Psychopathy

Concepts

There are multiple conceptualizations of psychopathy,^[4] including Cleckleyan psychopathy (Hervey Cleckley's conception entailing bold, disinhibited behavior, and "feckless disregard") and criminal psychopathy (a meaner, more aggressive and disinhibited conception explicitly entailing persistent and sometimes serious criminal behavior). The latter conceptualization is typically used as the modern clinical concept and assessed by the Psychopathy Checklist.^[4] The label "psychopath" may have implications and stigma related to decisions about punishment severity for criminal acts, medical treatment, civil commitments, etc. Efforts have therefore been made to clarify the meaning of the term.^[4]

The triarchic model^[1] suggests that different conceptions of psychopathy emphasize three observable characteristics to various degrees. Analyses have been made with respect to the applicability of measurement tools such as the Psychopathy Checklist (PCL, PCL-R) and Psychopathic Personality Inventory (PPI) to this model.^[1][4]

• Boldness. Low fear including stress-tolerance, toleration of unfamiliarity and danger, and high self-confidence and social assertiveness. The PCL-R measures this relatively poorly and mainly through Facet 1 of Factor 1. Similar to PPI fearless dominance. May correspond to differences in the amygdala and other neurological systems associated with fear.^[1][4]
• Disinhibition. Poor impulse control including problems with planning and foresight, lacking affect and urge control, demand for immediate gratification, and poor behavioral restraints. Similar to PCL-R Factor 2 and PPI impulsive antisociality. May correspond to impairments in frontal lobe systems that are involved in such control.^[1][4]
• Meanness. Lacking empathy and close attachments with others, disdain of close attachments, use of cruelty to gain empowerment, exploitative tendencies, defiance of authority, and destructive excitement seeking. The PCL-R in general is related to this but in particular some elements in Factor 1. Similar to PPI, but also includes elements of subscales in impulsive antisociality.^[1][4]

Measurement

An early and influential analysis from Harris and colleagues indicated that a discrete category, or taxon, may underlie PCL-R psychopathy, allowing it to be measured and analyzed. However, this was only found for the behavioral Factor 2 items they identified, child problem behaviors; adult criminal behavior did not support the existence of a taxon.^[14] Marcus, John, and Edens more recently performed a series of statistical analyses on PPI scores and concluded that psychopathy may best be conceptualized as having a "dimensional latent structure" like depression.^[15]

Marcus et al. repeated the study on a larger sample of prisoners, using the PCL-R and seeking to rule out other experimental or statistical issues that may have produced the previously different findings.^[16] They again found that the psychopathy measurements do not appear to be identifying a discrete type (a taxon). They suggest that while for legal or other practical purposes an arbitrary cut-off point on trait scores might be used, there is actually no clear scientific evidence for an objective point of difference by which to label some people "psychopaths"; in other words, a "psychopath" may be more accurately described as someone who is "relatively psychopathic".^[4]

The PCL-R was developed for research, not clinical forensic diagnosis, and even for research purposes to improve understanding of the underlying issues, it is necessary to examine dimensions of personality in general rather than only a constellation of traits.^[4][17]

Personality dimensions

Studies have linked psychopathy to alternative dimensions such as antagonism (high), conscientiousness (low) and anxiousness (low).^[18]

Psychopathy has also been linked to high psychoticism—a theorized dimension referring to tough, aggressive or hostile tendencies. Aspects of this that appear associated with psychopathy are lack of socialization and responsibility, impulsivity, sensation-seeking (in some cases), and aggression.^[19][20][21]

Otto Kernberg, from a particular psychoanalytic perspective, believed psychopathy should be considered as part of a spectrum of pathological narcissism, that would range from narcissistic personality on the low end, malignant narcissism in the middle, and psychopathy at the high end.^[21]

Psychopathy, narcissism and Machiavellianism, three personality traits that are together referred to as the dark triad, share certain characteristics, such as a callous-manipulative interpersonal style.^[22] The dark tetrad refers to these traits with the addition of sadism.^{[23][24][25][26][27][28]}

Criticism of current conceptions

The current conceptions of psychopathy have been criticized for being poorly conceptualized, highly subjective, and encompassing a wide variety of underlying disorders. Dorothy Otnow Lewis has written:

