Psychopathy

Psychopathy is a mental disorder characterized primarily by a lack of empathy and remorse, shallow emotions, egocentricity, and deceptiveness. Psychopaths are highly prone to antisocial behavior and abusive treatment of others, and are very disproportionately responsible for violent crime. Though lacking empathy and emotional depth, they often manage to pass themselves off as normal people by feigning emotions and lying about their pasts.

Until the 1980s, the term formally referred to a personality disorder characterized by the inability to form human attachment and an abnormal lack of empathy, masked by an ability to appear outwardly normal. The publication of the Diagnostic and Statistical Manual of Mental Disorders third edition (DSM-III) changed the name of this mental disorder to antisocial personality disorder, and also broadened the diagnostic criteria considerably by shifting from clinical inferences to behavioral diagnostic criteria. However, the DSM-V working party is recommending a revision of antisocial personality disorder to include "Antisocial/Psychopathic Type", with the diagnostic criteria having a greater emphasis on character than on behavior. The ICD-10 diagnostic criteria of the World Health Organization also lacks psychopathy as a personality disorder. The 1992 manual included dissocial (antisocial) personality disorder, which encompasses amoral, antisocial, asocial, psychopathic, and sociopathic personalities.

Despite being currently unused in diagnostic manuals, psychopathy and related terms such as psychopath are still widely used by mental health professionals and laymen alike. In particular, NATO has funded a series of Advanced Study Institutes on psychopathy, both before and after the publication of DSM-III. Researcher Robert Hare has been a particular champion of the term; his Hare Psychopathy Checklist is the standard tool for differentiating between those with antisocial personality disorder and the subset who are psychopaths. According to this scale the prevalence of antisocial personality disorder is two to three times that of psychopathy.

According to a chapter about treatment in Christopher J. Patrick's Handbook of Psychopathy, there is little evidence of a cure or any effective treatment for psychopathy; no medications can instill empathy, and psychopaths who undergo traditional talk therapy might become more adept at manipulating others and more likely to commit crime. Others suggest that psychopaths may benefit as much as others from therapy, at least in terms of effect on behavior even if not on the central personality traits. According to Hare, the consensus among researchers in this area is that psychopathy stems from a specific neurological disorder which is present from birth, although a 2008 review indicated multiple causes and variation between individuals. Hare estimates that about one percent of the US population are psychopaths.

Despite the similarity of the names, psychopaths are rarely psychotic.

History
The current concept of psychopathy has been thematically linked to writings by Theophrastus, a student of Aristotle in Ancient Greece, whose description of The Unscrupulous Man is said to embody the characteristics of psychopathy:

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 they fully understood the irrationality of their behavior but continued with it anyway.

The scientific study of individuals thought to lack a conscience flourished in the latter half of the 19th century. Notably, Cesare Lombroso rejected the view that criminality could occur in anyone and instead sought to identify particular "born criminals" whom he thought showed certain physical defects.

By the turn of the 20th century, Henry Maudsley had begun writing about the "moral imbecile", and was arguing 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 antisocial personality disorder. By 1915 he had identified them as defective in either affect or volition, dividing the types further into different categories, only some of which correspond to the current descriptions of antisocial personality disorder.

In 1909, Birnbaum introduced the term "sociopathic", intended to emphasize the social causes of antisocial behavior.

The Mask of Sanity by Hervey M. Cleckley, M.D., first published in 1941, is considered a seminal work which provided a vivid series of case studies of individuals (mostly prisoners) described by Cleckley as psychopathic. Cleckley proposed 16 characteristics of psychopathy. The title refers to the "mask" of normality that Cleckley thought concealed the disorganization or mental disorder of what he saw as the psychopathic person.

A 1977 study, however, found little relationship with the characteristics commonly attributed to psychopaths and concluded that the concept was being used too widely and loosely.

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders incorporated various concepts of psychopathy/sociopathy/antisocial personality in early versions but, starting with the DSM-III in 1980, used instead a diagnosis of antisocial personality disorder. This was based on some of the criteria put forward by Cleckley but operationalized in behavioral terms and more specifically related to conduct and criminality. The World Health Organization's ICD incorporates a similar diagnosis of Dissocial Personality Disorder. Both the DSM and the ICD state that psychopathy (or sociopathy) are synonyms of their diagnosis.

However, there remained no international agreement on the diagnosis of psychopathy. One author referred to it in 1987 as an "infinitely elastic, catch-all category". In 1988, Blackburn wrote in the British Journal of Psychiatry that the concept as commonly used in psychiatry is little more than a moral judgement masquerading as a clinical diagnosis, and argued that it should be scrapped.

