David Baxter PhD
Late Founder
Rethinking Antisocial Behavior
By Dr. Michael Brodsky, Clinical Psychiatry News
February 24, 2012
After years of reduced visibility, the psychopathic personality has returned to prominence in both the popular imagination and in the domain of clinical psychiatry.
In 2010, British television personality Jon Ronson published "The Psychopath Test," a somewhat cynical inquiry into the use, and purported misuse, of the Hare Psychopathology Checklist-Revised (PCL-R) in forensic, medical, and corporate settings. In recent years, research into the neurobiology of psychopathic traits has been cited in prominent articles and editorials in the American Journal of Psychiatry (2011;168:569-71). And now, as the DSM-5 work groups revise their proposals for diagnostic criteria, the psychopathic personality is poised to appear in the diagnostic manual, albeit in modified form.
Traditionally, the term "psychopathy" has referred to a cluster of affective and interpersonal features that predispose individuals to antisocial behavior. The classic psychopath is notable for an absence of remorse, a reduced ability to experience guilt, and a limited degree of emotionality. With little capacity for empathy, the classic psychopath is unencumbered by concerns about the dignity and humanity of others, and is therefore relatively free to exploit them at will.
Psychopathy?s definition is distinguished from that of antisocial personality disorder (ASPD) by its emphasis on intrapsychic and interpersonal elements of personality style, rather than on the observable behaviors stipulated by most of the ASPD diagnostic criteria.
The construct and clinical utility of the concept of psychopathy is somewhat controversial, and has been the subject of extensive and thoughtful critiques (Psychol. Sci. Public Interest 2011;12:93-4). Nevertheless, evidence suggests that antisocial personality in the presence of psychopathy is associated with a more severe and intractable course of misconduct than in the absence of psychopathy. Antisocial individuals with psychopathic features manifest more severe criminal behavior (J. Abnorm. Psychol. 2006;115:798-806), more convictions for criminal violence (Compr. Psychiatry 2010;51:426-33), and greater involvement in illegal drug activity (Am. J. Psychiatry 1999;156:849-56) than do those without psychopathic features.
Psychopathy carries a highly pejorative connotation, and the labeling of individuals with this term has direct and measurable adverse consequences within the legal system. For example, researchers at Sam Houston State University in Huntsville, Tex., showed that potential jurors believe that juveniles who are explicitly labeled as psychopaths deserved longer prison sentences than did unlabeled juveniles who met criteria for psychopathy (Behav. Sci. Law 2008;26:487-510).
Over the years, several terms have been proposed as less pejorative stand-ins for the word itself. In the 1960s, "sociopathy" was offered more or less as a symptom for psychopathy, with an etymological emphasis on the purported societal roots of the disorder. Later, the DSM-III used the specifier "undersocialized" to describe a subtype of conduct disorder characterized by "a lack of concern for the feelings, well-being, and wishes of others" (Washington, D.C.: American Psychiatric Association, 1980, p. 45). Although free of negative connotations, the term "undersocialized" lent the erroneous impression that the disorder stemmed from a lack of social stimulation.
More recently, clinicians and researchers have promulgated the term "callous-unemotional (CU) traits" in lieu of the psychopathy label. The callous-unemotional terminology has been well received by clinicians and researchers alike, and now appears regularly in the psychiatric research literature. The DSM-5 Work Group on ADHD and Disruptive Behavior Disorders is currently considering inclusion of CU traits in its definition of conduct disorders. Two members of the work group, Paul J. Frick, Ph.D., and Terrie Moffitt, Ph.D., have proposed that the DSM-5 include a specifier for a callous-unemotional subtype of conduct disorder, characterized by lack of remorse or guilt; callousness and lack of empathy; lack of concern about performance; and shallow or deficient affect.
A profusion of research has investigated the neurobiology of CU traits. Much of this research has focused on the potential role of hypoactivity of the limbic system, particularly the fear-mediating structures contained within the amygdala. Conduct-disordered individuals with CU traits show less heart-rate variability in response to sadness-inducing film clips (J. Abnorm. Child Psychol. 2012;40:211-23), blunted levels of salivary cortisol in response to experimentally induced stress (Psychiatry Res. 2011;187:204-9), and reduced reactivity of the amygdala to fearful faces as measured by functional MRI imaging (Am. J. Psychiatry 2009;166:95-102).
Findings that implicate a limbic basis for callous-unemotional traits and/or psychopathy are accruing, but they are by no means definitive. As of yet, there is no clear biological basis of either psychopathic traits or antisocial behavior. In fact, trends in research suggest that antisocial behavior might result from a heterogenous set of factors, both environmental and biological. Despite this, the latest findings are highly suggestive of a biological substrate for a lifelong personality set and pattern of maladaptive behavior. This is perhaps more true of ASPD than of any of the other personality disorders.
The proposal by Dr. Frick and Dr. Moffitt for the CU specifier is currently published on the dsm5.org website; it is an elegantly written and cogent argument that makes many persuasive points about the advantages of including this specifier for conduct disorder. Now, the work group is faced with the task of deciding whether including the specifier will help or hinder clinicians in reaching an accurate assessment of their conduct-disordered patients. Such an addition would appear to clarify, rather than obscure, the root causes, and key intrapsychic and developmental aspects of antisocial behavior. In light of this, I hope the proposal is adopted.
Dr. Brodsky is the medical director of Bridges to Recovery in Pacific Palisades, Calif., as well as the director of psychiatric services at the Venice (Calif.) Family Clinic. He is a member of the teaching faculty of the department of psychiatry at the University of California, Los Angeles. Dr. Brodsky can be reached at cpnews@elsevier.com.
