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PSYCHOPATHY OR PSYCHOPATHIC PERSONALITIES

A DIMENSIONAL APPROACH TO THE MASK OF EVIL

2016

Cludio Vieira
Mestrado Integrado em Psicologia (Universidade de Coimbra)
Mestrando em Psiquiatria Forense (Kings College of London)
Coordenador e Supervisor de Terapias Psicolgicas
Servios Forenses para Perturbaes da Personalidade
Sistema Nacional de Sade Britnico & Ministrio da Justia

E-mail de contato:
claudio.vieira@kcl.ac.uk

RESUMO

Psychopathy covers a wide range of emotional, interpersonal, and behavioural features,

including empathy deficits, callousness, impulsivity, and an overall indifference for the societal
norms and the rights of others . It shows a robust association with aggressive behaviour, and its
diagnosis is often used as a strong risk factor in predicting general and violent reoffending , even
when other factors such as delinquent peers, intelligence, self-control and family background are
controlled.
Psychopathy is commonly classified as a distinct disorder measured by an overall PCL-R
score; yet there is still a debate on whether it is a result of partially independent causal processes
or rather it constitutes a coherent syndrome. The aim of this article is thus to set a discussion on
this question, providing up-to-date evidences alongside significant pieces of research.

Palavras-chave: antisocial behaviour, psychopathy, violence, aggression.

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INTRODUCTION

Antisocial personality traits, including callousness, impulsivity and manipulativeness, have

probably been present since the ascent of man [1,2]. It is estimated that 0.61.2% of the community
and 1530% of the prison population in the Western world can be diagnosed as psychopath. Further
research also indicates that although psychopaths are represented by 1% in general population,
they were likely responsible for 50% of all violent offending [3,4].

Psychopathy covers a wide range of emotional, interpersonal, and behavioural features,

including empathy deficits, callousness, impulsivity, and an overall indifference for the societal
norms and the rights of others [5,6,7,15]. It shows a robust association with aggressive behaviour,
and its diagnosis is often used as a strong risk factor in predicting general and violent reoffending
[7], even when other factors such as delinquent peers, intelligence, self-control and family
background are controlled [8].

Psychopathy is commonly classified as a distinct disorder measured by an overall PCL-R

score; yet there is still a debate on whether it is a result of partially independent causal processes
or rather it constitutes a coherent syndrome. The aim of this essay is thus to set a discussion on this
question, providing up-to-date evidences alongside significant pieces of research.

PSYCHOPATHY AN OVERVIEW

Up to the 19th century, psychopathy was perceived as a demoniac personality or rather an

evil spiritual state as opposed to a mental disorder [8,9].
Philippe Pinel, a French psychiatrist, was the first clinician to suggest that a specific group
of patients exhibited manie sans dlire (insanity without delirium); that this, individuals with no
intellectual difficulties but with a profound deficit in behaviour typified by marked impulsivity and
aggressive acts, substance misuse, and immorality that would occur in the absence of confusion in
mind and intellect, in contrast with psychotic illness [4,8].

The current term psychopathy was not introduced until the end of the 19th century by the
German psychiatrist Julius Ludwig August Koch [4].

The following core publication came in 1941 from Hervey Cleckley, an American
neuropsychiatrist, with his work The Mask of Sanity in which he aimed to clarify the construct [1].
Cleckley, however, left the debate on whether psychopathy was characterized by a coalescence of
manifestations of dimensional attributes or categorized as a coherent syndrome. In his paper,

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Cleckley was on the view that psychopaths display a markedly positive impression of robust mental
health upon first sight; however also exhibit deficits in understanding and registering punishment,
which makes them incapable to adjust their maladaptive ways. To explain the dissonance between
the extreme lack of insight into their own emotional difficulties and their intellectual understanding
that their behaviour causes harm to others, Cleckley introduced the term semantic aphasia [1,4]
to describe a loss of recognition of the meaning of words and phrases. Thus, individuals with
psychopathy would articulately talk about of regret, guilt, and remorse, but they would not be in
touch with their emotional deeper meaning.