Hare developed a Psychopathy Checklist in 1980 based on the psychopath construct advanced by Cleckley, and later revised it in the 1990s (including the removal of two items).

Etymology
The word "psychopathy" comes from the Greek words psykhe (mind, mental) and pathos (suffering, feeling).

Characteristics
The prototypical psychopath has deficits or deviance in several areas: interpersonal relationships, emotion, and behavior. Psychopaths gain satisfaction through antisocial behavior, and do not experience shame, guilt, or remorse for their actions. 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. Psychopaths can have a superficial charm about them, enabled by a willingness to say anything to anyone without concern for accuracy or truth. Shallow affect also describes the psychopath's tendency for genuine emotion to be short-lived, glib and egocentric, with an overall cold demeanor. They tend to be impulsive and irresponsible, often failing to keep a job or defaulting on debts. Studies in 2010 at Vanderbilt University revealed that psychopaths seek rewards regardless of consequences or risk, characterised by high impulsivity.

Hare, whose Hare Psychopathy Checklist is widely used, describes psychopaths as "intraspecies predators". Also R.I. Simon uses the word predator to describe psychopaths. Elsewhere Hare and others write that psychopaths "use charisma, manipulation, intimidation, sexual intercourse and violence"   to control others and to satisfy their own needs. Hare states that: "Lacking in conscience and empathy, they take what they want and do as they please, violating social norms and expectations without guilt or remorse". He previously stated that: "What is missing, in other words, are the very qualities that allow a human being to live in social harmony".

According to Hare, many psychopaths are superficially charming, and can excellently mimic normal human emotion; some psychopaths can blend in, undetected, in a variety of surroundings, including corporate environments.

Lack of empathy
Psychopaths possess a general lack of empathy; they are simply unable to understand the emotional states of other people, except in a purely detached, intellectual sense. When a normal person sees someone else in pain or distress, he instinctively feels distress as well, but a psychopath never does. Thus, psychopaths can commit acts of stunning cruelty and callousness because they are not deterred by any unpleasant reaction to their victims' suffering. A violent psychopath can mutilate a person with all the emotion of a chef carving up a turkey. A psychopathic con man can swindle his parents out of their life savings and not give a second thought to the ruin he has left them in. Because the experiences of others provokes no emotion in psychopaths, they regard others as little more than objects for their personal gratification.

Shallow emotions
Psychopaths do not feel emotions as deeply as normal people. Though they are not completely unemotional, their emotions are so shallow that some clinicians have described them as mere "proto-emotions: primitive responses to immediate needs."

Psychopaths do not feel fear as deeply as normal people and do not manifest any of the normal physical responses to threatening stimuli. For instance, if a normal person were accosted in the street by a gun-wielding mugger, he might sweat, tremble, lose control of his bowels or vomit. A psychopath would feel no such sensations, and are often perplexed when they observe them in others. Psychopaths' lack of fear make them often reckless risk-takers. This is not to say they are oblivious to the potential consequences of their actions. Rather, the thought of pain and punishment does not provoke an emotional reaction in them and thus has a weak restraining effect.

Psychopaths do not feel love and are incapable of forming emotional bonds with people. Though a psychopath can sometimes charm a person into being infatuated with him, he cannot reciprocate the feelings, only feign them. Though they derive pleasure from sexual encounters, these relations are superficial and impersonal.

Although psychopaths do not feel deep emotions, they often claim to experience them. However, their fabricated descriptions of their fictitious emotions are often flawed. Their choice of words may be incongruous with the context or their tone of voice. For instance, a psychopath may express grief over the recent death of a parent, but deliver his words in a monotone voice that betrays his indifference. Psychopaths may often put on short-lived, dramatic displays of emotion, such as fits of rage, only to quickly revert to a calm state moments later. This often leaves some observers with the impression that they are play- acting.

In conversations, psychopaths cannot intuitively understand the impact their words should have on others or themselves. They instead read their listeners' reactions for cues as to how they should emote. For instance, Hare writes of a convicted murderer who described his murders in a totally dispassionate, bland manner until he noticed the horrified expression of the interviewer, at which point he started feigning remorse and distress over his crimes.

Researchers have conducted brain scans on psychopaths while exposing them to emotionally-charged words such as "rape", "murder", and "love". In a normal person, these words will provoke activity in the limbic system, which governs emotions. Psychopaths showed no such activity. They react to emotionally-charged words as if they were neutral words (e.g. "tree", "chair", "spoon"). They do, however, show activity in the brain areas associated with language processing, suggesting that their response is more cognitive than emotional.

