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See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/301779251 Gåden om psykopati [English translation: The puzzle of psychopathy] Chapter · January 2016 CITATIONS 0 READS 72 1 author: Some of the authors of this publication are also working on these related projects: Understanding Stalking Recidivism View project (Closed)The Validity Project of HCR-20 in Korean Correctional Service: A Field Research. View project Stephen David Hart Simon Fraser University 220 PUBLICATIONS 16,703 CITATIONS SEE PROFILE All content following this page was uploaded by Stephen David Hart on 22 July 2020. The user has requested enhancement of the downloaded file.

Running head: THE PUZZLE OF PSYCHOPATHY 1 Chapter 1: The Puzzle of Psychopathy Stephen D. Hart Simon Fraser University and University of Bergen Author Notes Stephen D. Hart, Department of Psychology, Simon Fraser University and Faculty of Psychology, University of Bergen. This chapter is based on a presentation given by the author at the Bergen International Conference on the Treatment of Psychopathy in November, 2011. Key facts have been updated where new research permits. Address correspondence to Professor Stephen D. Hart, Department of Psychology, Simon Fraser University, 8888 University Drive, Burnaby, British Columbia, Canada V5A 1S6. Email: hart@sfu.ca

THE PUZZLE OF PSYCHOPATHY 2 Chapter 1: The Puzzle of Psychopathy Psychopathy is a form of mental disorder known as personality disorder. All mental disorders involve abnormal psychological processes that cause problems of daily living. The psychological processes are abnormal because they are unusual, unexpected, or disturbed. The problems in daily living include distress, dysfunction, or disability, sometimes referred to as functional impairment. Personality disorders are mental disorders whose symptoms involve disturbance of basic personality (personality being the characteristic way in which people’s psychological processes are organized and expressed) that take the form of extreme and inflexible traits. Psychopathy—known variously as psychopathy, sociopathy, and antisocial, dissocial, or psychopathic personality disorder—is only one of several commonly occurring forms of personality disorder. (Borderline, narcissistic, schizoid, and avoidant personality disorder are some of the other forms of personality disorder.) Psychopathy is distinguished from these other forms of personality disorder by its symptom pattern, which includes traits such as hostile dominance, lack of attachment to or empathy for others, callousness and suspiciousness, impulsivity and irresponsibility, lack of anxiety or remorse, and egocentrism and grandiosity. Psychopathy is often characterized as a “controversial” disorder. This is a bit misleading. There is no real controversy regarding the existence of psychopathy as a commonly occurring pattern of maladaptive personality traits. It has been discussed in the psychopathological literature in its current form for more than a hundred years. The controversy is limited to rather specific issues. One important issue is exactly which traits should be included in the set that best defines psychopathy and distinguishes it from other disorders. A second issue is whether psychopathy is best conceptualized in categorical or dimensional terms. Because personality traits are “more or less” as opposed to “either/or” phenomena, there is no clear or simple

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THE PUZZLE OF PSYCHOPATHY 3 boundary between psychopathy and normal personality or between psychopathy and other personality disorders. A third issue is the extent to which psychopathy can or should play a role in real-world decisions regarding such things as violence risk (dangerousness), treatability, culpability (criminal responsibility), and commitment (detention). Psychopathy is a puzzle. As readers will learn, it is a problem we have identified but we don’t know how to solve. We don’t know exactly what it is. We don’t know exactly what causes it. We don’t know exactly what to do about it. This sounds rather hopeless, although the same things hold true for the vast majority of mental disorders. We are still in the early stages of research on psychopathology. But the scientific research literature on psychopathy is quite impressive—in fact, more extensive and rich than the literature concerning most other mental disorders. This means that although we don’t know everything, we still know quite a bit, and we learn more every day. In the rest of this chapter, we will discuss why psychopathy is so important to understand. We will also provide an overview of the chapters that follow, which will expand on many of the ideas and themes presented here. Caring For and About Psychopathy If psychopathy is a puzzle, it is one we are ambivalent about. We are sometimes curious or perplexed by it, yet by and large most people don’t care much about psychopathy, at least not in any positive or productive way. Indeed, we fear and loathe the very idea of psychopathy, as well as people with the disorder. Our reactions are understandable in many respects. People with mental disorders all have adjustment problems to a greater or lesser degree (by definition). Most people with mental disorders are obviously distressed by those adjustment problems, affected those problems as much or more than are others, and desirous of improving their lives. But the same is not true for people with psychopathy. They do not appear to be distressed, adversely