Coincident with the publication of DSM-III in

1980 which first included the Antisocial Personality
Disorder as a new diagnostic category, the Canadian
psychologist Robert D. Hare, based on Hervey
Cleckleys previous work, developed the 20-items
diagnostic tool to rate a persons psychopathic traits
The Psychopathy Checklist (PCL) [5,6,7,15], in which
a cut-off of 25 or greater is used to diagnosis
psychopathy in United Kingdom, whereas in United
States of America the threshold is 30 [15].
Early factor analysis of the PCL-R determined it
contained two main factors. Factor 1 includes traits related to interpersonal and affective deficits
of psychopathy whereas Factor 2 emphasizes symptoms emerged in antisocial behaviour (table 1).

Factor 1 has been distinctively associated to emotional deficits, instrumental and goal-
orientated aggression and has also been related with both adaptive and maladaptive behavioural
patterns such as emotional resilience to stress and threat, deliberate risk-taking, professional
success, and social dominance. This factor comprises a wide range of traits which are absent from
Cleckley's list (e.g. grandiose sense of self-worth), addressing a more callous and deceitful
personality [4,5,7,15].

On the other hand, Factor 2 comprises poor behavioural control, reactive/impulsive

aggression, antisocial personality disorder, and has been mainly attached to maladaptive
behavioural patterns (e.g., criminal aggression, poor academic achievement, impulsive risk-taking,
psychiatric care, suicide attempts, and financial problems) [10-13,15-19].

These psychopathic traits have been shown to be normally distributed both in the general
population and in offenders, and recidivism has been considerably related with higher scores on
the PCL-R [20]. Further, PCL-R scores indicate a close relation with higher rates of aggressive
behaviour even for individuals without psychopathy [21].

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Another important piece of research [6] has shown that individuals with psychopathic traits
share a wide range of cognitive and affective deficiencies linked to specific parts of the brain. Their
impairment in instrumental learning, response reversal and difficulties in executive functioning is
associated with deficits in their orbitofrontal cortex [22-26]. On the contrary, the impairment in
aversive conditioning [27] alongside dysfunctional response to anothers sad facial expressions
[28] and impaired processing expressions of fear [29] are strongly associated with deficits in the
functions of the amygdala [30].
The associations with particular neurobiological, cognitive and affective structures
highlighted above suggest the likelihood that certain neurobiological deficits may be essential
antecedents of this condition.

THE CALLOUS-UNEMOTIONAL TRAITS

Several research papers [34] have demonstrated that psychopathic traits are a robust predictor
of antisocial behaviours and are often used to describe a severe, chronic, and resistant-to-treatment
group of offenders A wide range of studies have also supported the view that antisocial behaviours
in adulthood have their roots in childhood [33,35]. Further, conduct problems associated to
difficulties in preserving social relationships during childhood are linked to an increase of violence
and aggression, a poorer clinical prognosis and also with a less response to treatment [36].
Gathering all these findings together, a bloom of studies on psychopathy in children and
adolescents started to rise [33].
The research on psychopathy in youth has been conducted under two main theoretical
approaches. The first approach, explored by Lynam [37], includes formulating a subtype of
behaviour disorder recognized on its comorbidity with hyperactivity and impulsivity. This
approach suggests that children who present both impulsive impulsive/hyperactive behaviour and
conduct disorder are more vulnerable to display more acute and persistent antisocial behaviour
when compared to those with either impulsivity or conduct disorder. Lynam [36] argued that
antisocial behaviours observed in boys with both impulsive/hyperactive and conduct disorder are
more severe and persistent than the antisocial behaviours displayed by boys with only impulsivity.
Furthermore, psychopathic traits (e.g. difficulties with response modulation) have been shown in
children with both conduct disorder and impulsive/hyperactive behaviours. However, this
correlation was not verified among children with either problem alone [39].

Other authors [39,86,87] have also correlated psychopathy with attention deficit
hyperactivity disorder (ADHD) due to overlapping symptomology (e.g. substance misuse and
criminal activity and sensation-seeking) alongside parallels in the neurobiological function
underlying both ADHD and psychopathy. As result, both present high levels of impulsivity which

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often leads to interpersonal difficulties and antisocial behaviour in both childhood and adulthood.
Mathias and colleagues [85] also addressed a correlation between the impulsivity trait of
psychopathy with the hyperactive factor of ADHD and a relationship between the narcissistic and
callous traits with the inattentive element of ADHD.

