leans towards the hereditary whereas sociopathy tends towards the environmental.

## Relationship to Antisocial personality disorder
The criteria for the Antisocial Personality Disorder were derived from the Research Diagnositic Criteria developed by Spitzer, Endicott and Robbins (1978). There was concern in the development of DSM-IV that there was too much emphasis on research data and not enough on the more traditional psychopathic traits such as a lack of empathy, superficial charm, and inflated self appraisal. Field trial data indicated that some of these traits of psychopathy derived from the Psychopathy Checklist developed by Hare et al., 1992, were difficult to assess reliably and thus were not included. Lack of remorse is an example. The antisocial person may express genuine or false guilt or remorse and/or offer excuses and rationalizations. However, a history of criminal acts in itself suggests little remorse or guilt.
The American Psychiatric Association removed the word "psychopathy" or "psychopathic", and started using the term "Antisocial Personality" to cover the disorder in DSM-II.
The World Health Organization's stance in its ICD-10  refers to psychopathy, sociopathy, antisocial personality, asocial personality, and amoral personality as synonyms for dissocial personality disorder. Further, the DSM was meant as a diagnostic guide, and the term psychopath best fit the criteria met for antisocial personality disorder.

# Research findings
The prototypical psychopath has deficits or deviances in several areas: interpersonal relationships, emotion, and self-control. Psychopaths lack a sense of guilt or remorse for any harm they may have caused others, instead rationalizing the behavior, blaming someone else, or denying it outright. Psychopaths also lack empathy towards others in general, resulting in tactlessness, insensitivity, and contemptuousness. All of this belies their tendency to make a good, likable first impression. Psychopaths have a superficial charm about them, enabled by a willingness to say anything without concern for accuracy or truth.
This extends into their pathological lying and willingness to con and manipulate others for personal gain or amusement. The prototypical psychopath's emotions are described as a shallow affect, meaning their overall way of relating is characterized by mere displays of friendliness and other emotion for personal gain; the displayed emotion need not correlate with felt emotion, in other words.
Shallow affect also describes the psychopath's tendency for genuine emotion to be short lived and egocentric with an overall cold demeanor. Their behavior is impulsive and irresponsible, often failing to keep a job or defaulting on debts.
Most research studies of psychopaths have taken place among prison populations. This remains a limitation on its applicability to a general population.
It has been shown that punishment and behavior modification techniques do not improve the behavior of what Hare and other followers of this theory call a  psychopath. They have been regularly observed to respond to both by becoming more cunning and hiding their behavior better. It has been suggested by them that traditional therapeutic approaches actually make psychopaths if not worse, then far more adept at manipulating others and concealing their behavior. They are generally considered to be not only incurable but also untreatable.
Psychopaths also have a markedly distorted sense of the potential consequences of their actions, not only for others, but also for themselves. They do not, for example, deeply recognize the risk of being caught, disbelieved or injured as a result of their behaviour.

## Relation to sex offenders
No clinical definition of psychopathy indicates that psychopaths are especially prone to commit sexually-oriented murders, and scientific studies do not suggest that a large proportion of psychopaths have committed these crimes. Although some claim a large proportion of such offenders have been classified as psychopathic, this evidence comes from single, unrepeated research study using the Rorschach Inkblot Test, an invalid test for psychopathy and for sex offenders, references not considering psychopathy , and studies concerning sexual homicide, a somewhat different population that the general class of sex offenders. and not from meta studies combining repeatable results.