THE PUZZLE OF PSYCHOPATHY 4 affected by their adjustment problems, or motivated to change. This makes us frustrated, even angry, when dealing with people with psychopathy. It is possible, at least in theory, that fear and loathing can motivate us to better understand a problem and a search for its solutions. But in the case of psychopathy, the opposite has happened. We respond with primitive defenses: we dehumanize, even demonize, people with psychopathy to convince ourselves that they are—and should remain—fundamentally different or distinct from the rest of us, undeserving of concern or care. Our attitude toward psychopathy is reflected in the language used by those who study the disorder. For many years, researchers and clinicians who write about mental disorder have been urged not to objectify people by referring to them in terms of the disorders from which they suffer. For example, according to the American Psychological Association’s official manual of writing style, we should not to refer to “diabetics” or “schizophrenics” but rather to “people with diabetes” or “people with schizophrenia.” But this rule flies out the window when writing about psychopathy. It is perfectly acceptable in scientific writing to refer to people with psychopathy collectively as “psychopaths”—or, even worse, as “the psychopath”—thus denying their diversity and individuality. (I have made this mistake myself, on occasion.) We characterize them as “intraspecies predators” (e.g., Hare, 1996) or even “super-predators” (e.g., DeLisi, Dooley, & Beaver, 2007), as if they were a subspecies of homo sapiens . We perceive them as having special strengths that make them fearless, bold, and cunning—superior to the rest of us mere mortals in some respects, possibly even a special “evolutionary adaption” (e.g., Mealey, 1995). We zoomorphize them, calling them “snakes” (e.g., Babiak & Hare, 2009), noting their “reptilian gaze” (e.g., Hare, 1993), and calling children who may be developing psychopathic features “fledgling psychopaths” (e.g., Lynam, 1996). Potentially offensive language such as the examples above are typically caught and corrected by reviewers, editors, or copyeditors prior to

THE PUZZLE OF PSYCHOPATHY 5 publication—but not in the case of books, chapters, and articles about psychopathy. No one worries too much about maligning people with this particular disorder. Psychopathy is the disorder we love to hate. We could, quite literally, care less about people with psychopathy. Our reaction to psychopathy is not the same as for many other mental disorders. Take, for example, schizophrenia. We care a lot about schizophrenia. Key symptoms of that disorder include disturbances of perception, thought content, thought form, emotion, and behavior. Schizophrenia has a high lifetime prevalence rate, affecting about 0.5% to 1% of humanity—one out of every 100 to 200 people born on this planet. It strikes without regard to gender, nationality, or social class; each of us will come to know someone with schizophrenia. It also strikes people early in life, and so half of all those who develop the disorder do so before the age of 30. Symptoms of the disorder are chronic or persistent in about 60% of people who develop the disorder. At the individual level, the consequences of schizophrenia may be serious, but at the collective level they are, inarguably, devastating. Due to its symptomatology, high prevalence, early age onset, and persistence, schizophrenia can result in serious impairment of interpersonal relations (e.g., poor relations with family, problems developing friendships and intimate relationships), as well as impairment of educational and vocational achievement (e.g., problems completing school, problems getting and keeping a job). Sufferers may require episodic or even long-term support or treatment by family members, health care providers, and social service agencies. According to the World Health Organization, schizophrenia on its own accounts for about 3% of the total global burden of human disease—a figure that includes all direct and indirect costs. It is ranked 14 th in terms of leading causes of disability, and 5 th to 6 th in terms of leadings cause of lost healthy years of life. The estimated disability-adjusted lost years of healthy life (DALY) attributable to schizophrenia is 16.8 million annually, representing 1.1% of the total