Lying and manipulation
Psychopaths are incorrigible and consummate liars. They frequently and readily lie to get what they want or to impress people, and they do so with such skill that even experienced interrogators are sometimes fooled. This talent lies in a confident presentation that never betrays signs of anxiety, hesitation, or shame, even when they're confronted with contradictory evidence or inconvenient questions. This frequently baffles their listeners and distracts them from the inconsistencies in their words. They believe the psychopath is honest because it is hard for them to believe a liar can be so bold and unflappable.

Normal people typically feel anxiety when they lie, hesitating with their words especially when confronted. When a psychopath lies, however, they are completely indifferent to the possibility of being caught in a lie. When they're caught in a lie, they are rarely perplexed or embarrassed. Without hesitating, they will simply rework the tale so that it appears consistent.

A psychopath's power to deceive stems more often from his presentation (body language, confidence, etc.) than from the content of their speech. In fact, the tales psychopaths weave are often riddled with inconsistencies and contradictions. The first reason for this is the often improvisational nature of their lying. When caught in a lie or confronted with unexpected questions, they simply rework their tale to fit the new facts without pausing to think things through. The second reason is that psychopaths appear to have difficulty properly integrating the language and emotional components of their thoughts, and thus fail to notice contradictions in their speech. Hervey Cleckley, a pioneer researcher in psychopathy, called this "semantic aphasia". Consider this statement by serial killer Ted Bundy when asked about his drug habits:

"Cocaine? I've never used it. I've never tried cocaine. I think I might have tried it once and got nothing out of it.   Just snorted a little bit. And I just don't mess with it. It's too expensive. And I suppose if I was on the streets and had  enough of it, I might get into it. But I'm strictly a marijuana man.  All I do is... I love to smoke a reefer.  And valiums. And of course alcohol."

- Ted Bundy

In the above dialogue, Bundy alternately denies and admits to using drugs and is never firm about his preferences, suggesting he had difficulty in maintaining a cohesive line of thinking when assembling his words. Another psychopathic inmate once told Hare: "I had to steal sometimes to get out of town, yeah, but I'm not a fucking criminal."

Some psychopaths also possess great charm and a great ability to manipulate others. They have fewer social inhibitions, are extroverted, dominant, and confident. They are not afraid of causing offense, being rejected, or being put down. When these things do happen, they tend to dismiss them and are not discouraged from trying again. Thus, psychopaths practice manipulation harder than most people and tend to become very good at it.

It should be noted that not all psychopaths are smooth charmers. Often due to poor upbringing, some lack the necessary social grace and education to impress people. Such psychopaths tend to rely more on intimidation, coercion, and violence to get their way.

Psychopaths see other people as objects for their personal gratification. They often adopt a parasitic lifestyle, conning people out of their wealth and resources. They have been known to seduce people simply to obtain money and sex, or fabricate tales of misfortune to obtain money from relatives and friends. When the victim is no longer useful or profitable, psychopaths coldly abandon them.

Impulsivity, irresponsibility
Psychopaths are impulsive by nature. They do not deeply recognize the risk of being caught, disbelieved or injured as a result of their behavior. They seek quick satisfaction and thrills. Their crimes are often spur-of-moment affairs.

Psychopaths live day-to-day, changing their plans frequently and generally do not have any realistic long term goals. Psychopaths often claim to have ambitious goals in life, but fail to appreciate the work, skill and discipline it would take to achieve them. Hare writes of one psychopathic inmate who planned to become a professional swimmer after release, despite the fact he was in his late thirties and overweight. They are known to break off relationships, change plans, and quit jobs on a whim. A characteristic life pattern is of bouncing from one job to another and sometimes in and out of prison. They are generally not embarrassed or concerned about their lack of achievement in their lives.

Psychopaths are commonly irresponsible. In the workplace, they are known for erratic performance, frequent absences, embezzlement, and untrustworthiness. They are financially irresponsible, often living beyond their means, incurring debt and defaulting on loans. They often neglect their children. They often have unprotected sex, siring children that they abandon and transmit STDs. When they get in trouble due to their negligence, they typically blame other people or external factors. They do not hesitate to exploit the resources of friends and family to get them out of trouble, such as being bailed out of jail.

Psychopaths often fail to learn from past experiences and do not modify their behavior to avoid trouble. They often pursue the same old bad habits despite having suffered retribution and humiliation numerous times. Punishment and rehabilitation have no positive effect on them, and their condition is considered untreatable. The rate of recidivism among psychopaths is roughly double that of normal criminals, with the rate for violent recidivism being roughly three times higher than normal.