While these findings appear promising, one limitation with this approach is its focus on an
impulsive-antisocial dimension of behaviour, which has not established to be exact to adults with
psychopath, i.e., a predisposition impulsive-antisocial seems to be high and robust in most adults
with significant criminal background and/or a diagnosis of Antisocial Personality Disorder [15].
An additional approach amid the conceptualization of psychopathy in youth has been the
emphasis on the callous-unemotional (CU) traits which have been dominant to clinical formulation
of psychopathy in adulthood [1,15, 40,41, 45-47].

As observed within the affective dimension of adult psychopathy, CU traits incorporate lack
of guilt and empathy, and shallow affect. The prevalence of high CU traits in children and
adolescents with conduct disorder is estimated to range from 1046% in community samples to
2159% in clinic-samples [52] and display moderate to strong heritability (as greater as 50%)
among children and adolescents with behavioural problems [45,46,47,89].
Further, several studies [84] have demonstrated a robust stability of CU traits across youth.
Nevertheless, those do not suggest that CU traits are enduring as they seem to be somewhat flexible
and to be predisposed by environmental factors [58]. For instance, Frick and colleagues [88],
through a 4-year investigation, shown that a group of adolescents viewed their levels of CU traits
being reduced throughout the progress of the research, regardless their stability. Other authors [89]
have highlighted their findings for particular genetic stability in CU 13% of the genetic impact
in the CU traits at age 19 was shown with the equivalent effects at age 16 [89].

Frick, Bodin, & Barry [41] determined that in a sample of both clinic-referred and non-
referred children, CU traits develop a constant and distinct dimension from other psychopathic
traits such as impulsivity and narcissism. Whilst impulsivity does not seem to discriminate discrete
subgroups within children with acute and early-onset conduct disorder or adolescents with criminal
conducts [44,43,40], high levels of CU traits display a moderate role on the presence of antisocial
behaviours and conduct disorder on the risk of developing psychopathy [33]

Other authors, such as Loeber & Pardini [48], have suggested that causal factors (e.g. low
temperamental fear) could moderate the conduct disorder in children with callous-unemotional
traits. Additional research supported these findings by demonstrating a correlation between low
fearful arousal and development of severe antisocial behaviour and violence. Also, as highlighted
by Fowles & Kochanska [49] children with low fear disposition display deficits in empathy and
remorse due to experiencing reduced emotional arousal in response to distress or punishment. It

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appears that a fearless temperamental may contribute to the development of early antisocial
problems as it decreases the efficacy of punishment-oriented socialization techniques and
moderates the development of callous-unemotional traits [47].
In line with this, Hawes & Dadds [50] found that children with conduct problems alongside
callous-unemotional traits did not show any improvements from parenting when compared to the
control group. In their study, the callous-unemotional traits were the single predictor of less
engagement to treatment even after external variables such as parenting and family characteristic
and socioeconomic status were controlled.

Callous-unemotional traits can also be utilised as a robust predictor of instrumental antisocial

behaviours in children, discriminate them from children whose aggression and violence are mostly
impulsive and reactive [46,47]. Thus, and although a diagnosis of psychopathy in children would
lack sensibility and responsiveness, it has been well-documented that a specific subgroup of
children who shows conduct disorders alongside callous-unemotional traits are placed at enhanced
risk for fostering psychopathy in adulthood [33,47].