The concept and subsequent reification of the diagnosis "psychopathy" has, to this author’s mind, hampered the understanding of criminality and violence. [...] According to Hare, in many cases one need not even meet the patient. Just rummage through his records to determine what items seemed to fit. Nonsense. To this writer's mind, psychopathy and its synonyms (e.g., sociopathy and antisocial personality) are lazy diagnoses. Over the years the authors' team has seen scores of offenders who, prior to evaluation by the authors, were dismissed as psychopaths or the like. Detailed, comprehensive psychiatric, neurological, and neuropsychological evaluations have uncovered a multitude of signs, symptoms, and behaviors indicative of such disorders as bipolar mood disorder, schizophrenia spectrum disorders, complex partial seizures, dissociative identity disorder, parasomnia, and, of course, brain damage/dysfunction.^[29]

Half of the Hare Psychopathy Checklist consists of symptoms of mania, hypomania, and frontal-lobe dysfunction, which frequently results in underlying disorders being dismissed.^[30] Hare's conception of psychopathy has also been criticized for being reductionist, dismissive, tautological, and ignorant of context as well as the dynamic nature of human behavior.^[31] Some have called for rejection of the concept altogether, due to its vague, subjective and judgmental nature that makes it prone to misuse.^[32]

Psychopathic individuals do not show regret and remorse. This was thought to be due to an inability to generate this emotion in response to negative outcomes. However, in 2016, people with antisocial personality disorder and dissocial personality disorder were found to experience regret, but did not use the regret to guide their choice in behavior. There was no lack of regret but a problem to think through a range of potential actions and estimating the outcome values.^[33]

In an experiment published in March 2007 at the University of Southern California neuroscientist Antonio R. Damasio and his colleagues showed that subjects with damage to the ventromedial prefrontal cortex lack the ability to empathically feel their way to moral answers, and that when confronted with moral dilemmas, these brain-damaged patients coldly came up with "end-justifies-the-means" answers, leading Damasio to conclude that the point was not that they reached immoral conclusions, but that when they were confronted by a difficult issue – in this case as whether to shoot down a passenger plane hijacked by terrorists before it hits a major city – these patients appear to reach decisions without the anguish that afflicts those with normally functioning brains. According to Adrian Raine, a clinical neuroscientist also at the University of Southern California, one of this study's implications is that society may have to rethink how it judges immoral people: "Psychopaths often feel no empathy or remorse. Without that awareness, people relying exclusively on reasoning seem to find it harder to sort their way through moral thickets. Does that mean they should be held to different standards of accountability?"

Offending

Criminality

Psychopathy is strongly correlated with crime, violence, and antisocial behavior.

In terms of simple correlations, the PCL-R manual states an average score of 22.1 has been found in North American prisoner samples, and that 20.5% scored 30 or higher. An analysis of prisoner samples from outside North America found a somewhat lower average value of 17.5. Studies have found that psychopathy scores correlated with repeated imprisonment, detention in higher security, disciplinary infractions, and substance misuse.^[35][36]

Psychopathy, as measured with the PCL-R in institutional settings, shows in meta-analyses small to moderate effect sizes with institutional misbehavior, postrelease crime, or postrelease violent crime with similar effects for the three outcomes. Individual studies give similar results for adult offenders, forensic psychiatric samples, community samples, and youth. The PCL-R is poorer at predicting sexual re-offending. This small to moderate effect appears to be due largely to the scale items that assess impulsive behaviors and past criminal history, which are well-established but very general risk factors. The aspects of core personality often held to be distinctively psychopathic generally show little or no predictive link to crime by themselves. For example, Factor 1 of the PCL-R and Fearless dominance of the PPI-R have smaller or no relationship to crime, including violent crime. In contrast, Factor 2 and Impulsive antisociality of the PPI-R are associated more strongly with criminality. Factor 2 has a relationship of similar strength to that of the PCL-R as a whole. The antisocial facet of the PCL-R is still predictive of future violence after controlling for past criminal behavior which, together with results regarding the PPI-R which by design does not include past criminal behavior, suggests that impulsive behaviors is an independent risk factor. Thus, the concept of psychopathy may perform poorly when attempted to be used as a general theory of crime.^[4][37]