Low tolerance for boredom
Psychopaths have a low tolerance for boredom and an excessive need for excitement and stimulation. They frequently break rules, commit crimes, and risk their safety for the sake of cheap thrills. In the workplace, they routinely shirk duties they find unexciting, and even quit jobs on a whim. They are more likely than normal people to abuse drugs.

Poor behavior controls
Psychopaths are notorious for their hair-trigger tempers. They are highly reactive to perceived insults and slights, and throw tantrums over trivialities. Their tantrums are often short-lived, and they can revert to a perfectly calm state moments later. Although their aggression is poorly inhibited, it is generally not uncontrolled. Their aggression lacks the intense emotional turmoil normal people feel when they lose their temper, and thus they do not actually go "mad with rage".

Remorselessness
Psychopaths have a total lack of remorse for the abuses they commit. Even when they are aware of the consequences of their actions, they frequently rationalize their behavior so as to minimize the seriousness or shrug off responsibility. They often blame their victims for their crimes; "he shouldn't have provoked me" and "suckers deserve to be swindled" are common sayings.

"I loved her so deeply. I miss her so much. What happened was a tragedy. I lost my best lover and my best friend.... Why doesn't anybody understand what I've been going through?"

- Kenneth Taylor after murdering his wife

Egocentricity and grandiosity
Psychopaths have extremely inflated self-esteem. Their egocentricity is comparable to that of narcissists, and indeed it is occasionally hard to distinguish the two conditions from each other. They think they are the center of the universe and see themselves as superior beings. They often appear arrogant, opinionated, domineering, and cocky. A psychopath always thinks he is the smartest person in the room and has no respect for the differing opinions of others. Psychopaths have an exaggerated sense of entitlement. They expect large rewards for mediocre efforts, apply for important jobs despite lacking qualifications, demand authority and privileges above their rank, and are ungrateful. It is not uncommon for psychopaths to describe their victims as weak, inferior beings who deserve to be taken advantage of.

Psychopaths often claim to have grand goals in life and believe they can be anything they want to be. These claims are often unrealistic, given their track record for irresponsibility. They show little appreciation for the hard work, discipline, devotion, and talent required to achieve their ambitions. As an example, Hare wrote of one psychopathic inmate who planned to become a professional swimmer after release, despite the fact he was in his late thirties and overweight. These grand goals often change as psychopaths are notoriously fickle, abandoning projects when they become frustrating or boring. Psychopaths are unashamed and dismissive of the legal, financial, or personal problems in their lives. They blame everyone and everything but themselves for their failures - bad luck, an unfair system, unsupportive colleagues, etc. - or they might dismiss their old projects as wastes of time. They may even portray their bad qualities as virtues: many psychopaths brag about their criminal versatility, the number of crimes they got away with, and their talent for deception.

Intelligence
Hare and Neumann (2008) state that there is at most only a weak association between psychopathy and IQ. "Moreover, there is no obvious theoretical reason why the disorder described by Cleckley or other clinicians should be related to intelligence; some psychopaths are bright, others less so. If a psychopath has a high intelligence or IQ, they will rarely show it."

Facial affect recognition
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 the control group, 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 right-hemispheric mechanisms" (i.e., sadness) were used, psychopaths had more difficulty accurately identifying emotions. This study did not replicate Blair, et al. (1997)'s findings that psychopaths are specifically less sensitive to nonverbal cues of fear or distress.

Vocal affect recognition
In a 2002 experiment, Blair, Mitchell, et al. used the Vocal Affect Recognition Test to measure psychopaths' recognition of the emotional intonation given to connotative neutral words. Psychopaths tended to make more recognition errors than controls with a particularly high rate of error for sad and fearful vocal affect.

Stroop tasks
A study on Stroop tasks found that there is "a circumscribed attentional deficit in psychopathy that hinders the use of unattended information that is (a) not integrated with deliberately attended information and (b) not compatible with current goal-directed behavior."

Childhood precursors
Psychopathic tendencies can sometimes be recognized in childhood or early adolescence. If recognized, a diagnosis of Conduct Disorder, or possibly the related Oppositional Defiant Disorder, may be given. However, while these childhood signs have been found in a significantly higher proportion of psychopaths than in the general population, it must be stressed that not all the subjects of such childhood diagnoses turn out to be psychopaths as adults, or even disordered at all. Therefore, psychopathy is not normally diagnosed in children or adolescents, and some jurisdictions explicitly forbid diagnosing minors with psychopathy and similar personality disorders. This is because such a diagnosis "fails to capture the emotional, cognitive, and interpersonality traits — egocentricity and 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. These indicators are sufficient - but not necessary - indicators of possible psychopathy.


