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.

Note to readers-This article was originally published in Psychiatric Times and posted on PsychiatricTimes.com in 2006. Ever since, it has remained one of the best-read articles. We re-publish it here with updates from Dr Martens.

Disclosures:

Dr Martens is Chair of the W. Kahn Institute of Theoretical Psychiatry and Neuroscience. He is also Psychiatry Advisor of the European Commission (Leonardo da Vinci) and a member of the Royal College of Psychiatrists.

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