VARIABLES OF PSYCHOPATHY.Are they universally recognized in the same way?

 

‘The unscrupulous man will go and borrow more
money from a creditor he has never paid. When marketing he reminds the butcher
of some service he has rendered him and, standing near the scales, throws in
some meat, if he can, and a soup-bone. If he succeeds, so much the better; if
not, he will snatch a piece of tripe and go off laughing.'(Theophrastus, 3 sec
a.c.)

 

Psychopathy
is a mental disorder characterized by a lack of empathy and remorse, hidden
emotions, egocentricity and deception. Psychopaths are strongly inclined to
assume criminal behaviours and other aggressive acts towards others, as well as
being oriented to towards violent crime. Often they seem normal people: they
simulate emotions that do not actually prove, or lie about their identity
(Hare, 2009).

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Until the
eighties, psychopathy referred to a personality disorder characterized by the
inability to attachment and an abnormality in the emotion management system,
masked by the ability to appear like a normal person (Helfgott, 2004, p.3). The
publication of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-III) changed the name used to define this mental disorder in antisocial
personality disorder and it increased the diagnostic criterion for behavioural
sciences (Hare, 1996).

Starting
from the findings that the modern conception of psychopathy is the result of
several hundred years of clinical research made by European and North American
psychiatrists and psychologists, we will now analyze several authors and
theories from different eras, culture and historical periods.

Despite being
greatly overlooked in the diagnostic manuals, psychopathy and related terms, like
‘psychopathic’, are widely used by mental health professionals and criminologist.
In particular, NATO founded a series of Avanced Research Institutes on
psychopathy, both before and after the publication of the Scientific Diagnostic
Manual-III (Patrik, 2005, p. 61). Robert Hare (1991), Canadian researcher in
the field of criminal psychology, he was very fruitful in this field, and to
him goes the merit of having invented the Hare Psychopathy Checklist which is a
method to differentiate antisocial personality disorder from psychopathy.
According to these studies, the spread of antisocial personality disorder is two-three
times higher than psychopathy.

In 1801 the
French psychiatrist, Philippe Pinel, described some patients who were mentally
disturbed but not enough to denote self-injurious acts. It was said at the time
that they were ‘non-delirious sick’ (Pinel, 1801) that is people who understood
their irrational status but continued to act accordingly.

The
scientific study of individual cases failed to develop further until the second
half of the nineteenth century, when the Italian sociologist Cesare Lombroso
(1896) rejected the traditional theory that criminality can involve anyone, and
instead identified a particular type of ‘delinquent born ‘, defined as such
based on somatic evidence.

At the
beginning of the twentieth century, the British psychiatrist Henry Maudsley
(1876) published a work on the ‘moral imbecile’ in which he described the cases
of those irrecoverable persons by means of traditional correction systems.
Maudslay realized that this resistance derived from the punitive effects of
re-socialization, by making sure that the patients somehow activated some sort
of defense mechanism against their own future failures (p.77). In 1904 Emil
Kraepelin, a German psychiatrist, described four types of personality related
to the antisocial personality disorder and defined them as a deficit of
volition, dividing the following types into different categories, some of which
corresponded to the current description of the antisocial behaviour disorder, finding
a shortage or absence of remorse in their actions (p.435). Pinel (1801)
perceived his patients as morally neutral, reflecting a humanistic approach to
mental health.

In 1909,
Karl Birnbaum, a German-American neurologist, introduced the term sociopathic,
intending to emphasize the trigger of this behaviour. The Mask of Sanity by
Hervey M. Cleckley (American psychiatrist), published in 1941, is considered a
study that provides a remarkable series of clinical cases of patients, mostly
inmates, described as psychopaths. Cleckley proposed sixteen characteristics
for the definition of psychopath. The title derives from the mask of pseudo
normality that the author thought was underlying to this mental disorder.

A research
in 1977, on the characteristics of Cleckley, however, concluded that the
concept had been used too broadly and dispersively (Psychopathic personality: a conceptual problem, 1977, p.631).

Along the
lines of Cleckley’s description of psychopathy, in 1980 Robert Hare developed
the Psychopathy Checklist (PCL), reviewed in 1991 and named Psychopathy
Checklist-Rivised (PCL-R), for the classification of adult psychopathy.