 * An extended period of bedwetting past the preschool years, not due to any identified medical problem.
 * Precocious sadism, often expressed as cruelty to animals.
 * Pathological firesetting, lacking in obvious homicidal intent. 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. These lies are so extensive it is often impossible to know lies from truth.
 * Theft and truancy.
 * Aggression towards peers and relatives. The aggression can include physical and verbal abuse, getting others into trouble, or a campaign of psychological torment.

The three indicators &mdash; bedwetting, cruelty to animals and firestarting, known as the Macdonald triad &mdash; were first described by J.M. MacDonald as "red flag" indicators of psychopathy and future episodic aggressive behavior. However, subsequent research has found that bedwetting is not a significant factor. 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. Many of the above characteristics can be paralleled in bullying at school and elsewhere.

Evolutionary explanations
Researchers within evolutionary psychology have proposed several evolutionary explanations for psychopathy. One is that psychopathy represents a frequency dependent socially parasitic strategy. This may work as long as there are few other psychopaths in the community since more psychopaths means increasing the risk of encountering another psychopath as well as non-psychopaths likely adapting more countermeasures against cheaters.

Genetics
Genetic factors may generally influence the development of psychopathy while environmental factors affect the specific traits that predominate.

A 2005 twin study found that children with antisocial behavior can be classified into two groups: those who also had high "callous-unemotional traits" were "under extremely strong genetic influence and no influence of shared environment" while those who were ranked low of those traits were under both "moderate genetic and shared environmental influence."

Neuroanatomy
"The amygdala is crucial for stimulus-reinforcement learning and responding to emotional expressions, particularly fearful expressions that, as reinforcers, are important initiators of stimulus-reinforcement learning. Moreover, the amygdala is involved in the formation of both stimulus-punishment and stimulus-reward associations. Individuals with psychopathy show impairment in stimulus-reinforcement learning (whether punishment or reward based) and responding to fearful and sad expressions. It is argued that this impairment drives much of the syndrome of psychopathy (Blair, 2008).

People scoring ≥25 in the Psychopathy Checklist Revised, with an associated history of violent behavior, appear to have significantly reduced microstructural integrity in their uncinate fasciculus &mdash; white matter connecting the amygdala and orbitofrontal cortex. The more extreme the psychopathy, the greater the abnormality.

Recent studies have triggered theories on determining whether there is a biological relationship between the brain and psychopathy. One theory suggests that psychopathy is associated with both the amygdala, which is associated with emotional reactions and emotional learning, and the prefrontal cortex, associated with impulse control, decision-making, emotional learning and behavioral adaptation. Some studies have shown there is less "gray matter" in these areas in psychopaths than in non-psychopaths.

There is DT-MRI evidence of breakdowns in the white matter connections between these two important areas in a small British study of nine criminal psychopaths. This evidence suggests that the degree of abnormality was significantly related to the degree of psychopathy and may explain the offending behaviors.

A 2008 review found various abnormalities (based on group differences from average) reported in the literature, centered on a prefrontal-temporo-limbic circuit &mdash; regions that are involved in emotional and learning processes, as well as many other processes. However, the authors report that the people classed as "psychopathic" cannot in fact be seen as a homogeneous group (i.e. as all having the same characteristics), and that the associations between structural changes and psychopathic characteristics do not enable causal conclusions to be drawn. They conclude that psychopathic characteristics involve multifactorial processes including neurobiological, genetic, epidemiological, and sociobiographical (the person's life in society) factors.

Neurotransmitters and hormones
High levels of testosterone combined with low levels of cortisol have been theorized as contributing factors. Testosterone is "associated with approach-related behavior, reward sensitivity, and fear reduction". Cortisol increases "the state of fear, sensitivity to punishment, and withdrawal behavior". Injecting testosterone "shift[s] the balance from punishment to reward sensitivity", decreases fearfulness, and increases "responding to angry faces". Some studies have found that antisocial and aggressive behaviors are associated with high testosterone levels but it is unclear if psychopaths have high testosterone levels. A few studies have found psychopathy to be linked to low cortisol levels.

High testosterone levels combined with low serotonin levels may increase violent aggression. Some research suggests that testosterone alone does not cause aggression but increases dominance seeking-behaviors. Low serotonin is associated with "impulsive and highly-negative reactions" which if combined with high testosterone may cause aggression if an individual becomes frustrated.