Childhood and adolescent precursors

The PCL:YV is an adaptation of the PCL-R for individuals aged 13–18 years. It is, like the PCL-R, done by a trained rater based on an interview and an examination of criminal and other records. The "Antisocial Process Screening Device" (APSD) is also an adaptation of the PCL-R. It can be administered by parents or teachers for individuals aged 6–13 years. High psychopathy scores for both juveniles, as measured with these instruments, and adults, as measured with the PCL-R and other measurement tools, have similar associations with other variables, including similar ability in predicting violence and criminality.^[4][60][61] Juvenile psychopathy may also be associated with more negative emotionality such as anger, hostility, anxiety, and depression.^[4][62] Psychopathic traits in youth typically comprise three factors: callous/unemotional, narcissism, and impulsivity/irresponsibility.^[63][64]

There is positive correlation between early negative life events of the ages 0–4 and the emotion-based aspects of psychopathy.^[65] There are moderate to high correlations between psychopathy rankings from late childhood to early adolescence. The correlations are considerably lower from early- or mid-adolescence to adulthood. In one study most of the similarities were on the Impulsive- and Antisocial-Behavior scales. Of those adolescents who scored in the top 5% highest psychopathy scores at age 13, less than one third (29%) were classified as psychopathic at age 24. Some recent studies have also found poorer ability at predicting long-term, adult offending.^[4][66]

Mental traits

Genetic

Genetically informed studies of the personality characteristics typical of individuals with psychopathy have found moderate genetic (as well as non-genetic) influences. On the PPI, fearless dominance and impulsive antisociality were similarly influenced by genetic factors and uncorrelated with each other. Genetic factors may generally influence the development of psychopathy while environmental factors affect the specific expression of the traits that predominate. A study on a large group of children found more than 60% heritability for "callous-unemotional traits" and that conduct problems among children with these traits had a higher heritability than among children without these traits.^[4][73][90]

Environment

From accidents such as the one of Phineas Gage, it is known that the prefrontal cortex plays an important role in moral behavior.

A study by Farrington of a sample of London males followed between age 8 and 48 included studying which factors scored 10 or more on the PCL:SV at age 48. The strongest factors included having a convicted parent, being physically neglected, low involvement of the father with the boy, low family income, and coming from a disrupted family. Other significant factors included poor supervision, harsh discipline, large family size, delinquent sibling, young mother, depressed mother, low social class, and poor housing.^[91] There has also been association between psychopathy and detrimental treatment by peers.^[92] However, it is difficult to determine the extent of an environmental influence on the development of psychopathy because of evidence of its strong heritability.^[93]

Other theories

Psychological

Some laboratory research demonstrates correlations between psychopathy and atypical responses to aversive stimuli, including weak conditioning to painful stimuli and poor learning of avoiding responses that cause punishment, as well as low reactivity in the autonomic nervous system as measured with skin conductance while waiting for a painful stimulus but not when the stimulus occurs. While it has been argued that the reward system functions normally, some studies have also found reduced reactivity to pleasurable stimuli. According to the response modulation hypothesis, psychopathic individuals have also had difficulty switching from an ongoing action despite environmental cues signaling a need to do so.^[98] This may explain the difficulty responding to punishment, although it is unclear if it can explain findings such as deficient conditioning. There may be methodological issues regarding the research.^[4] While establishing a range of idiosyncrasies on average in linguistic and affective processing under certain conditions, this research program has not confirmed a common pathology of psychopathy.^[99]

Neurological

Dysfunction of the orbitofrontal cortex, among other areas, is implicated in the mechanism of psychopathy.

Thanks to advancing MRI studies, experts are able to visualize specific brain differences and abnormalities of individuals with psychopathy in areas that control emotions, social interactions, ethics, morality, regret, impulsivity and conscience within the brain. Blair, a researcher who pioneered research into psychopathic tendencies stated, “With regard to psychopathy, we have clear indications regarding why the pathology gives rise to the emotional and behavioral disturbance and important insights into the neural systems implicated in this pathology”.^[81] Dadds et al., remarks that despite a rapidly advancing neuroscience of empathy, little is known about the developmental underpinnings of the psychopathic disconnect between affective and cognitive empathy.^[100]