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THE PUZZLE OF PSYCHOPATHY 6 annual DALY. The DALY figure for schizophrenia is due in part to an increased risk for premature death. Each year, about 30,000 premature deaths around the world—many due to suicide—are attributed to schizophrenia, which is equivalent to a premature death rate of about 0.1% annually among suffers. Good estimates of the financial costs associated with schizophrenia are available in many countries. In Canada, for example, total costs have been assessed at CAD $6.8 billion annually, including CAD $2.0 billion in direct costs and CAD $4.8 billion in indirect costs. In the United States, the total costs have been assessed at USD $62.7 billion annually, including USD $30.3 billion in direct costs and USD $32.4 billion in indirect costs. Schizophrenia also impacts public safety. Schizophrenia is an established risk factor for perpetration of violence—notwithstanding that most people with schizophrenia do not commit violence and, conversely, most people who commit serious violence do not have schizophrenia. Meta-analyses have found that schizophrenia increases the risk of violence by a factor of about 4 to 6 relative to people who are mentally healthy, as indexed by odds ratios. They have also found that the prevalence of schizophrenia in correctional populations is about 3%, which means it is over-represented by a factor of about 3, as indexed by rate ratios. In light of these figures, it is makes sense that schizophrenia has been identified by the World Health Organization as one of the worst global health care problems—not just among mental health problems, but among all health problems, which includes such things as malaria, tuberculosis, HIV/AIDS, and infant diarrhea. It is also completely understandable that, in every industrialized country, there are specialized governmental (i.e., health care and social) services, as well as non-governmental agencies that provide public information and education, networking and referral, and advocacy services, for all those affected by schizophrenia, including sufferers, their families, and their service providers. A lot of research is devoted to the topic of

THE PUZZLE OF PSYCHOPATHY 7 schizophrenia, as well. There are numerous academic journals and professional organizations that focus primarily or even solely on the disorder. Governmental and non-governmental agencies provide considerable funding for research on schizophrenia. For example, in the United States, the National Institute of Mental Health devotes about USD $125 million to $150 million of funding annually to research on schizophrenia, representing about 13% to 15% of its total budget for research on mental disorders. A substantial proportion of research evaluates treatments for schizophrenia. In fact, a systematic review of high-quality research on treatment conducted in 1998, one that included only randomized controlled trials or RCTs, located more than 2,000 studies. Although the resources devoted to schizophrenia are enormous, many critics still express concern they are inadequate for a problem of such magnitude. What are the costs of psychopathy? Surprisingly, little has been written about this topic, but it is still possible to draw some tentative conclusions based on published research. The best estimates are that the lifetime prevalence of psychopathy is about 0.5% to 1.0%—a rate virtually identical to that of schizophrenia. And, like schizophrenia, psychopathy afflicts people without regard to gender, nationality, or social class. The age onset of psychopathy is actually younger than that of schizophrenia: Symptoms of psychopathy typically are first evident between the ages of about 6 to 10. By definition, all of those who develop the disorder do so by the age of 18 to 25 and, again by definition, symptoms of the disorder are chronic or persistent in all people who develop the disorder. Like schizophrenia, psychopathy causes widespread impairment of social functions. This includes problems with interpersonal relations and educational or vocational adjustment, as well as failure to abide by social norms and respect the rights and welfare of others. The latter is associated with increased risk for conduct problems that are diverse, serious, persistent, and frequent in nature, ranging from disruptive behavior in childhood to delinquency in adolescence

THE PUZZLE OF PSYCHOPATHY 8 to criminality in adulthood. Because symptoms of psychopathy are chronic, so are their adverse consequences—the impairment may be evident in childhood but persists through adolescence into middle or even late adulthood. There is some evidence of increased risk of morbidity (i.e., physical and mental health problems) and mortality (i.e., premature death) among people with the disorder. There is also some evidence of increased burden of care for family members of those affected, as well as for health care, social service, law enforcement, and corrections agencies. But there is no systematic research on the absolute or relative costs psychopathy that would permit direct comparison with the costs of schizophrenia. For example, the World Health Organization does not have estimates of the global burden of care, the DALY factor, or the excess mortality associated with psychopathy. The best information about the social costs of psychopathy concerns the disorder’s impact on public safety. Psychopathy, like schizophrenia, is an established risk factor for violence. In fact, psychopathy is a more important risk factor than is schizophrenia: it has a stronger and more consistent statistical association with violence, and increases risk for more forms of violence. Meta-analyses have found that psychopathy increases the risk of violence by a factor of about 5 to 10, as indexed by odds ratios, even relative to non-psychopathic offenders or forensic psychiatric patients— including those suffering from schizophrenia. Based on these estimates, relative to health people living in the community, psychopathy likely increases the risk of violence by a factor of at least 20, and perhaps as high as 60, as indexed by odds ratios. Psychopathy also substantially increases risk for non-violent criminality; schizophrenia does not. The prevalence of psychopathy in correctional settings is very high. Prevalence rates for psychopathy in corrections range from a lower-bound estimate of about 10% to an upper-bound estimate of about 25%, depending on factors such as nationality, security level, and so forth. Using an estimated prevalence of 1% in the general population and a conservatively estimated