Psychopathy was also associated in two studies with an increased ratio of HVA (a dopamine metabolite) to 5-HIAA (a serotonin metabolite).

Several animal studies note the role of serotonergic functioning in impulsive aggression and antisocial behavior.

A 2010 British study found that a large 2D:4D digit ratio, an indication of high prenatal estrogen exposure, was a "positive correlate of psychopathy in females, and a positive correlate of callous affect (psychopathy sub-scale) in males".

Diagnosis
The classification of mental disorders, also known as psychiatric nosology or taxonomy, is a key aspect of psychiatry and other mental health professions and an important issue for consumers and providers of mental health services.

Hare Psychopathy Checklist
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 behavioral deficits or antisocial lifestyle, more specifically: reactive anger, anxiety, increased risk of suicide, criminality, and impulsive violence. PCL-R Factor 1, in contrast, is associated with personality deficits or aggressive narcissism, more specifically: extraversion 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). Both case history and a semi-structured interview are used in the analysis.

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.

PCL-R 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.


 * 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
 * 11) Many short-term marital relationships
 * 12) Criminal versatility

One issue related to the assessment of individuals who may exhibit affective, interpersonal, and behavioral features associated with psychopathy is the ability to overcome gender myths when the psychopathy features are present in females. The Hare Psychopathy Checklist-Revised has both percentiles and T-score tables for male and female offenders.

DSM and ICD
There are currently two widely established systems for classifying mental disorders &mdash; Chapter V of the International Classification of Diseases (ICD-10) produced by the World Health Organization (WHO) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) produced by the American Psychiatric Association (APA). Both list categories of disorders thought to be distinct types, and have deliberately converged their codes in recent revisions so that the manuals are often broadly comparable, although significant differences remain.

While previous versions of the DSM listed psychopathy as a personality disorder, currently it is not an diagnosis in these classifications. Labeling a person as a psychopath involves forensic measurement, using a diagnostic tool such as the Hare Psychopathy Checklist (PCL-R). The PCL-R is widely considered the "gold standard" for assessing psychopathy. Psychopathy is most strongly correlated with DSM-IV antisocial personality disorder (ASPD), and the ICD-10 antisocial personality disorder and dissocial personality disorder (DPD). However, the PCL-R criteria for identifying a psychopath are stricter than the diagnostic criteria for ASPD or DPD; psychopaths represent a subset of those with ASPD, and psychopaths' traits are more severe. A psychopath will score high on both PCL-R factors, whereas someone with ASPD who is not a psychopath will score high only on Factor 2.

Some researchers are critical of the changed diagnostic criteria. Antisocial personality disorder is diagnosed via behavior and social deviant behaviors, whereas a diagnosis of psychopathy also includes affective and interpersonal personality factors. The Hare Psychopathy Checklist is better able to predict future criminality, violence, and recidivism than the diagnosis of ASPD using the DSM-III-R. Robert D. Hare writes that there are also differences between psychopaths and others on "processing and use of linguistic and emotional information" while such differences are small between those diagnosed with ASPD and not. However, the Hare Psychopathy Checklist requires the use of a rather long interview and availability of considerable additional information as well as depending in part on judgements of character rather than observed behavior. Hare writes that the field trials for the DSM-IV found personality traits judgements to be as reliable as those diagnostic criteria relying only on behavior but that the personality traits criteria were dropped in part because it was feared that the average clinician would not use them correctly. Hare criticizes the instead used DSM-IV criteria for being poorly empirically tested. In addition, the introductory text description describes the personality characteristics typical of psychopathy, which Hare argues make the manual confusing and actually containing two different sets of criteria. He also argues that confusion regarding how to diagnose ASPD, confusion regarding the difference between ASPD and psychopathy, as well as the differing future prognoses regarding recidivism and treatability, may have serious consequences in settings such as court cases where psychopathy is often seen as aggravating the crime.

The DSM-V working party is recommending a revision of antisocial personality disorder to include "Antisocial/Psychopathic Type", with the diagnostic criteria having a greater emphasis on character than on behavior.

Cleckley Checklist
In his 1941 book, Mask of Sanity, Hervey M. Cleckley introduced 16 behavioral characteristics of a psychopath:
 * 1) Superficial charm and good "intelligence"*
 * 2) Absence of delusions and other signs of irrational thinking*
 * 3) Absence of nervousness or psychoneurotic manifestations*
 * 4) Unreliability
 * 5) Untruthfulness and insincerity
 * 6) Lack of remorse and shame
 * 7) Inadequately motivated antisocial behavior
 * 8) Poor judgment and failure to learn by experience
 * 9) Pathologic egocentricity and incapacity for love
 * 10) General poverty in major affective reactions
 * 11) Specific loss of insight
 * 12) Unresponsiveness in general interpersonal relations
 * 13) Fantastic and uninviting behavior with drink and sometimes without
 * 14) Suicide threats rarely carried out*
 * 15) Sex life impersonal, trivial, and poorly integrated
 * 16) Failure to follow any life plan.