A 2008 review by Weber et al. suggested that psychopathy is sometimes associated with brain abnormalities in prefrontal-temporo-limbic regions that are involved in emotional and learning processes, among others.^[101] Neuroimaging studies have found structural and functional differences between those scoring high and low on the PCL-R in a 2011 review by Skeem et al. stating that they are "most notably in the amygdala, hippocampus and parahippocampal gyri, anterior and posterior cingulate cortex, striatum, insula, and frontal and temporal cortex".^[4] A 2010 meta-analysis found that antisocial, violent and psychopathic individuals had reduced structure function in the right orbitofrontal cortex, right anterior cingulate cortex and left dorsolateral prefrontal cortex.^[102]

The amygdala and frontal areas have been suggested as particularly important.^[71] People scoring 25 or higher in the PCL-R, with an associated history of violent behavior, appear on average to have significantly reduced microstructural integrity between the white matter connecting the amygdala and orbitofrontal cortex (such as the uncinate fasciculus). The evidence suggested that the degree of abnormality was significantly related to the degree of psychopathy and may explain the offending behaviors.^[72] Furthermore, changes in the amygdala have been associated with "callous-unemotional" traits in children. However, the amygdala has also been associated with positive emotions, and there have been inconsistent results in the studies in particular areas, which may be due to methodological issues.^[4]

Some of these findings are consistent with other research and theories. For example, in a neuroimaging study of how individuals with psychopathy respond to emotional words, widespread differences in activation patterns have been shown across the temporal lobe when psychopathic criminals were compared to "normal" volunteers, which is consistent with views in clinical psychology. Additionally, the notion of psychopathy being characterized by low fear is consistent with findings of abnormalities in the amygdala, since deficits in aversive conditioning and instrumental learning are thought to result from amygdala dysfunction, potentially compounded by orbitofrontal cortex dysfunction, although the specific reasons are unknown.^[81][103]

Considerable research has documented the presence of the two subtypes of primary and secondary psychopathy.^[104][105] Proponents of the primary-secondary psychopathy distinction and triarchic model argue that there are neurological differences between these subgroups of psychopathy which support their views.^[106] For instance, the boldness factor in the triarchic model is argued to be associated with reduced activity in the amygdala during fearful or aversive stimuli and reduced startle response, while the disinhibition factor is argued to be associated with impairment of frontal lobe tasks. There is evidence that boldness and disinhibition are genetically distinguishable.^[4]

Biochemical

High levels of testosterone combined with low levels of cortisol and/or serotonin have been theorized as contributing factors. Testosterone is "associated with approach-related behavior, reward sensitivity, and fear reduction", and injecting testosterone "shift[s] the balance from punishment to reward sensitivity", decreases fearfulness, and increases "responding to angry faces". Some studies have found that high testosterone levels are associated with antisocial and aggressive behaviors, yet other research suggests that testosterone alone does not cause aggression but increases dominance-seeking. It is unclear from studies if psychopathy correlates with high testosterone levels, but a few studies have found that disruption of serotonin neurotransmission disrupts cortisol reactivity to a stress-inducing speech task. Thus, dysregulation of serotonin in the brain may contribute to the low cortisol levels observed in psychopathy. Cortisol increases withdrawal behavior and sensitivity to punishment and aversive conditioning, which are abnormally low in individuals with psychopathy and may underlie their impaired aversion learning and disinhibited behavior. High testosterone levels combined with low serotonin levels are associated with "impulsive and highly negative reactions", and may increase violent aggression when an individual is provoked or becomes frustrated.^[107] Several animal studies note the role of serotonergic functioning in impulsive aggression and antisocial behavior.^{[108][109][110][111]}

However, some studies on animal and human subjects have suggested that the emotional-interpersonal traits and predatory aggression of psychopathy, in contrast to impulsive and reactive aggression, is related to increased serotoninergic functioning.^{[112][113][114][115]} A study by Dolan and Anderson, regarding the relationship between serotonin and psychopathic traits in a sample of personality disordered offenders, found that serotonin functioning as measured by prolactin response, while inversely associated with impulsive and antisocial traits, were positively correlated with arrogant and deceitful traits, and, to a lesser extent, callous and remorseless traits.^[116] Bariş Yildirim theorizes that the 5-HTTLPR "long" allele, which is generally regarded as protective against internalizing disorders, may interact with other serotoninergic genes to create a hyper-regulation and dampening of affective processes that results in psychopathy's emotional impairments.^[117] Furthermore, the combination of the 5-HTTLPR long allele and high testosterone levels has been found to result in a reduced response to threat as measured by cortisol reactivity, which mirrors the fear deficits found in those afflicted with psychopathy.^[118]

