October 7, 2014
Psychopathy is characterized
by diagnostic features such as superficial charm, high intelligence, poor
judgment and failure to learn from experience, pathological egocentricity and
incapacity for love, lack of remorse or shame, impulsivity, grandiose sense of
self-worth, pathological lying, manipulative behavior, poor self-control,
promiscuous sexual behavior, juvenile delinquency, and criminal versatility,
among others.1,2 As a consequence of these criteria, the image of the
psychopath is that of a cold, heartless, inhuman being. But do all psychopaths
show a complete lack of normal emotional capacities and empathy?
Like healthy people, many
psychopaths love their parents, spouse, children, and pets in their own way,
but they have difficulty in loving and trusting the rest of the world.
Furthermore, psychopaths suffer emotionally as a consequence of separation,
divorce, death of a beloved person, or dissatisfaction with their own deviant
behavior.3
Sources of sadness
Psychopaths can suffer
emotional pain for a variety of reasons. As with anyone else, psychopaths have
a deep wish to be loved and cared for. This desire remains frequently
unfulfilled, however, because it is obviously not easy for another person to
get close to someone with such repellent personality characteristics.
Psychopaths are at least periodically aware of the effects of their behavior on
others and can be genuinely saddened by their inability to control it. The
lives of most psychopaths are devoid of a stable social network or warm, close
bonds.
The life histories of
psychopaths are often characterized by a chaotic family life, lack of parental
attention and guidance, parental substance abuse and antisocial behavior, poor
relationships, divorce, and adverse neighborhoods.4 These persons may feel
that they are prisoners of their own etiological determination and believe that
they had, in comparison with normal people, fewer opportunities or advantages
in life.
Despite their outward
arrogance, psychopaths feel inferior to others and know they are stigmatized by
their own behavior. Some psychopaths are superficially adapted to their
environment and are even popular, but they feel they must carefully hide their
true nature because it will not be acceptable to others. This leaves
psychopaths with a difficult choice: adapt and participate in an empty, unreal
life, or do not adapt and live a lonely life isolated from the social
community. They see the love and friendship others share and feel dejected
knowing they will never be part of it.
Psychopaths are known for
needing excessive stimulation, but most foolhardy adventures only end in
disillusionment because of conflicts with others and unrealistic expectations.
Furthermore, many psychopaths are disheartened by their inability to control
their sensation-seeking and are repeatedly confronted with their weaknesses.
Although they may attempt to change, low fear response and associated inability
to learn from experiences lead to repeated negative, frustrating, and
depressing confrontations, including trouble with the justice system.
As psychopaths age, they are
not able to continue their energy-consuming lifestyle and become burned-out and
depressed while they look back on their restless life full of interpersonal
discontentment. Their health deteriorates as the effects of their recklessness
accumulate.
Violent psychopaths
Ultimately they reach a point
of no return, where they feel they have cut through the last thin connection
with the normal world
Risk factors
Hidden suffering, loneliness,
and lack of self-esteem are risk factors for violent, criminal behavior in
psychopaths
Emotional pain and violence
Social isolation, loneliness,
and associated emotional pain in psychopaths may precede violent criminal acts.5 They
believe that the whole world is against them and eventually become convinced
that they deserve special privileges or rights to satisfy their desires. As
psychopathic serial killers Jeffrey Dahmer and Dennis Nilsen expressed, violent
psychopaths ultimately reach a point of no return, where they feel they have
cut through the last thin connection with the normal world. Subsequently, their
sadness and suffering increase, and their crimes become more and more bizarre.6
Dahmer and Nilsen have stated
that they killed simply for company.5 Both men had no friends and their
only social contacts were occasional encounters in homosexual bars. Nilsen
watched television and talked for hours with the dead bodies of his victims;
Dahmer consumed parts of his victims’ bodies in order to become one with them:
he believed that in this way his victims lived further in his body.6
For the rest of us, it is
unimaginable that these men were so lonely—yet they describe their loneliness
and social failures as unbearably painful. Each created his own sadistic
universe to avenge his experiences of rejection, abuse, humiliation, neglect,
and emotional suffering.
