I was recently asked by a Year 12 student to answer her questions on Psychopathy and Serial Murder. I have posted this here primarily for my future reference, but also for those interested in the topic, especially given one keen reader asked for a part 2 as a follow up to my post "Who is the Antisocial?" (Link: https://juliantoh.wixsite.com/website/single-post/2017/03/31/Who-is-the-Antisocial). Thank you for inspiring me to write this, you know who you are Anita!

In the opening photo I have tried to symbolize Hervey Cleckley’s “Mask of Sanity” : a book of case studies he wrote in 1941 before the term ‘Psychopathy’ was constructed. A century before this, James Prichard coined the term ‘Moral Insanity’ to describe his cases that in retrospect, clearly evinced features of Psychopathy.

So, without further ado, the following is the QnA Kyra (the keen and curious student) and I engaged in:

What is your experience in the psychiatrist field, and how long have you been a psychiatrist for?

I have been a consultant psychiatrist since 2006, and work primarily in community mental health services. I am also a qualified psychotherapist, and my experience centres around the management of patients with severe psychosis syndromes and personality disorders, often with accompanying issues around suicide and violence/aggression risks. I work in a team that is multidisciplinary, with professions including mental health nurses, social workers, psychologists and occupational therapists. We also regularly liaise with the Police and our Forensic psychiatry colleagues as well as Child and other Protection agencies.

Do you think that serial killers and psychopaths are the same thing? If so why, and if not why?

Probably the best way to answer this is to say that not all Psychopaths are serial killers, but most serial killers will have psychopathic traits.

Psychopathy is a disorder that is characterised by a genetic predisposition to a lack of ‘emotional empathy’. They may have ‘cognitive empathy’ , which is a rational, more intellectual and detached understanding of peoples emotional and mental states. Ali G’s cousin Simon Baron-Cohen is a neuroscientist who has written a book called ‘Zero degrees of Empathy’ which explains the distinction between cognitive and emotional empathy very well. Uma Thurman's character in Kill Bill, The Bride, sums it up succintly: "It's mercy, compassion, and forgiveness I lack. Not rationality."

Psychopaths are unable to feel distress and do not learn from adverse consequences. This is because of the three ‘A’s (as described by psychopathy researcher J Reid Meloy) they possess in addition to lack of emotional empathy: Low Arousal and reduced capacity to feel distress, Avoidant attachment patterns and lack of Anxiety (they are immune to feelings of fear and disgust).

This is qualitatively different to Sociopathy: sociopaths on the surface look and feel like psychopaths however they retain a capacity to feel anxiety and distress. They also retain empathy and have preserved fear conditioning: they can learn from adverse consequences. They have suppressed these domains usually due to severe childhood trauma and abuse, and develop violent fantasies and an apparent detached emotional state in order to defend themselves against feelings of vulnerability, weakness and shame. Psychopathy per se is much more of a ‘genetic’ disorder, however these traits can be amplified further by childhood and developmental trauma.

Psychopaths can be found in the wider population: in fact some studies quote 1-2% of us have these traits. They can be very very successful in the business and corporate world, where a lack of empathy and skills in manipulating/dominating others are actually valued and taught. Of course, these ‘Snakes in Suits’ (a term coined by Paul Babiak) generally are not serial killers, although outside of the work domain they often leave a trail of destruction and chaos in their interpersonal relationships.

Now, to Serial Killers. In the criminology literature there are two general typologies of homicides: Catathymic and Compulsive. Serial killers tend to fall in the latter category, which is the typology that is far less influenced by environmental factors and far more ‘inherited’. This means that again, genetics play a major role in compulsive homicides, and if you look at the characteristics of the Compulsive serial killer you will recognise that a significant number of these are consistent with the construct of Psychopathy. This includes utility of symbolism and ritual in their crimes to pervade a sense of triumph and total domination and control over those they kill. Of course, other conditions such as Schizophrenia and even those in the Autistic spectrum can at times predispose someone to becoming a serial killer. Probably the underlying core of the personality is once again, a lack of or reduction in empathy.

A note on catathymia however. This is a concept first described by Frederic Wertham. He described the Catathymic process as consisting of five stages. First, a person develops ruminations and recurrent thoughts based on shame and humiliation. These then crystallise into a resolution plan, based on murder. However, emotional tension builds relentlessly as this murder fantasy is felt as 'ego dystonic'; in simple terms it does not fit with the persons' basic morals and values. Here again, we see a similarity more akin to the psychodynamics of sociopathy described previously. Some may then commit the actual murderous act, with subsequent resolution of the previously intense and pervasive emotional tension. In the ideal fifth stage, insight occurs and the person, feeling intense guilt and regret, realises the flawed and destructive nature of his thinking process and tries to resolve it. However, some may get 'stuck' between the second and fourth stages, and evolve (de-volve?) into a Serial Murderer.

A quick note on Evil: modern psychology opines that this morally laden and archaic term may perhaps be more neutrally understood and studied as a Tetrad: Narcissism, Psychopathy, Machiavallianism and Sadism. The renown psychoanalyst Otto Kernberg also independently described his own tetrad: Narcissism, psychopathy, ego syntonic aggression and paranoid personality traits. Certainly many of these features can be found in several combinations within Serial Killers.

Is it true to believe that genetics has a part to play in the making of a serial killer and psychopath?