* These characteristics have since been depreciated.

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).

The primary psychopath engages in antisocial behavior as a result of a genetic-biological predisposition directed by particular psychodynamic forces that occur in infancy. The secondary psychopath's antisocial behavior is the result of strictly environmental forces (e.g., membership in a deviant group) that occur at developmental stages beyond infancy. The fundamental distinction between the two is the ability to attach emotionally to others and to experience the natural anxiety associated with human attachment. The primary psychopath forms no attachments as a result of early developmental obstruction, and thus is capable of harming others with little or no anxiety. The secondary psychopath forms human attachments, possibly to deviant subgroups, or not. However, whether or not the secondary psychopath appears to be attached to others, emotional connection to other human beings is present.

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:

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.

Psychopathy vs. sociopathy
Hare writes that the difference between sociopathy and psychopathy may "reflect the user's views on the origins and determinates of the disorder." The term sociopathy may be preferred by sociologists that see the causes as due to social factors. The term psychopathy may be preferred by psychologists who see the causes as due to a combination of psychological, genetic, and environmental factors.

David T. Lykken proposes psychopathy and sociopathy as two distinct kinds of antisocial personality disorder. He believes 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. On the other hand, he claims sociopaths 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 the result of an interaction between genetic predispositions and environmental factors, but psychopathy leans towards the hereditary whereas sociopathy tends towards the environmental.

Three-factor model
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.

Hare and colleagues have published detailed critiques of the Cooke & Michie hierarchical ‘three’-factor model, citing severe statistical problems. Hare and colleagues note that the Cooke & Michie model actually contains ten factors, and results in impossible parameters (negative variances). Hare and colleagues also note conceptual problems with this model.

Discrete vs. continuous
As part of the larger debate on whether personality disorders are distinct from normal personality, or if they are 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. Otto Kernberg believed psychopathy should fall under a spectrum of pathological narcissism, that ranged from narcissistic personality on the low end, malignant narcissism in the middle, and psychopathy at the high end.

Early taxonometric analysis from Harris and colleagues indicated a discrete category may underlie psychopathy, but this was only found for the behavioural Factor 2 items, indicating this analysis may be related to Antisocial Personality Disorder rather than psychopathy per se. Marcus, John, and Edens more recently performed a series of statistical analysis on previously attained PCL–R and PPI scores and concluded psychopathy may best be conceptualized as having a "dimensional latent structure" like depression.

Comorbidity
Psychopaths may have various others mental conditions, although, in contrast to people with antisocial personality disorder, comorbidity among psychopaths is generally found to be low.

Substance abuse has been associated with psychopathy, particularly Factor 2 (anti-social behaviour), but not Factor 1 (emotional) scores of the PCL-R. Conduct disorder and ADHD have both been associated with psychopathy; which may be explained by disruption to dorsolateral prefrontal cortex. This area is associated with executive function, which is affected in all three disorders.

There is some evidence of an association between ASPD and other personality disorders (i.e. histrionic, narcissistic and borderline personality disorders), however, evidence for a link with psychopathy is more tentative.

Anxiety may be associated positively with antisocial behaviour, but it is inversely associated with Factor I (emotional) scores on the PCL-R. Depression is inversely associated with psychopathy. There is no conclusive evidence for a link between psychopathy and schizophrenia.

It has been suggested that psychopathy may be comorbid with several other diagnoses than these, however limited work on comorbidity has been carried out. This may be because of difficulties in using inpatient groups from certain institutions to assess comorbidity, owing to the likelihood of some bias in sample selection. Furthermore, comorbidity may be more reflective of poor discriminant validity of categories in the DSM-IV than reflective of underlying aetiologically separate conditions.