Studies have suggested other correlations. Psychopathy was associated in two studies with an increased ratio of HVA (a dopamine metabolite) to 5-HIAA (a serotonin metabolite).^[107] Studies have found that individuals with the traits meeting criteria for psychopathy show a greater dopamine response to potential "rewards" such as monetary promises or taking drugs such as amphetamines. This has been theoretically linked to increased impulsivity.^[119] A 2010 British study found that a large 2D:4D digit ratio, an indication of high prenatal estrogen exposure, was a "positive correlate of psychopathy in females, and a positive correlate of callous affect (psychopathy sub-scale) in males".^[120]

Findings have also shown monoamine oxidase A to affect the predictive ability of the PCL-R.^[121] Monoamine oxidases (MAOs) are enzymes that are involved in the breakdown of neurotransmitters such as serotonin and dopamine and are, therefore, capable of influencing feelings, mood, and behavior in individuals.^[122] Findings suggest that further research is needed in this area.^[123][124]

Tools

Comorbidity

Studies suggest strong comorbidity between psychopathy and antisocial personality disorder. Among numerous studies, positive correlations have also been reported between psychopathy and histrionic, narcissistic, borderline, paranoid, and schizoid personality disorders, panic and obsessive–compulsive disorders, but not neurotic disorders in general, schizophrenia, or depression.^{[36][136][137][138][139]}

Attention deficit hyperactivity disorder (ADHD) is known to be highly comorbid with conduct disorder (a theorized precursor to ASPD), and may also co-occur with psychopathic tendencies. This may be explained in part by deficits in executive function.^[136] Anxiety disorders often co-occur with ASPD, and contrary to assumptions, psychopathy can sometimes be marked by anxiety; this appears to be related to items from Factor 2 but not Factor 1 of the PCL-R. Psychopathy is also associated with substance use disorders.^{[38][136][138][140][141]}

It has been suggested that psychopathy may be comorbid with several other conditions than these,^[141] but limited work on comorbidity has been carried out. This may be partly due to difficulties in using inpatient groups from certain institutions to assess comorbidity, owing to the likelihood of some bias in sample selection.^[136]

Sex differences

Research on psychopathy has largely been done on men and the PCL-R was developed using mainly male criminal samples, raising the question of how well the results apply to women. Men score higher than women on both the PCL-R and the PPI and on both of their main scales. The differences tend to be somewhat larger on the interpersonal-affective scale than on the antisocial scale. Most but not all studies have found broadly similar factor structure for men and women.^[4]

Many associations with other personality traits are similar, although in one study the antisocial factor was more strongly related with impulsivity in men and more strongly related with openness to experience in women. It has been suggested that psychopathy in men manifest more as an antisocial pattern while in women it manifests more as a histrionic pattern. Studies on this have shown mixed results. PCL-R scores may be somewhat less predictive of violence and recidivism in women. On the other hand, psychopathy may have a stronger relationship with suicide and possibly internalizing symptoms in women. A suggestion is that psychopathy manifests more as externalizing behaviors in men and more as internalizing behaviors in women.^[4] Furthermore, one study has suggested substantial gender differences were found in the etiology of psychopathy. For girls, 75% of the variance in severe callous and unemotional traits was attributable to environmental factors and just 0% of the variance was attributable to genetic factors. In boys, the link was reversed.^[142]

Studies have also found that women in prison score significantly lower on psychopathy than men, with one study reporting only 11 percent of violent females in prison met the psychopathy criteria in comparison to 31 percent of violent males.^[143] Other studies have also indicated that high psychopathic females are rare in forensic settings.^[144]

