Article summary with Psychopathy Primer by De Brito et al. - 2021

What is psychopathy?

Psychopathy is a personality disorder characterized by a constellation of affective, interpersonal, lifestyle, and antisocial features. People with psychopathy lack empathy, guilt, or remorse, and are callous and have shallow and deficient affect. On an interpersonal level they are grandiose, deceitful, arrogant, and manipulative. From an early age they often engage in planned acts of antisocial behavior and aggression. They can display impulsive and irresponsible behavior. 

What is the Hare Psychopathy Checklist-Revised?

The Hare Psychopathy Checklist-Revised (PCL-R) is the most widely accepted and used conceptualization of psychopathy. It uses two correlated dimensions, namely interpersonal and affective features and chronic antisocial lifestyle. These two dimensions are both divided into two facets. This leads to a four-facet model:

• Interpersonal facet (superficial charm, grandiose sense of self-worth, pathological lying, conning, manipulative).

• Affective facet (shallow affect, lack of empathy, lack or remorse/guilt, failure to accept responsibility for own actions).

• Lifestyle facet (parasitic lifestyle, lack of realistic long-term goals, proneness to boredom, impulsivity, irresponsibility).

• Antisocial facet (juvenile delinquency, poor behavioral controls, early behavioral problems, criminal versatility, revocation of conditional release).

What is the difference between psychopathy and antisocial personality disorder (ASPD)?

Although both these disorders include a lifelong pattern of antisocial behavior, they are distinct. The diagnostic criteria for ASPD mostly focuses on a severe and chronic pattern of antisocial and criminal behavior, whereas psychopathy looks more at personality features with an emphasis on emotional impairments and interpersonal features. Most individuals with psychopathy would match a diagnosis of ASPD, but not many individuals with ASPD match a diagnosis of psychopathy.

What causes psychopathy?

The aetiology of psychopathy is complex. There are contributions of both genetic and environmental risk factors, and gene-environment interactions and correlations. Genetic risk factors at play are autonomic, neurocognitive, and those to do with social information processing, temperament, and personality traits. There are three main forms of neurocognitive disruption found in individuals with psychopathy that are discussed below. Environmental risk factors are prenatal maternal stress, child maltreatment, harsh parental discipline, negative parental emotions, disorganized parent-child attachment, and disrupted family functioning. 

What forms of neurocognitive disruption are found in individuals with psychopathy?

Neurocognitive disruptions are found in three areas:

• Emotional responsiveness. This is expressed via increased risk of anger-based reactive aggression, disrupted empathic and fear responses, reduced aversive conditioning, and impaired emotion expression recognition. 

• Reinforcement-based decision-making. Reduced reinforcement sensitivity or responsiveness results in an individual that makes poorer decisions and is more likely to be impulsive and show frustration-induced aggression.

• Attention. People with psychopathy over-focus on certain features at the expense of other features. They also compromise selective attention when performing basic attentional tasks.

What is known about the brain of people with psychopathy?

Psychopathy is characterized by reduced responses in cortical (the prefrontal and insular cortices) and subcortical (amygdala and striatum) regions. Callous-unemotional traits (including a lack of guilt, lack of empathy, lack of concern over poor performance in important activities, and shallow/deficient affect) are negatively related to grey matter volume and thickness in the amygdala, insular and temporal cortices, but positively associated with the volume of the striatum.

How can psychopathy be treated?

There are no effective treatments for adults with psychopathy, but preliminary interventions that target key neurocognitive disturbances show promising results. Psychopathy is often comorbid with other psychiatric disorders, which increases the risk of physical health problems, accidents, criminality, and educational and employment failure. For this reason it is important to identify children and young people at risk for psychopathy and doing preventative work. Interventions aimed at the antecedents of psychopathic features in children and adolescents are effective.