The
Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the
American Psychiatric Association included several concepts of psychopathy /
sociopathy / antisocial personality in early editions but, starting in 1980,
attributed a diagnosis on antisocial personality disorder that was based on one
of the criteria already employed by Cleckley but modified differently and, moreover,
more specifically related to criminology. The taxonomy (ICD) of the World
Health Organization currently includes a similar diagnosis. Both the ICD and
the DSM establish that psychopathy and sociopathy are synonymous with the same
diagnosis (Cameron, 1987).

In 1980,
Hare developed the Psychopathy Checklist based on the assumptions made by
Cleckley and subsequently revised. The development of the Psychopathy Checklist
(Hare, 1980, p.249) and of the III edition of the Diagnostic and Statistical
Manual of Mental Disorder (DSM-III, 1980) represented the starting point for
the establishment of a thriving research network on the theoretical and
empirical construct of psychopathy.

Historically
summarizing the most used terms to indicate psychopathy are: non-scrupulous man
(Theophrastus, 3rd century BC), mania without delirium – manie sans délire
(Pinel, 1801) or sociopathy (Birnbaum, 1909).

In light of
these different studies, theories and definitions on psychopathy, similarities
are found that converge on defining more or less universal aspects that
characterize the psychopath: psychopathy consists of a deficit for different
areas, such as interpersonal relationships, emotions, and behaviours.

Hare (2003)
described psychopaths as ‘intraspecies predators’. Hare and other
criminologists wrote about the phenomenon as ‘the use of a particular charisma,
manipulation, intimidation, sexual relations and violence’ in order to control
other people and pursue their own interests:

‘Missing consciousness
and empathy, they do what they want and as they like, violating social norms
and social expectations without guilt or remorse, what is missing, in other
words, is the true quality that makes a human able being to distinguish himself
from an  animal’ (Hare , 1999, p.182).

Following
Hare (2006), many psychopaths are apparently able of striking the attention of
others because they can perfectly mimic the most common human emotions, and can
wander, in disguise, in a variety of environments, including corporations or
other similar associations (p. 48).

Regarding empathy,
psychopathy prevents understanding the emotional states of other people, except
in the purely intellectual sense of expression.

Psychopaths
do not perceive their emotions like normal people. Even if they are not completely
impassive, their emotions are so low that some doctors have described them as
simple ‘proto-emotions’ or ‘primitive responses to immediate needs’ (Hare,
1999, p.196).

Psychopaths
do not feel the need to establish a romantic relationship and are not able to
form emotional bonds with people. Although a psychopath can sometimes perceive
a person’s charm or be infatuated with him / her, he cannot reciprocate his
feelings, but only pretend and enjoy sexual encounters, even if they are
superficial and impersonal (Hare et al., 2006 , p.39).

The
researchers obtained brain scans on psychopaths while exposing them to
emotionally charged speeches like rape, murder and love. In a normal person,
these words cause success in the limbic system, which governs emotions.
Psychopaths did not show these  activities but reacted in a totally
indifferent way (for example ‘tree / love’, ‘chair / rape’, ‘spoon / murder’),
however, they showed reactivity in the cerebral areas associated with language
processing, suggesting that their response was more cognitive than emotional
(Hare, et al., 2006, p.41).

Another
aspect concerns plagiarism and manipulation: psychopaths are incorrigible and
recidivist liars. Often they can get what they want or to impress people, and
they do it with such skill that the investigators, even those with considerable
experience behind them, are sometimes misled (Cleckley, 1976).

A potential
psychopath tries to deceive more often than it seems (body language, trust,
etc.). In fact, psychopathic stories are often full of inconsistencies and
contradictions. The first reason for this is the often improvised nature of
their consciousness. If they are caught or faced with unforeseen questions,
they simply rework their narrative to adapt to the new reality without stopping
to reflect on things. The second reason is that psychopaths seem to have
difficulty properly integrating the language and emotional components of their
thoughts, and this does not make it possible to notice the contradictions in
their speech. Hervey Cleckley (1976), a pioneering researcher of psychopathy,
called this anomaly as ‘semantic aphasia’.