Clinical

Psychopathy has often been considered untreatable. Its unique characteristics makes it among the most refractory of personality disorders, a class of mental illnesses that are already traditionally considered difficult to treat.^[145][146] People afflicted with psychopathy are generally unmotivated to seek treatment for their condition, and can be uncooperative in therapy.^[127][145] Attempts to treat psychopathy with the current tools available to psychiatry have been disappointing. Harris and Rice's Handbook of Psychopathy says that there is currently little evidence for a cure or effective treatment for psychopathy; as yet, no pharmacological therapies are known to or have been trialed for alleviating the emotional, interpersonal and moral deficits of psychopathy, and patients with psychopathy who undergo psychotherapy might gain the skills to become more adept at the manipulation and deception of others and be more likely to commit crime.^[147] Some studies suggest that punishment and behavior modification techniques are ineffective at modifying the behavior of psychopathic individuals as they are insensitive to punishment or threat.^[147][148] These failures have led to a widely pessimistic view on its treatment prospects, a view that is exacerbated by the little research being done into psychopathy compared to the efforts committed to other mental illnesses, which makes it more difficult to gain the understanding of this condition that is necessary to develop effective therapies.^[149][150]

Although the core character deficits of highly psychopathic individuals are likely to be highly incorrigible to the currently available treatment methods, the antisocial and criminal behavior associated with it may be more amenable to management, the management of which being the main aim of therapy programs in correctional settings.^[145] It has been suggested that the treatments that may be most likely to be effective at reducing overt antisocial and criminal behavior are those that focus on self-interest, emphasizing the tangible, material value of prosocial behavior, with interventions that develop skills to obtain what the patient wants out of life in prosocial rather than antisocial ways.^[151][152] To this end, various therapies have been tried with the aim of reducing the criminal activity of incarcerated offenders with psychopathy, with mixed success.^[145] As psychopathic individuals are insensitive to sanction, reward-based management, in which small privileges are granted in exchange for good behavior, has been suggested and used to manage their behavior in institutional settings.^[153]

Psychiatric medications may also alleviate co-occurring conditions sometimes associated with psychopathy or with symptoms such as aggression or impulsivity, including antipsychotic, antidepressant or mood-stabilizing medications, although none have yet been approved by the FDA for this purpose.^{[4][7][10][154][155]} For example, a study found that the antipsychotic clozapine may be effective in reducing various behavioral dysfunctions in a sample of high-security hospital inpatients with antisocial personality disorder and psychopathic traits.^[156] However, research into the pharmacological treatment of psychopathy and the related condition antisocial personality disorder is minimal, with much of the knowledge in this area being extrapolations based on what is known about pharmacology in other mental disorders.^[145][157]

Legal

The PCL-R, the PCL:SV, and the PCL:YV are highly regarded and widely used in criminal justice settings, particularly in North America. They may be used for risk assessment and for assessing treatment potential and be used as part of the decisions regarding bail, sentence, which prison to use, parole, and regarding whether a youth should be tried as a juvenile or as an adult. There have been several criticisms against its use in legal settings. They include the general criticisms against the PCL-R, the availability of other risk assessment tools which may have advantages, and the excessive pessimism surrounding the prognosis and treatment possibilities of those who are diagnosed with psychopathy.^[4]

The interrater reliability of the PCL-R can be high when used carefully in research but tend to be poor in applied settings. In particular Factor 1 items are somewhat subjective. In sexually violent predator cases the PCL-R scores given by prosecution experts were consistently higher than those given by defense experts in one study. The scoring may also be influenced by other differences between raters. In one study it was estimated that of the PCL-R variance, about 45% was due to true offender differences, 20% was due to which side the rater testified for, and 30% was due to other rater differences.^[4]

To aid a criminal investigation, certain interrogation approaches may be used to exploit and leverage the personality traits of suspects thought to have psychopathy and make them more likely to divulge information.^[158]

In the workplace

There is limited research on psychopathy in the general work populace, in part because the PCL-R includes antisocial behavior as a significant core factor (obtaining a PCL-R score above the threshold is unlikely without having significant scores on the antisocial-lifestyle factor) and does not include positive adjustment characteristics, and most researchers have studied psychopathy in incarcerated criminals, a relatively accessible population of research subjects.^[172]