There is increasing evidence to show this to be so. There are variations of certain Serotonin/Dopamine transporter and Monoamine Oxidase Inhibitor (the so called ‘Warrior Gene’) genes that can predispose a person to utilise violence more readily as a ‘solution’ to problems.

However, this comes with a caveat: Most of these studies have been carried out on those with Antisocial Personality Disorder (ASPD). While sharing some similarities, this is overall a different construct to psychopathy as it relies heavily on behavioural observations for diagnosis. Psychopathy per se additionally requires a description of internal motivations and traits for diagnosis.

You can look up Robert Hare’s Psychopathy Checklist for further details. Another useful resource to help you understand the differences can be found in J Reid Meloy’s writings on Impulsive versus Instrumental Aggression. The former is more prominent in those with ASPD; the latter in psychopathy.

Do you think serial killers/psychopaths can be treated? If so, why and how?

It depends on the underlying internal causes or motivating factors. In the relatively rare situation where the killings are driven by a schizophrenic psychosis or severe mood disorder, then specific psychotherapy and pharmacological treatments may very much help.

However, the evidence base is disappointing regarding the treatment of psychopathy. In fact, early studies have shown that psychotherapy can INCREASE the risk of recidivism as it actually teaches psychopaths how better to manipulate others.

There are some group interventions regarding empathy training, as well as strict, structured and graded behavioral reinforcement frameworks involving small positive rewards for valued behaviours that have a small evidence base. Patients with psychopathy will not respond to a punitive approach as they cannot feel fear. If a high sex drive (see below) is a factor, then reducing this with medications can also be considered to reduce risk.

Is it true to believe that environment has a part to play in the making of a serial killer? If so why, and if not why?

Yes, apart from genetics in particular the childhood and home environment still play a major role, up to 50% or more in the opinions of many experts. This runs the risk of a very long answer, however to keep it short if a child that is born with a predisposition to psychopathy is exposed to some of the risk factors I have described in response to another question below, he/she is left with unmet dependency needs, a lack of capacity to regulate or even describe emotions, and unprocessed persistent rage and anger at parental figures.

Persistent developmental trauma and in particular sexual abuse can lead to a core of shame and felt sense of lack of control. They may learn early that actively dissociating themselves from emotions can be a useful defence against the pain of unrelenting and often secret trauma. If violence is fused with sexual fantasies and experiences (usually abusive ones such as rape, torture etc), then this can give them a very powerful sense of positive reward and thus predispose them to future killings. In the absence of other coping strategies or positive life experiences, this can become a dangerous focus that can then fuel the malignant development of a murder blueprint. Fantasies can be further elaborated on, thus enabling a felt sense of triumph and control, as well as satisfying vengeful fantasies and the need to humiliate and shame others.

Many may engage in the bondage/sadomasochism (BDSM) subculture; however they may be rejected because in that culture, the requirements of Safety, Sanity and CONSENT are often repeatedly ignored and not adhered to. This necessary rejection can further enforce a sense of abandonment and anger, which may then perpetuate their first solo acts of violence against other living things. Of course all of this is but one of many potential pathways to serial murder.

It is very important to note that the vast majority of BDSM practitioners are in fact highly intelligent, affluent, have stable attachment styles and are employed within the higher echelons of society. Forensic Psychiatrist Dr Park Dietz has conducted many studies to support this observation with direct evidence.

Are there any other influences that play a part in the making of a serial killer/psychopath that you think people are yet to discover?

We do need to generally research more into the environmental and genetic factors, certainly. In terms of general propensities for violence there are many environmental risk factors that have a solid evidence base within the research literature. Low cholesterol (usually associated with physical health benefits!), aberrant levels of lead, cadmium and mercury and a raft of other dietary issues are examples of these 'other influences'. However to my knowledge there are no studies addressing the direct linkage of these to serial killing per se.

What do you believe are the main characteristics of a serial killer?

While the science of characterising serial killers remains far from complete, forensic psychologist Louis Schlesinger has compiled a list of ’10 ominous signs’ of a future serial, compulsive murderer. These are:

(1) childhood abuse;

(2) inappropriate maternal (sexual) conduct;

(3) pathological lying and manipulation;

(4) sadistic fantasy with a compulsion to act;

(5) animal cruelty, particularly against cats;

(6) the need to control and dominate others;

(7) repetitive fire-setting;

(8) voyeurism, fetishism, and sexual burglary;

(9) unprovoked attacks on females;

(10) evidence of ritualistic behavior.

The common elements again seem to be psychopathic traits; a need for control and sexual fantasies that are fused with violence. A personal communication I had with esteemed forensic psychiatrist Dr Park Dietz elicited that a high sex drive, coupled with such sadistic fantasies and a lack or reduction in moral beliefs are also risk factors.

Do you believe that males are more prone to becoming psychopaths or serial killers?

History and cumulative studies suggest that most serial killers are Male. However this is not to say that women do not engage in this heinous act. A look through history will show you that there have been many and across different epochs, ranging from Elizabeth Bathory to more recently the likes of Aileen Wournos (portrayed by Charlize Theron in the film ‘Monster’). Their methods of murder also tend to be different, with poisoning and relational aggression in general featuring more strongly. Peter Vronsky has written an excellent book on Female serial killers if you want to know more.