Some researchers
at the University of Sydney claim that psychopathy is pure impulsivity. It is
not possible to measure the risk of being surprised, discovered or affected as
a result of one’s behaviour (Dadds et al., 2006, p.280).

The
psychopath lives day by day, changing his plans frequently and generally has no
realistic long-term goals. Psychopaths often claim to have ambitious goals in
life, but they cannot appreciate the consistency, skill or discipline necessary
to achieve them (Hare, 1999, p.196). In the workplace, on the contrary, they
are known for irregular frequency, frequent absences, embezzlement, and
unreliability. They are financially irresponsible, often living above their
means, incurring in debts and defaults on loans. They often neglect their
children, often have unprotected sex, they make children and then abandon them and
transmit sexually transmitted diseases (Harris et al., 2006, p.184).

The
recurrence rate of psychopaths is twice the number of common offenders with
peaks three times higher for the most violent crimes (Hare, 1999).

Smith and
Newman (1990), scholars of the University of Wisconsin note that psychopaths
have a low tolerance for boredom and an excessive need for excitement and
stimulation. They often break the rules, commit crimes, and risk their lives to
try cheap thrills: they are more likely to take drugs than normal people.

Psychopaths
also abuse their self-esteem. Their egocentrism is comparable to that found in
the narcissistic personality disorder and, in fact, it is sometimes difficult
to distinguish the two conditions from each other (Hare, et al., 2006). They
believe they are at the center of the universe and see themselves as superior
beings, often appear to be opinionated, bullies and arrogant. A psychopath
always thinks he is the smartest person in the world and has no respect for the
divergent opinions of others.

It has been
demonstrated that there is a correlation between psychopathy and IQ:

Hare and
Neumann (2008) state that there is only a weak association between psychopathy
and IQ but that ‘there is no obvious reason why the theoretical disorder
described by Cleckley or other clinicians should be linked to intelligence;
some psychopaths are lucid, others less so. Even if a psychopath were to
possess a great intelligence or IQ, he would rarely prove this’ (p.893).

Genetic
factors can generally influence the development of psychopathy, while
environmental factors influence specific traits that predominate.

In 2005, a
study of twins found that children with antisocial behaviour can be classified
into two groups: those with high “insensitive-emotional” attitude
were conditioned by hereditary and non-environmental factors, while those who
were classified minimum quantity of those attitudes were conditioned by both
hereditary and environmental factors (Viding, et al., 2005, p.593).

‘The
amygdala is crucial for the stimulation-reinforcement in learning and responding
to emotional expressions, e.g. the fear that, like reinforcements, is an
important factor in stimulating and reinforcing learning. Furthermore, the
amygdala is involved in the formation of both the stimulus of punishment and
reward. Individuals with insufficiency in learning stimuli and responses to
expressions of panic and pain, suffer from psychopathy syndrome ‘(Blair, 2008,
p.2557).

Recent
studies have refuted theories on how to determine the biological relationship
between the brain and psychopathy. One of these suggests that psychopathy is
associated both with the amygdala, which is associated with emotional reactions
and emotional learning, and with the prefrontal cortex, associated with impulse
control, decision-making, learning and emotional-behavioural adaptation (Weber
et al., 2008, p.8).

Criminal
endocrinology

High levels
of testosterone combined with low levels of serotonin can increase violent
aggression. Some researches suggests that testosterone alone does not cause
aggression, but increases the dominance of violent behaviour. Low serotonin is
associated with impulsive or highly negative reactions and, when combined with
testosterone, may result in aggression following frustration.

In 2010 a
British study found that a great value of the 2D: 4D ratio, indication of a
high estrogens value, indicate a positive correlation of psychopathy in
females, and a positive correlation of insensitivity (sub-scale psychopathy) in
males (Blanchard et al., 2010, p.23)

The
psychopathic tendency can sometimes be recognized in childhood or during
adolescence. Not all the subjects diagnosed during childhood turn out to be
psychopathic as adults, or even to all the sufferers of other disorders.
Therefore, psychopathy is not normally diagnosed in children or adolescents,
and some jurisdictions explicitly prohibit this diagnosis for children with personality
disorders or similar. This is because a diagnosis ‘cannot detect any emotional,
cognitive or other personality traits such as egocentrism and lack of remorse, empathy,
guilt that are so important in the diagnosis of psychopathy’ (Hare, 1999,
p.186).