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THE PUZZLE OF PSYCHOPATHY 9 prevalence of 10% in correctional settings, then psychopathy is over-represented in correctional settings by a factor of 10, as indexed by rate ratios. It is possible to make some estimates of the economic costs associated with psychopathy using based on the figures presented above. We will err on the side of being conservative. For example, let’s assume that only 10% of offenders in the United States in Canada have psychopathy. (As noted above, the prevalence is likely higher institutional settings and lower in community settings.) Next, let’s assume that offenders with psychopathy commit crime at more or less the same rate as other offenders. (As note above, the rates of violent and serious criminality are higher in psychopathic offenders compared to non-psychopathic offenders, but the psychopathic offenders may also have a higher rate of incarceration as a result that limits their opportunity to commit new crimes.) This means the best educated guess is that 10% of the overall costs of crime may be attributable to psychopathy. In Canada, the costs of crime have been estimated at CAD $99.6 billion annually. This figure includes CAD $31.4 billion in direct costs (e.g., for law enforcement, corrections, and court services) and a further CAD $68.2 billion in indirect costs (e.g., for health care and social services, as well as property, productivity, and wage losses due to victimization). Psychopathy likely accounts for 10% of these costs, of about CAD $10 billion annually. In the United States, the overall costs of crime are in excess of USD $1,000 billion annually. This figure includes about USD $500 billion in direct costs (e.g., for law enforcement, corrections, and court services) and another USD $500 billion in indirect costs (e.g., for health care and social services, as well as property, productivity, and wage losses due to victimization). Again, psychopathy likely accounts for 10% of these costs, or about USD $100 billion annually. These cost estimates are staggering. In relative terms, the costs of psychopathy are higher than those of schizophrenia—somewhere between 50% and 300% higher. In Canada, the costs of

THE PUZZLE OF PSYCHOPATHY 10 psychopathy are equivalent to ½ of total military spending and about 1/5 of total education spending by all levels of government. In the United States, the costs of psychopathy are equivalent to about 1/5 of total military or education spending by all levels of government. In absolute terms, the costs of psychopathy on both countries may exceed 0.5% of gross domestic product. And remember that the costs estimated here are conservative. First, we assumed that psychopathy is found in 10% of all offenders and therefore accounts for 10% of all crime and 10% of the total costs of crime. But there are good reasons to believe that offenders with psychopathy commit offenses at a higher rate than nonpsychopathic offenders, and so account for more than 10% of all crime; and that psychopathic offenders account for a disproportionate amount of violent crime more specifically, which has much greater costs than does property crime. Second, we focused on the costs of crime in adult offenders, ignoring the costs of crime in childhood and adolescence. Psychopathy likely accounts for an even greater proportion of the costs of crime in childhood or adolescence than it does in adulthood, due to the disorder’s early onset. Third, we focused only on the costs of crime —investigating offenses, processing and supervising offenders, and servicing victims. We ignored the fact that psychopathy appears to have substantial costs outside of crime, including especially health care costs and lost wages. If you agree that it is understandable to care about schizophrenia, then you should also care about psychopathy. The social costs of psychopathy are at least as great as those of schizophrenia, and may be at least two to three times higher. Better data and good econometric analyses will likely reveal that psychopathy should replace schizophrenia as the worst health problem affecting humanity due to its prevalence, impact on individual functioning, and social costs.