Dahmer and Nilsen claimed that
they did not enjoy the killing act itself. Dahmer tried to make zombies of his
victims by injecting acid into their brains after he had numbed them with
sleeping pills. He wanted complete control over his victims, but when that
failed, he killed them. Nilsen felt much more comfortable with dead bodies than
with living people—the dead could not leave him. He wrote poems and spoke
tender words to the dead bodies, using them as long as possible for company. In
other violent psychopaths, a relationship has been found between the intensity
of sadness and loneliness and the degree of violence, recklessness, and
impulsivity.5,6
Self-destruction
Violent psychopaths are at
high risk for targeting their aggression toward themselves as much as toward
others. A considerable number of psychopaths die a violent death a relatively
short time after discharge from forensic psychiatric treatment as a result of
their own behavior (for instance, as a consequence of risky driving or
involvement in dangerous situations).7 Psychopaths may feel that all life
is worthless, including their own.3,5,6
Treatment
In the past decade,
neurobiological explanations have become available for many of the traits of
psychopathy. For example, impulsivity, recklessness/irresponsibility,
hostility, and aggressiveness may be determined by abnormal levels of
neurochemicals, including monoamine oxidase (MAO), serotonin and
5-hydroxyindoleacetic acid, triiodothyronine, free thyroxine, testosterone,
cortisol, adrenocorticotropic hormone, and hormones of the
hypothalamic-pituitary-adrenal and hypothalamic-pituitary-gonadal axes.8
Other features, such as
sensation-seeking and an incapacity to learn from experiences, might be linked
to cortical underarousal.4 Sensation-seeking could also be related to low
levels of MAO and cortisol and high concentrations of gonadal hormones, as well
as reduced prefrontal gray matter volume.9 Many psychopaths can thus be
considered, at least to some degree, victims of neurobiologically determined
behavioral abnormalities that, in turn, create a fixed gulf between them and
the rest of the world.
It may be possible to diminish
traits such as sensation-seeking, impulsivity, aggression, and related
emotional pain with the help of psychotherapy, psychopharmacotherapy, and/or
neurofeedback. Long-term psychotherapy (at least 5 years) seems effective in
some categories of psychopaths, in so far as psychopathic personality traits
may diminish.10-12
Psychotherapy alone may be
insufficient to improve symptoms. Psychopharmacotherapy may help normalize
neurobiological functions and related behavior/personality traits.13 Lithium
is impressive in treating antisocial, aggressive, and assaultive behavior.14 Hollander15 found
that mood stabilizers, such as divalproex, SSRIs, MAOIs, and neuroleptics, have
documented efficacy in treating aggression and affective instability in
impulsive patients. There have been no controlled studies of
psychopharmacotherapy for other core features of psychopathy.
Cortical underarousal and low
autonomic activity-reactivity can be substantially reduced with the help of
adaptive neurofeedback techniques.16,17
CASE VIGNETTE
Norman was raised by his aunt;
his parents were divorced and neither was capable of or interested in caring
for him. As a child and adolescent, he had numerous encounters with law
enforcement for joyriding, theft, burglary, fraud, and assault and battery. He
was sent to reform school twice. When he was 21, he was convicted of armed
robbery and served 1½ years in jail. His only close friend was another violent
criminal; he had many short-term relationships with girlfriends. At 29, he
killed two strangers in a bar who had insulted him and was sentenced to
forensic psychiatric treatment. The diagnosis was psychopathy, according to
Hare’s psychopathy checklist.2
Norman showed little
improvement over the course of 7 years of behavioral psychotherapy and became
less and less motivated. The staff of the forensic psychiatric hospital
considered him untreatable and intended to stop all treatment attempts.
Norman’s lawyer arranged for an examination by a forensic neurologist, who
subsequently found that Norman suffered from severe cortical underarousal,
serotonin and MAO abnormalities, and concentration problems.
Treatment with D,L-fenfluramine,
a serotonin-releasing drug, was started. (Fenfluramine was voluntarily
withdrawn from the US market in 1997.) Acute challenge doses (0.2 mg/kg to 0.4
mg/kg) produced significant dose-dependent decreases in impulsive and
aggressive responses. After 1 month, an MAOI (pargyline, 10 mg/kg) and
psychodynamic psychotherapy were added. Pargyline produced some normalization
of his EEG pattern and was titrated to 20 mg/kg over 5 months. Neurofeedback
was started after 2 months and continued for 15 months. His EEG pattern
gradually normalized, and his capacity for concentration and attention
increased.