Psychopathy and Sexual Deviance
Sexual preferences are usually considered deviant when they stray statistically from the norm and, when acted on, tend to inflict unwanted harm on oneself or others (Lalumière & Quinsey, 1999). In a study conducted by Barbaree et al. (1994) using Penile Plethysmography, psychopaths showed more increased penile blood flow than did controls upon being shown deviant visual and auditory stimuli. This may be due to the psychopath’s complete disregard for social norms and lack of attachment to others. The desire to be socially accepted is so deeply ingrained into the minds and personalities of average humans, that to some extent this dictates our sexual feelings. While the psychopath will attempt to blend in, their undisclosed desires are completely uninhibited by social standards. There is also evidence to suggest that psychopathic sexual offenders use more violence against their victims than do nonpsychopathic sexual offenders, suggesting that the psychopath may have a higher propensity to be sexually sadistic. Woodworth et al. (2003) examined the correlation between PCL-R scores and types of aggression expressed in a sample of 38 sexual murderers. 84.7% of these individuals scored in the moderate to high range (scores significantly higher than those of a group of nonsexual murderers). Also, murders committed by psychopaths (those with a score of 20 or above) showed more gratuitous and sadistic violence than those of nonpsychopaths. 82.4% of psychopaths committed sadistic violence against their victims, compared to only 52.6% of nonpsychopaths.

Epidemiology
It is estimated that approximately one percent of the general population are psychopaths. A 2009 British study reported a community prevalence of 0.6%, consistent with the estimate given by the screening version of the psychopathy checklist.

The psychologist Robert Hare in his book, "Without Conscience: The Disturbing World of Psychopaths among Us", argues that psychopathy has a genetic predisposition. He goes on to state that many psychopaths have a pattern of mating with, and quickly abandoning women, and as a result, have a high fertility rate. These children may inherit a predisposition to psychopathy. Hare describes the implications as chilling.

Among criminals
A 2002 literature review of studies on mental disorders in prisoners stated that 47% of male prisoners and 21% of female prisoners had anti-social personality disorder. According to an unsourced article in popular science magazine Scientific American, studies indicate that about 25% of prison inmates meet diagnostic criteria for psychopathy. A 2009 study of British prisoners found a prevalence for "categorically diagnosed psychopathy" of 7.7% in men and 1.9% in women.

Homicides by psychopaths were almost always (93.3%) done in "cold blood" and premeditated in a 2002 study. For non-psychopaths the figure was 48.4% due to a much larger share of "crimes of passion".

Despite having several characteristics that may seem useful to terrorists, there is little evidence that the majority of terrorists are psychopaths. Other characteristics such self-centeredness, unreliability, poor behavioral controls, and unusual behaviors may be disadvantages or make psychopaths unwilling to sacrifice themselves for a perceived higher cause. Indeed, the increased narcissism may produce the attitude that there is no higher cause than the pleasure of the psychopath.

A 2011 study of conditional releases for Canadian male federal offenders found that psychopathy was related to more violent and non-violent offences but not more sexual offences. For child molesters psychopathy was associated with more offences. Despite "their extensive criminal histories and high recidivism rate", psychopaths showed "a great proficiency in persuading parole boards to release them into the community." "High-psychopathy offenders (both sexual and non-sexual offenders) were about 2.5 times more likely to be granted conditional release than non-psychopathic offenders."

Clinical management
In practice, mental health professionals rarely treat psychopathic personality disorders as they are often considered untreatable and no interventions have proved to be effective. However, some of the difficulty has been attributed to the lack of clarity about the concept and diagnosis of psychopathy; the threat of danger to staff, or deceit or poor motivation from patients; and a lack of follow-up to test effectiveness. Despite pessimism, as of 1999, treatment of patients still takes place in a variety of psychiatric hospitals and secure units, and the research has indicated that some individuals do show some improvements when the right treatment is identified, and that longer periods of therapy often produce better results.

It has been shown that punishment and behavior modification techniques do not improve the behavior of psychopaths. Psychopathic individuals have been regularly observed to become more cunning and better able to hide their behaviour. It has been suggested that traditional therapeutic approaches actually make psychopaths more adept at manipulating others and concealing their behavior. They are generally considered to be not only incurable but also untreatable.

However, some researchers suggest that psychopaths can benefit as much as others from psychological treatment, at least in terms of criminal behaviors even if not on the central personality traits. For example, one therapeutic approach to juveniles reports reduced re-offending over a two year period compared to usual care.

United Kingdom
In the United Kingdom, "Psychopathic Disorder" was 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." This term, which did not equate to psychopathy, was intended to reflect the presence of a personality disorder, in terms of conditions for detention under the Mental Health Act 1983. With the subsequent amendments to the Mental Health Act 1983 within the Mental Health Act 2007, the term 'psychopathic disorder' has been abolished, with all conditions for detention (e.g. mental illness, personality disorder, etc.) now being contained within the generic term of 'mental disorder'.

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.

United States
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 20 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.
 * Washington

California enacted a psychopathic offender law in 1939, since greatly outmoded 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.
 * California