The
following indicators are used in criminology to detect child psychopathic
diagnosis; not all items must be present at the same time, but at least many of
them must be present for a period of years (McClellan, 2007 p.30):

 A
long period of nocturnal enuresis past preschool age, not because of any
problem identified by the doctor; Early sadism, often expressed as cruelty to
animals; Pathological, e.g. pyromania, is the intentional setting of
destructive fires with the total disregard for the property and life of others
but lacking obvious murderous intentions; Tendency to lie, often without clear
objectives, which extends beyond the normal impulse of a child not to be
punished; Theft and unjustified absences.

The three
indicators: enuresis, animal cruelty and pyromania, are known as Macdonald
triads and have been described by JM MacDonald (2011) as a ‘red dot’ of
psychopathy and a future episodic aggressive behaviour (p.601).

Psychopathy
is often measured with the PCL-R, which is a scale formed by twenty items each
of which indicates three values ??(0, 1, 2) underlying two factors (Hare,
2003).

PCL-R
Factor 2 is associated with behavioural deficits or an antisocial lifestyle,
PCL-R factor 1, on the contrary, is associated with personality deficit or
aggressive narcissism.

Because scores
of an individual can have important consequences for his future, the
possibility of causing damage is considerable, if the test is used or handled
incorrectly. The test can be considered valid if administered by a qualified
doctor and carried out under controlled conditions (Hare et al., 2006, p.58).

THE PCL-R
consists of 20 items. They investigate the emotional, interpersonal and behavioural
characteristics of the individual. Each item is rated on a score from zero to
two. The total sum determines the extent of a person’s psychopathy (Semple,
2005, p.448).

People with
psychopathic personality disorder pose an elevated risk of violence, respond
less well to treatment and disrupt the treatment of others (Hare et al, 1999, p.556). In the UK the
diagnosis of psychopathy is relied on heavily when making release decisions in
prison and forensic psychiatric settings. However, the most commonly used
diagnostic procedure, the Psychopathy Checklist – Revised (PCL–R; Hare, 1991),
was developed and has been used primarily in North America. This is a potential
concern as the manifestations of personality disorders are likely to vary
across cultures (Cooke & Michie, 1999, p.67; Lopez & Gaurnaccia, 2000,
p.571). Because of the serious nature of the forensic decisions in which it is
applied, the PCL–R has great potential for causing harm if used improperly.

A problem
related to the evaluation of subjects that may have affective, relational and
behavioural characteristics associated with psychopathy, is the ability to
overcome gender bias when psychopathic characteristics are present in females
(Frank et al., 2010, p.52).

DSM and ICD

There are
currently two widely established systems of classification of mental disorders
– Chapter V of the International Classification of Diseases (ICD-10) published
by the World Health Organization (WHO) and the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV) published by the American Psychiatric
Association (APA). Both publications list thought disorders as different types,
and are deliberately converging their codes into recent revisions so that the
manuals are more easily comparable, even if the differences remain significant.

While
previous versions of DSM lists psychopathy as a personality disorder, it is not
currently a diagnosis of these classifications. Labeling a person as a
psychopath involves a metric assessment, using a diagnostic tool such as the
Hare Psychopathy Checklist Revised (PCL-R). PCL-R is widely considered the
‘gold standard’ for the assessment of psychopathy that is most strongly
correlated with the DSM-IV personality antisocial disorder (ASPD), and ICD-10
antisocial personality disorder and personality disorder (DPD). However, the
criteria for identifying a psychopath are different for both the ASPD and the
DPD; psychopaths represent a subset of those with ASPD, and psychopathic
attitudes are more severe (Semple, 2005, p.449).

Some
researchers are skeptics about changing diagnostic criteria.

Hare (1996)
argues that the confusion about the ASPD diagnostic modalities, as well as the
difference between ASPD and psychopathy, as well as the prognosis regarding
relapse and treatability, can have serious consequences in certain environments
such as judicial cases in which psychopathy it is often seen as an aggravating factor
of crime (p.39).