Norman continued to
receive D,L-fenfluramine and psychotherapy for 2 years, at which point he
was discharged from forensic treatment. He voluntarily continued psychotherapy
for an additional 3 years and, in the 4 years since his release, has not
reoffended.
Conclusions
It is extremely important to
recognize hidden suffering, loneliness, and lack of self-esteem as risk factors
for violent, criminal behavior in psychopaths. Studying the statements of
violent criminal psychopaths sheds light on their striking and specific
vulnerability and emotional pain. More experimental psychopharmacotherapy,
neurofeedback, and combined psychotherapy research is needed to prevent and
treat psychopathic behavior.
The current picture of the
psychopath is incomplete because emotional suffering and loneliness are ignored.
When these aspects are considered, our conception of the psychopath goes beyond
the heartless and becomes more human.
References:
1. Cleckley HM. Mask
of Sanity: An Attempt to Clarify Some Issues About the So-Called Psychopathic
Personality. 6th ed. St Louis: CV Mosby Co; 1982.
2. Hare RD, Harpur TJ,
Hakstian AR, et al. The revised psychopathy checklist: descriptive statistics,
reliability, and factor structure. Psychol Assess. 1990;2:338-341.
3. Martens W. Hidden
suffering of the psychopath: new insight on basis of self-reports of
psychopaths; 2013. https://www.smashwords.com/books/view/304901.
Accessed September 15, 2014.
4. Martens WHJ.
Antisocial and psychopathic personality disorders: causes, course and
remission: a review article. Int J Offender Ther Comp Criminol.
2000;44:406-430.
5. Martens WH, Palermo
GB. Loneliness and associated violent antisocial behavior: analysis of the case
reports of Jeffrey Dahmer and Dennis Nilsen. Int J Offender Ther Comp
Criminol. 2005;49:298-307.
6. Martens WH. Sadism
linked to loneliness: psychodynamic dimensions of the sadistic serial killer
Jeffrey Dahmer. Psychoanal Rev. 2011;98:493-514.
7. Black DW, Baumgard CH,
Bell SE, Kao C. Death rates in 71 men with antisocial personality disorder: a
comparison with general population mortality. Psychosomatics.
1996;37:131-136.
8. Martens WHJ. A new
multidimensional model of antisocial personality disorder. Am J Forensic
Psychiatry. 2005;25:59-73.
9. Raine A, Lencz T,
Bihrle S, et al. Reduced prefrontal gray matter volume and reduced autonomic
activity in antisocial personality disorder. Arch Gen Psychiatry.
2000;57:119-127.
10. Dolan B, Coid
J. Psychopathic and Antisocial Personality Disorders: Treatment and
Research Issues. London: Gaskell; 1993.
11. Dolan B. Therapeutic
community treatment for severe personality disorders. In: Millon T, Simonsen E,
Birket-Smith M, Davis RD, eds.Psychopathy: Antisocial, Criminal, and Violent
Behaviors. New York: Guilford Press; 1998:407-438.
12. Sanislow CA,
McGlashan TH. Treatment outcome of personality disorders. Can J Psychiatry.
1998;43:237-250.
13. Martens WH.
Criminality and moral dysfunctions: neurologic, biochemical and genetic
dimensions. Int J Offender Ther Comp Criminol. 2002; 46:170-182.
14. Bloom FE, Kupfer DJ,
eds. Psychopharmacology: The Fourth Generation of Progress. New York:
Raven Press; 1994.
15. Hollander E. Managing
aggressive behavior in patients with obsessive-compulsive disorder and
borderline personality disorder. J Clin Psychiatry. 1999;60(suppl
15):38-44.
16. Martens WH. Effects
of antisocial or social attitudes on neurobiological functions. Med
Hypotheses. 2001;56:664-671.
17. Raine A. Autonomic
nervous system factors underlying disinhibited, antisocial, and violent
behavior. Biosocial perspectives and treatment implications. Ann N Y Acad
Sci. 1996;794:46-59.
No comments:
Post a Comment