An additional prominent target of the current research on psychopathy has been the study of
how the brains of psychopaths process information in a different way from those without
psychopathy [52], highlighting and recognizing anatomical parts of the brain which operate in a
dysfunctional way [83].
The critical impairments of the brains of adults with psychopathy are observed in the
functionality of the ventrolateral/orbitofrontal cortex (e.g. represent a particular reward or
punishment) and the amygdala (e.g. social signs of emotions and fear conditioning) [53,54].
Research on psychopathy in children and adolescents assisted by functional magnetic resonance
imaging (fMRI) have emphasized that this age-group also display abnormalities in the
ventrolateral/orbitofrontal cortex, amygdala functioning and hippocampus, i.e., in areas of the
brain well-known for their role in emotional regulation and empathic processing [52,55,56].
Nevertheless, contrasting the findings in adult psychopathy where a decreased in the orbitofrontal
cortex grey matter is noted, children with CU traits and behavioural problems display an increased
grey matter concentration, observed particularly in the medial orbitofrontal cortex and in the
anterior cingulate cortex.

Additionally, children with callous-unemotional traits and behavioural problems, like adult
psychopaths, show difficulties in reversal learning and decision making mediated by the
orbitofrontal cortex [52,56]. Other critical findings in the neurobiological field came from Lozier
et al. [57] who aimed to examine whether neural impairments linked to callous-unemotional traits
play a moderate role in the relationship between callousness and proactive aggression in children
(7-10 years old) with behavioural problems.

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Consistent with previous literature, these findings suggested that proactive aggression in
children with callous-unemotional traits is related to response deficits in the amygdala to emotional
expressions. The amygdala is thus thought to constitute a phenotype that associates CU traits in
children with behavioural problems to a behavioural phenotype [57].

Additionally, genetics underlying various aspects of the serotonergic pathway have also been
accounted with regards to callous-unemotional traits. A wide range of evidences [90,91,92] suggest
that males with high levels of CU traits show deficits in levels of serotonin in the basolateral
amygdala which are associated to reductions in the conditioned fear response a response which
is consistently diminished in adults with high levels of psychopathic traits. Sadeh et al. [90] also
suggested that that 5-HTT genotype was highly correlated with the impulsivity dimension of
psychopathy [90].

In recent days a comprehensive discussion about the dimensions which best categorize the
construct of psychopathy in adulthood is still taking place. Three core dimensions have emerged
so far 1) the callous-unemotional traits labelled as deficient affective experience, 2) a deceiving
and narcissistic interpersonal style and 3) a pattern of impulsive and irresponsible behaviour
alongside proneness to boredom [58]. Nevertheless, in order to enhance the utility of psychopathy
as a construct it is also required to account significant areas of independence from broad measures
of antisocial behaviour.
Cooke & Michie [59] suggested that in samples of adults with psychopathy, the callous-
unemotional dimension is the most specific and determinant dimension used to distinguish
individuals with high levels of psychopathy to other individuals. Caputo et al. [43] found the same
results in children and adolescents, i.e., in their research aggressive sex offenders showed higher
callous-unemotional traits when compared to other offenders. However, other dimensions of
psychopathy did not show any statistically significant differences across the offender groups [43].

PSYCHOPATHY OR PSYCHOPATHIES

Although psychopathy is often classified as a distinct and specific construct measured by a

total PCL-R score, an ongoing debate which continues to be core of the research attention is the
extent to which individuals with psychopathy are a categorical class [31, 32,62] or share a
coalescence of extreme levels of distributed personality traits [66,63].

The controversy between dimensionality and taxonomy has a major impact on debate related
to psychopathy, specifically its etiology. For instance, a categorical approach might be explained
by a particular dependent factor (e.g., Downs syndrome which is caused by the presence of an

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extra chromosome 21); however, if psychopathy was proved to be dimensional, it would be

unlikely to result from a single underlying agent, such as an injury in the frontal lobe or from a
particular gene [62].
In psychopathology, taxon is well described by Meehl & Golden [62] as an entity, i.e., a
nonarbitary class of individuals that are authentic in nature and distinguished from the general
population.

Researchers like Harris, Skilling, and Rice [64] stressed that psychopaths are indeed a
discrete type of individuals who are fundamentally different from those who are classified as non-
psychopaths and who can be identified from a very early age. They proposed an alternative
psychopathy assessment tool Child and Adolescent Taxon Scale which supported psychopathy
as a taxon. Other studies have also sustained this approach in a community sample of children with
antisocial behaviours [65,60].