By Dr. Michael Brodsky, Clinical Psychiatry News
February 24, 2012
After years of reduced visibility, the psychopathic personality has returned to prominence in both the popular imagination and in the domain of clinical psychiatry.
In 2010, British television personality Jon Ronson published "The Psychopath Test," a somewhat cynical inquiry into the use, and purported misuse, of the Hare Psychopathology Checklist-Revised (PCL-R) in forensic, medical, and corporate settings. In recent years, research into the neurobiology of psychopathic traits has been cited in prominent articles and editorials in the American Journal of Psychiatry (2011;168:569-71). And now, as the DSM-5 work groups revise their proposals for diagnostic criteria, the psychopathic personality is poised to appear in the diagnostic manual, albeit in modified form.
Traditionally, the term "psychopathy" has referred to a cluster of affective and interpersonal features that predispose individuals to antisocial behavior. The classic psychopath is notable for an absence of remorse, a reduced ability to experience guilt, and a limited degree of emotionality. With little capacity for empathy, the classic psychopath is unencumbered by concerns about the dignity and humanity of others, and is therefore relatively free to exploit them at will.
Psychopathy?s definition is distinguished from that of antisocial personality disorder (ASPD) by its emphasis on intrapsychic and interpersonal elements of personality style, rather than on the observable behaviors stipulated by most of the ASPD diagnostic criteria.
The construct and clinical utility of the concept of psychopathy is somewhat controversial, and has been the subject of extensive and thoughtful critiques (Psychol. Sci. Public Interest 2011;12:93-4). Nevertheless, evidence suggests that antisocial personality in the presence of psychopathy is associated with a more severe and intractable course of misconduct than in the absence of psychopathy. Antisocial individuals with psychopathic features manifest more severe criminal behavior (J. Abnorm. Psychol. 2006;115:798-806), more convictions for criminal violence (Compr. Psychiatry 2010;51:426-33), and greater involvement in illegal drug activity (Am. J. Psychiatry 1999;156:849-56) than do those without psychopathic features.
Psychopathy carries a highly pejorative connotation, and the labeling of individuals with this term has direct and measurable adverse consequences within the legal system. For example, researchers at Sam Houston State University in Huntsville, Tex., showed that potential jurors believe that juveniles who are explicitly labeled as psychopaths deserved longer prison sentences than did unlabeled juveniles who met criteria for psychopathy (Behav. Sci. Law 2008;26:487-510).
Over the years, several terms have been proposed as less pejorative stand-ins for the word itself. In the 1960s, "sociopathy" was offered more or less as a symptom for psychopathy, with an etymological emphasis on the purported societal roots of the disorder. Later, the DSM-III used the specifier "undersocialized" to describe a subtype of conduct disorder characterized by "a lack of concern for the feelings, well-being, and wishes of others" (Washington, D.C.: American Psychiatric Association, 1980, p. 45). Although free of negative connotations, the term "undersocialized" lent the erroneous impression that the disorder stemmed from a lack of social stimulation.
More recently, clinicians and researchers have promulgated the term "callous-unemotional (CU) traits" in lieu of the psychopathy label. The callous-unemotional terminology has been well received by clinicians and researchers alike, and now appears regularly in the psychiatric research literature. The DSM-5 Work Group on ADHD and Disruptive Behavior Disorders is currently considering inclusion of CU traits in its definition of conduct disorders. Two members of the work group, Paul J. Frick, Ph.D., and Terrie Moffitt, Ph.D., have proposed that the DSM-5 include a specifier for a callous-unemotional subtype of conduct disorder, characterized by lack of remorse or guilt; callousness and lack of empathy; lack of concern about performance; and shallow or deficient affect.
A profusion of research has investigated the neurobiology of CU traits. Much of this research has focused on the potential role of hypoactivity of the limbic system, particularly the fear-mediating structures contained within the amygdala. Conduct-disordered individuals with CU traits show less heart-rate variability in response to sadness-inducing film clips (J. Abnorm. Child Psychol. 2012;40:211-23), blunted levels of salivary cortisol in response to experimentally induced stress (Psychiatry Res. 2011;187:204-9), and reduced reactivity of the amygdala to fearful faces as measured by functional MRI imaging (Am. J. Psychiatry 2009;166:95-102).
Findings that implicate a limbic basis for callous-unemotional traits and/or psychopathy are accruing, but they are by no means definitive. As of yet, there is no clear biological basis of either psychopathic traits or antisocial behavior. In fact, trends in research suggest that antisocial behavior might result from a heterogenous set of factors, both environmental and biological. Despite this, the latest findings are highly suggestive of a biological substrate for a lifelong personality set and pattern of maladaptive behavior. This is perhaps more true of ASPD than of any of the other personality disorders.
The proposal by Dr. Frick and Dr. Moffitt for the CU specifier is currently published on the dsm5.org website; it is an elegantly written and cogent argument that makes many persuasive points about the advantages of including this specifier for conduct disorder. Now, the work group is faced with the task of deciding whether including the specifier will help or hinder clinicians in reaching an accurate assessment of their conduct-disordered patients. Such an addition would appear to clarify, rather than obscure, the root causes, and key intrapsychic and developmental aspects of antisocial behavior. In light of this, I hope the proposal is adopted.
Dr. Brodsky is the medical director of Bridges to Recovery in Pacific Palisades, Calif., as well as the director of psychiatric services at the Venice (Calif.) Family Clinic. He is a member of the teaching faculty of the department of psychiatry at the University of California, Los Angeles. Dr. Brodsky can be reached at cpnews@elsevier.com.