However, psychologists Fritzon and Board, in their study comparing the incidence of personality disorders in business executives against criminals detained in a mental hospital, found that the profiles of some senior business managers contained significant elements of personality disorders, including those referred to as the "emotional components", or interpersonal-affective traits, of psychopathy. Factors such as boldness, disinhibition, and meanness as defined in the triarchic model, in combination with other advantages such as a favorable upbringing and high intelligence, are thought to correlate with stress immunity and stability, and may contribute to this particular expression.^[172] Such individuals are sometimes referred to as "successful psychopaths" or "corporate psychopaths" and they may not always have extensive histories of traditional criminal or antisocial behavior characteristic of the traditional conceptualization of psychopathy.^[59] Robert Hare claims that the prevalence of psychopathic traits is higher in the business world than in the general population, reporting that while about 1% of the general population meet the clinical criteria for psychopathy, figures of around 3–4% have been cited for more senior positions in business.^{[4][173][174]} Hare considers newspaper tycoon Robert Maxwell to have been a strong candidate as a "corporate psychopath".^[175]

Academics on this subject believe that although psychopathy is manifested in only a small percentage of workplace staff, it is more common at higher levels of corporate organizations, and its negative effects (for example, increased bullying, conflict, stress, staff turnover, absenteeism, reduction in productivity) often causes a ripple effect throughout an organization, setting the tone for an entire corporate culture. Employees with the disorder are self-serving opportunists, and may disadvantage their own organizations to further their own interests.^[176] They may be charming to staff above their level in the workplace hierarchy, aiding their ascent through the organization, but abusive to staff below their level, and can do enormous damage when they are positioned in senior management roles.^[177][178] Psychopathy as measured by the PCL-R is associated with lower performance appraisals among corporate professionals.^[179] The psychologist Oliver James identifies psychopathy as one of the dark triadic traits in the workplace, the others being narcissism and Machiavellianism, which, like psychopathy, can have negative consequences.^[180]

According to a study from the University of Notre Dame published in the Journal of Business Ethics, psychopaths have a natural advantage in workplaces overrun by abusive supervision, and are more likely to thrive under abusive bosses, being more resistant to stress, including interpersonal abuse, and having less of a need for positive relationships than others.^{[181][182][183]}

In fiction

Characters with psychopathy or sociopathy are some of the most notorious characters in film and literature, but their characterizations may only vaguely or partly relate to the concept of psychopathy as it is defined in psychiatry, criminology, and research. The character may be identified as having psychopathy within the fictional work itself, by its creators, or from the opinions of audiences and critics, and may be based on undefined popular stereotypes of psychopathy.^[184] Characters with psychopathic traits have appeared in Greek and Roman mythology, Bible stories, and some of Shakespeare's works.^[185]

Such characters are often portrayed in an exaggerated fashion and typically in the role of a villain or antihero, where the general characteristics and stereotypes associated with psychopathy are useful to facilitate conflict and danger. Because the definitions, criteria, and popular conceptions throughout its history have varied over the years and continue to change even now, many of the characters characterized as psychopathic in notable works at the time of publication may no longer fit the current definition and conception of psychopathy. There are several archetypal images of psychopathy in both lay and professional accounts which only partly overlap and can involve contradictory traits: the charming con artist, the deranged serial killer and mass murderer, the callous and scheming businessperson, and the chronic low-level offender and juvenile delinquent. The public concept reflects some combination of fear of a mythical bogeyman, the disgust and intrigue surrounding evil, and fascination and sometimes perhaps envy of people who might appear to go through life without attachments and unencumbered by guilt, anguish or insecurity.^[4]

Etymology

The word psychopathy is a joining of the Greek words psyche (ψυχή) "soul" and pathos (πάθος) "suffering, feeling".^[186] The first documented use is from 1847 in Germany as psychopatisch,^[187] and the noun psychopath has been traced to 1885.^[188] In medicine, patho- has a more specific meaning of disease (thus pathology has meant the study of disease since 1610, and psychopathology has meant the study of mental disorder in general since 1847. A sense of "a subject of pathology, morbid, excessive" is attested from 1845,^[189] including the phrase pathological liar from 1891 in the medical literature).