The evidences for psychopathy as a taxon expanded in 1994 with a study conducted by
Harris, Rice, and Quinsey [63], using a taxometric analysis of the PCL-R in a sample 653 male
offenders detained in Canadian mental health institutions. With their findings, Harris and
colleagues concluded that a taxon could be recognized using PCL-R scores, with a base rate in
their sample fluctuating from .44 to .46. Nevertheless, it was only found evidence of a taxon for
PCL-R Factor 2. That is, Factor 1 analyses were shown as inconsistent with a categorical structure
[62].

If psychopathy was shown to be dimensional, that would lead further researchers to focus
their studies on specific etiological and dimensional agents such as fearlessness. Further, it would
also support psychopathy research with community samples or with academic groups [62].
Although some researchers support the idea of psychopathy as a pattern of high scores on
distributed personality traits, such as low conscientiousness and low agreeableness [66], there are
not specific evidence for any dimensional model of psychopathy, as observed with the five-factor
model [67]. Other studies failed to support a categorical model of psychopathy. Marcus et al. [70]
led a research on a sample of prison inmates with the Psychopathic Personality Inventory and
consequent taxometric analysis. Consistent with previous studies no evidence supporting the
taxometric approach on psychopathy was found [60,70].

Hare [15] proposed a four-factor solution to the PCL-R in which the original Factor 1 and
Factor 2 are split into narrower facets. That is, Factor 1 would be composed of Interpersonal Facet
(e.g. manipulative) and Affective Facet (e.g. lack of remorse) whereas Factor 2 would include
Lifestyle facet (e.g. irresponsibility) and Antisocial Facet (e.g. poor behavioural controls). Hare
[15] suggested this model in order to enable taxometric analyses to be done at the scale level, which

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was not possible in previous studies [62]. Subsequently to Hares four-factor solution, several
debates started to emerge around its relevance and applicability [68,69]. Nevertheless, it has been
generally established that this new approach does account and emphasizes the multidimensional
nature of the construct of psychopathy and its emotional, behavioural, and interpersonal structures.
That is why in community and forensic services it is observed that most criminal offenders are not
diagnosed with psychopathy for this diagnosis is usually established for those who display
psychopathic features across these facets.

The multidimensional approach of the PCL-R proposes the likelihood of those who are
classified as psychopaths are a heterogeneous group of offenders. For instance, some psychopaths
dont reoffend during or after being in prison and engage fairly well in treatment [15,19,34].
Further, factor analyses indicates that the PCL-R Factor 1 highlights specific traits which are shown
in Cleckleys formulation of psychopathy (e.g. callousness), whereas Factor 2 stresses the criminal
and antisocial behaviour more consistent with the diagnosis of Antisocial Personality Disorder
[79]. These findings demonstrate that there is a constellation of reasons to disaggregate
psychopathy into homogeneous subgroups and also challenge the hypothesis that antisocial
behaviour of those who are diagnosed with psychopathy is unchallengeable, whilst addressing the
opportunity of exploring specific variants that might lead to different behaviours.

Skeem et al. [19] proposed a configuration of traits which might help to understand the
variances in psychopathy within a dimensional approach. The trait anxiety is often used to distinct
primary and secondary variants of psychopathy. PCLR appears to classify a heterogeneous group
as psychopathic, instead of categorizing a specific group of psychopaths with low levels of anxiety
[4,19]. However, psychopaths can be distinguished regarding their levels of anxiety - low-anxious
psychopaths (primary psychopaths) display deficiencies in emotional responses [80], and fear
conditioning [19]. Other researchers [81] suggest that whilst primary psychopaths present more
noticeable traits of emotional detachment (PCLR Factor 1 or Facet 2), secondary psychopaths
show more traits associated to irresponsibility and aggression [19].
Another variant identified by Blackburn [19,82] is the interpersonal behaviour and the degree
of withdrawal. Blackburn [19,82] emphasized that primary psychopaths are self-confident and
arrogant, whereas the secondary psychopath is passive, temperamental with low self-confidence.
Also, Blackburn [82] classified secondary psychopaths as consistent with borderline personality
traits (PCL-R Factor 2), whereas the personality of primary psychopaths would be more consistent
with narcissistic personality features (PCL-R Factor 1) [19].
If variants of psychopathy can be shown to be reliable with empiric support, researchers and
clinicians may be able to progress their understanding of this construct in order to develop further

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management plans and specialist treatment services for a subgroup of individuals who have been
labelled as high-risky and hopeless [1].