## Childhood precursors
Psychopathy is not normally diagnosed in children or adolescents, and some jurisdictions explicitly forbid diagnosing psychopathy and similar personality disorders in minors. Psychopathic tendencies can sometimes be recognized in childhood or early adolescence and, if recognised, are diagnosed as conduct disorder. It must be stressed that not all children diagnosed with conduct disorder grow up to be psychopaths, or even disordered at all, but these childhood signs are found in significantly higher proportions in psychopaths than in the general population.  Conduct disorder, as well as a related disorder, Oppositional Defiant Disorder, can sometimes develop into adult psychopathy.  However, conduct disorder "fails to capture the emotional, cognitive and interpersonality traits - egocentricity, lack of remorse, empathy or guilt - that are so important in the diagnosis of psychopathy."
Children showing strong psychopathic precursors often appear immune to punishment; nothing seems to modify their undesirable behavior. Consequently parents usually give up, and the behavior worsens.
The following childhood indicators are to be seen not as to the type of behavior, but as to its relentless and unvarying occurrence.  Not all must be present concurrently, but at least a number of them need to be present over a period of years:
- An extended period of bedwetting past the preschool years that is not due to any medical problem.
- Cruelty to animals beyond an angry outburst.
- Firesetting and other vandalism. Not to be confused with playing with matches, which is not uncommon for preschoolers.  This is the deliberate setting of destructive fires with utter disregard for the property and lives of others.
- Lying, often without discernible objectives, extending beyond a child's normal impulse not to be punished. Lies that are so extensive that it is often impossible to know lies from truth.
- Theft and truancy.
- Aggression to peers, not necessarily physical, which can include getting others into trouble or a campaign of psychological torment.
The three indicatorsbedwetting, cruelty to animals and firestarting, known as the MacDonald triadwere first described by J.M. MacDonald as indicators of psychopathy. The relevance of these indicators to serial murder etiology has since been called into question, and they are considered irrelevant to psychopathy.
The question of whether young children with early indicators of psychopathy respond poorly to intervention compared to conduct disordered children without these traits has only recently been examined in controlled clinical research. The empirical findings from this research have been consistent with broader anecdotal evidence, pointing to poor treatment outcomes.

## Discrete  vs. continuous dimension
As part of the larger debate on whether personality disorders are distinct from normal personality or extremes on various dimensions of normal personality is the debate on whether psychopathy represents something "qualitatively different" from normal personality or a "continuous dimension" shading from normality into severely psychopathic. Early taxonometric analysis from Harris and colleagues indicated that a discrete category may underlie psychopathy, however this was only found for the behavioural Factor 2 items, indicating that this analysis may be related to Anti-social Personality Disorder rather than psychopathy per se. Marcus, John, and Edens more recently performed a series of statistical analysis on previously attained PCLR and PPI scores and concluded that psychopathy may best be conceptualized as having a "dimensional latent structure" like depression.
In contrast, the PCLR sets a score of 30 out of 40 for North American male inmates as its cut-off point for a diagnosis of psychopathy, however this is an abitrary cut-off and should not be taken to reflect any sort of underlying structure for the disorder.

## Perceptual/emotional recognition deficits
In a 2002 study, David Kosson and Yana Suchy, et al. asked psychopathic inmates to name the emotion expressed on each of 30 faces; compared to controls, psychopaths had a significantly lower rate of accuracy in recognizing disgusted facial affect but a higher rate of accuracy in recognizing anger. Additionally, when "conditions designed to minimize the involvement of left-hemispheric mechanisms" (i.e. sadness) were used, psychopaths had more difficulty accurately identifying emotions. This study did not replicate Blaire, et al. (1997)'s findings that psychopaths are specifically less sensitive to nonverbal cues of fear or distress.
In a 2002 experiment, Blair, Mitchell, et al. used the Vocal Affect Recognition Test to measure psychopaths' recognition of the emotional intonation given to connotatively neutral words. Psychopaths tended to make more recognition errors than controls with a particularly high rate of error for sad and fearful vocal affect.
A 2004 experiment tested the hypothesis of overselective attention in psychopaths using two forms of the Stroop color-word and picture-word tasks: with color/picture and word separated and with color/picture and word together. They found that in the separated Stroop tasks, psychopaths performed significantly worse than controls; however, on standard Stroop tasks, psychopaths performed equally well as controls.
When split into low-anxious and high-anxious groups, low-anxious psychopaths and low-anxious controls showed less interference on the separated Stroop tasks than their high-anxious counterparts; for low-anxious psychopaths, interference was very nearly zero. They conclude that the inability to integrate contextual cues depends on the cues' relationship to "the deliberately attended, goal-relevant information."