A number of
studies support this finding: in 2002 showed that 47% of the male population
held in prison and 21% of the female population suffer from antisocial
personality disorders (Fazel et al., 2002, p.545). Following these statistics,
about 25% of detainees fall under the psychopathic diagnostic criteria
(Lilienfeld et al., 2007). In a 2009 survey on British prisoners it was found
that 7.7% of men and 1.9% of women suffered of psychopathy (Coid et al., 2009,
p.66).

Murders are
the most common crimes found in psychopaths (93.3%) both in “cold
blood” and premeditated. The percentage drops significantly for non-psychopaths
(48.4%) for the most part with a sentimental background (Woodworth et al.,
2002, p.437).

In 2009, a
study carried out in Canadian prisons found that psychopathy is more related to
crimes of greater violence than to sexual violence. Despite the high rate of
recidivism, psychopaths show a great ability to persuade social services to
insist on recovery treatments. The authors of psychopathic sexual violence are
about 2.5 times more likely to leave the conditional than non-psychopathic ones
(Porter et al., 2009, p.110).

A professor
of psychology at the University of Minnesota, Christopher J. Patrick (2006) has
published a book: Handbook of Psychopathy, in which he has dedicated a chapter
on treatment where there is evidence of a cure for this type of pathology; no
medicine can inject the empathy that the psychopath needs and, moreover, those
who follow traditional therapy can become much more dangerous in manipulating
others and more likely to commit a crime. Others suggest that psychopaths can
gain significant benefits from any therapy except those focusing on behavioural
attitude (Lilienfeld et al., 2007).

Despite the
pessimism, since 1999, the treatment of psychopathic patients is still taking
place in a variety of psychiatric hospitals and scientific research has shown
that some improvements occur in some individuals when it is possible to
identify the right treatment, and that long periods of therapy often produce
tangible results (Lee, 1999).

Regarding
social defense, however, it is interpreted differently according to the
legislation present in the State in question:

In the
United Kingdom, the psychopathic disorder has been legally defined in the
Mental Health Act (UK) as’ a persistent disorder or mental disability
(excluding significant impairment of intelligence) which results in an abnormal
aggressive or severely irresponsible behaviour on the part of the person
interested ‘(Mental Health Act, 2006). This definition, which is not the same
as psychopathy, was intended to reflect the presence of a personality disorder,
in terms of conditions of detention under the Mental Health Act 1983. With the
subsequent changes contained in the Mental Health Act 2007, the psychopathic
disorder has been abolished, with all other conditions of co-morbidity eg.
mental illnesses, personality disorders, etc. and currently they are contained
within the generic term ‘mental disorder’.

In England
and Wales, the diagnosis of asocial personality disorder is treated during
Mental Health Act detention in the psychiatric hospital if the subjects have
committed serious crimes, but since these individuals are destructive to other
patients and do not respond to treatment , you cannot do anything else but lock
them up in prison (Harrison et al., 2005, p.163).

In Sweden
and Belgium, to give another example, what is important to the criminal system is
not the evaluation of the person to determine himself in relation to his voluntary
behaviours but  find the sanction,
punishment or measure of security to be adopted in relation to certain
categories of offenders, regardless of psychic evaluations on the nature of the
criminal (Martin, 2005).

In the
United States, psychopathy is addressed differently according to different
jurisdictions. The American psychiatric association is firmly opposed to
non-medical definitions or definitions that do not take into account the
clinical context (Fitch, 2003, p.489).

In the
United States, about twenty states can now offer support services for sex
offenders or sexual predators, avoiding the use of the term
“psychopath”. These laws and their provisions are controversial and
are being reviewed by the Supreme Court as a violation of a fundamental right
of the person’s Fourteenth Amendment (Alexander, 1993, p.372).

Furthermore,
differences in the rate of psychopathy in different countries have been
hypothesised to stem from cultural differences, with the individualism of North
American culture, and specially in the US, in order to enable the free
expression of psychopathic behaviour. According to Wernke and Huss (2008) more
collectivist cultures, supress the overt expression of the anti-social aspect
of the syndrome. Individualistic cultures create competences and tendencies towards
superficiality and selfishness (p.111).

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