The term psychopathy initially had a very general meaning referring to all sorts of mental disorders and social aberrations, popularised from 1891 in Germany by Koch's concept of "psychopathic inferiority" (psychopathische Minderwertigkeiten). Some medical dictionaries still define psychopathy in both a narrow and broad sense, such as MedlinePlus from the U.S. National Library of Medicine.^[190] On the other hand, Stedman's Medical Dictionary defines psychopathy only as an outdated term for an antisocial type of personality disorder.^[191]

The term psychosis was also used in Germany from 1841, originally in a very general sense. The suffix -ωσις (-osis) meant in this case "abnormal condition". This term or its adjective psychotic would come to refer to the more severe mental disturbances and then specifically to mental states or disorders characterized by hallucinations, delusions or in some other sense markedly out of touch with reality.^[192]

The slang term psycho has been traced to a shortening of the adjective psychopathic from 1936, and from 1942 as a shortening of the noun psychopath,^[193] but it is also used as shorthand for psychotic or crazed.^[194]

The media usually uses the term psychopath to designate any criminal whose offenses are particularly abhorrent and unnatural, but that is not its original or general psychiatric meaning.^[195]

Precursors

Ancient writings that have been connected to psychopathic traits include Deuteronomy 21:18–21, which was written around 700 BCE, and a description of an unscrupulous man by the Greek philosopher Theophrastus around 300 BCE.^[185]

The concept of psychopathy has been indirectly connected to the early 19th century with the work of Pinel (1801; "mania without delirium") and Pritchard (1835; "moral insanity"), although historians have largely discredited the idea of a direct equivalence.^[204] Psychopathy originally described any illness of the mind, but found its application to a narrow subset of mental conditions when was used toward the end of the 19th century by the German psychiatrist Julius Koch (1891) to describe various behavioral and moral dysfunction in the absence of an obvious mental illness or intellectual disability. He applied the term psychopathic inferiority (psychopathischen Minderwertigkeiten) to various chronic conditions and character disorders, and his work would influence the later conception of the personality disorder.^[4][205]

The term psychopathic came to be used to describe a diverse range of dysfunctional or antisocial behavior and mental and sexual deviances, including at the time homosexuality. It was often used to imply an underlying "constitutional" or genetic origin. Disparate early descriptions likely set the stage for modern controversies about the definition of psychopathy.^[4]

20th century

Psychoanalyst Walter C. Langer described Adolf Hitler as a "neurotic psychopath".

An influential figure in shaping modern American conceptualizations of psychopathy was American psychiatrist Hervey Cleckley. In his classic monograph, The Mask of Sanity (1941), Cleckley drew on a small series of vivid case studies of psychiatric patients at a Veterans Administration hospital in Georgia to provide a description for psychopathy. Cleckley used the metaphor of the "mask" to refer to the tendency of psychopaths to appear confident, personable, and well-adjusted compared to most psychiatric patients, while revealing underlying pathology through their actions over time. Cleckley formulated sixteen criteria for psychopathy.^[4] The Scottish psychiatrist David Henderson had also been influential in Europe from 1939 in narrowing the diagnosis.^[206]

The diagnostic category of sociopathic personality in early editions of the Diagnostic and Statistical Manual (DSM)^[207] had some key similarities to Cleckley's ideas, though in 1980 when renamed Antisocial Personality Disorder some of the underlying personality assumptions were removed.^[7] In 1980, Canadian psychologist Robert D. Hare introduced an alternative measure, the "Psychopathy Checklist" (PCL) based largely on Cleckley's criteria, which was revised in 1991 (PCL-R),^[169][208] and is the most widely used measure of psychopathy.^[209] There are also several self-report tests, with the Psychopathic Personality Inventory (PPI) used more often among these in contemporary adult research.^[4]

Famous individuals have sometimes been diagnosed, albeit at a distance, as psychopaths. As one example out of many possible from history, in a 1972 version of a secret report originally prepared for the Office of Strategic Services in 1943, and which may have been intended to be used as propaganda,^[210][211] non-medical psychoanalyst Walter C. Langer suggested Adolf Hitler was probably a psychopath.^[212] However, others have not drawn this conclusion; clinical forensic psychologist Glenn Walters argues that Hitler's actions do not warrant a diagnosis of psychopathy as, although he showed several characteristics of criminality, he was not always egocentric, callously disregarding of feelings or lacking impulse control, and there is no proof he could not learn from mistakes.^[213]