FINAL CONSIDERATIONS

Psychopathy is still a broad concept which offers minor guides for clinical interventions in
forensic services, particularly for individuals who score 25 or above in the PCL-R. A wide range
of researchers have claimed that individuals with psychopathy fluctuate in their symptomology,
with distinctive patterns of aggression, and responsiveness to treatment. Thus, if those fluctuations
and variances were categorized by different risk factors for offending behaviour, those would have
critical implications for assessment, management, and treatment of psychopathy [79].
Several debates and controversy have aroused for the last decades regarding whether
psychopathy is a dimensional or categorical construct, i.e., whether individuals with psychopathy
differ from the rest of the population in degree or kind [74]. The PCL-R offers both a dimensional
and categorical approach to psychopathy by classifying an individual as psychopath-
nonpsychopath utilising either cut-off scores or continuous scores which can be determine where
an individual falls into the spectrum of psychopathic traits [15]. Also, psychopathic variants may
also be considered as distinct classes (primary psychopath and secondary psychopath) or as
dimensional constellations.
Further research should focus and direct their investigative efforts on whether variants in
psychopathy might fluctuate in their responsiveness to treatment as primary psychopaths are
conventionally perceived as unmanageable in therapeutic settings [15]. This may be due to low
levels of motivation and willingness to change their behaviours and challenge their schemas and
to low levels of insight into their psychopathology.

The difficulties in managing responsiveness to treatment in primary psychopathy seem to

have been overvalued [75] considering current findings that young offender psychopaths who are
exposed to long-term of treatment are less expected to engage in subsequent antisocial behaviours
than do those who are exposed to less or no treatment [76]. Given that, the treatment for primary
psychopaths should incorporate outlets for their risk-taking predispositions rather than targeting
enduring personality traits which may be an unrealistic and unachievable. On the other hand,
secondary psychopaths may engage in a wide range of interventions as they are able to experience
remorse and anxiety, thus may be motivated to seek treatment [77].

If practitioners emphasize simply a categorical approach suggesting that someone scoring 25

in the PCL-R is a psychopath and someone scoring 24 is not a psychopath, this could lead to
challenging consequences. For instance, whilst someone scoring 24 may be perceived as having

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good receptiveness to treatment and be at low risk, someone who scores 1 point higher would be
described as presenting poor treatment responsiveness and being at high risk for reoffending. Also,
clinicians are progressively adopting the psychopathy construct to address their decision-making
regarding treatment and assessment of individuals under this diagnosis. Hence, further
comprehensive research on the clinical implication of variants of psychopathy which are related to
significant repercussions in legal and clinical settings is desirable.

In conclusion several taxometric investigations suggest that psychopathy is a dimensional

construct when assessed by a wide range of instruments including self-report [70], PCL-R [60]
PCL-SV [71] and PCL-YV [72]. Those who argue that psychopathy is a dimensional approach
criticize the categorical view for building up limits where limits do not belong and for generating
specific classes that are overlapping, unclear, heterogeneous, and of dubious validity. In contrast,
those who argue for a categorical system stress that the categorical approach has shown to be a
rather operational shorthand form of communication among clinicians.
Investigative processes should also include cross-cultural studies of large community
samples using the PCL-R in order to extend our understanding of prevalence of psychopathic traits
in non-institutionalized samples. Taking into account cultural differences in incidence, exploring
how the picture of an institutionalized psychopath may differ from a non-institutionalized
psychopath (e.g. research on corporate psychopaths and how do they differ among themselves) and
also looking for additional variants on psychopathy might elucidate the heterogeneity within the
group within a robust framework. Also, most of the studies on psychopathy has been conducted in
males, thus it would be worth questioning variants of psychopathy in females as they may display
their traits differently from males (e.g. histrionic/borderline in women versus narcissistic/antisocial
in men).

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