THE PUZZLE OF PSYCHOPATHY 11 So how have we responded to the adverse social impact of psychopathy? Research funding for psychopathy is extremely limited. In the United States, in the same year NIMH spent about USD $125 million to $150 million (about 13% to 15% of its total budget) funding research on schizophrenia, it spent about USD $10 million (less than 1% of its total budget) on all personality disorders—about half of which was devoted to research on borderline personality disorder. There are no academic journals devoted to psychopathy, and only one small international association with annual meetings of a few hundred people and content focused almost exclusively on assessment and etiology. Research and publications on treatment or management are virtually non-existent, and all studies to date have serious methodological shortcomings. Think about that for a minute—if the figures above are even close to the truth, psychopathy may soon supplant schizophrenia as the worst health problem affecting humanity. Recall there are thousands of studies on the treatment of schizophrenia, including more than 2,000 randomized controlled trials (RCTs), which are the gold standard design for treatment studies—but to date, there has not been a single RCT on the treatment of psychopathy . This is more than a concern; it is deeply distressing, baffling, even outrageous. Solving the Puzzle Psychopathy, then, is a puzzle well worth solving. You should care about psychopathy. It is not in anyone’s best interests to ignore the disorder. There is no evidence to suggest that it is decreasing in prevalence or severity, or that it is getting easier to manage. And our fear and loathing notwithstanding, we must remember that people are psychopathy are, first and foremost, people—they are our family members, our life partners and business partners, our friends, our neighbors. They are part of our communities, and every difficulty they experience has consequences for the other members of or communities.

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THE PUZZLE OF PSYCHOPATHY 12 For millennia, humanity has held people with psychopathy morally culpable for the disorder from which they suffer. We have scorned, vilified, castigated, punished, and even executed people with psychopathy, with no obvious or tangible benefit. Our hatred hasn’t resulted in a cure, an effective treatment, or even a particularly good way to protect us from the disorder’s consequences. Maybe, after a few millennia, we should acknowledge our failure to learn from experience and our callous disregard (ironically, both things we associate with psychopathy) and look at the disorder in a different way? After all, we used to shun people with leprosy. It was not until we took a new look at that disease through a scientific rather than a moral lens that we found a cause and a treatment, and realized we were wrong to hold people with leprosy accountable for their own suffering. Hatred has failed as a way to deal with psychopathy. A closer look, a fresh perspective, a dispassionate consideration may help us to develop a better understanding of the disorder. They may help us to care about psychopathy, as well as to care for people with psychopathy, in a way that is positive and productive. To motivate the search for solutions to the puzzle of psychopathy, I think we should do two things. First, we should make it abundantly clear how much we have to gain by solving the puzzle. We need to do more and better research on the costs of psychopathy, both the costs for those who suffer from it and for society at large. We also need to help people understand how much pain and suffering could be prevented through better treatment or management of the disorder. Research of this sort will require mental health professionals with expertise in assessment and diagnosis of psychopathy to work closely with epidemiologists and economists, as well as with experts in public policy from fields such as sociology, criminology, and political science. But the research should not be too difficult or technically challenging. After all, the research would simply be replicating past studies that focused on other mental disorders, such as schizophrenia, depression, substance use, and so forth. For the same reason, neither does reach

THE PUZZLE OF PSYCHOPATHY 13 on the costs of psychopathy require huge amounts of money. What it will require is for scientists to stop viewing psychopathy as a “fascinoma”—a disease that is strange or curious, but actually rare and of limited practical importance—and instead to recognize it as a major public health concern. Psychopathy is not “cool” or “exciting”; it is a chronic and debilitating disorder that ruins lives. Second, I think we should start cumulating knowledge about psychopathy in a way that is both more systematic and more action-oriented. In my opinion, there is enough research being conducted that focuses on causal factors of psychopathy etiological factors that are distal, static, and biological. It is a truism among those who study mental disorder that all pathological conditions are associated with vulnerabilities, often of a genetic or constitutional nature; but it is also a truism that the same conditions are also associated with triggers, which are often social or psychological in nature. What we really need, I think, is more research on proximal, dynamic, and environmental causal factors of psychopathy. Research of this sort will not only give us a more full picture of how psychopathy develops, it will also highlight the fact that psychopathy, like all disorders, is capable of change. (For example, Down’s syndrome, a common form of mental retardation, is fundamentally genetic in origin; yet, its symptoms can be improved or worsened by environmental factors, such as good versus poor parenting practices.) Perhaps the best type of research to demonstrate the fact that psychopathy is not fixed and immutable, and to combat the nihilism surrounding the disorder that is all too common, is research on treatment and management. Not only do treatment studies provide critical insight into causal mechanisms from a basic science perspective, something that may have major long-term benefits, from an applied science perspective such studies also help to improve people’s lives in the short-term. Research of this second type also is entirely feasible. It can be undertaken using conventional methods. It can be done on a modest budget, or even at no additional cost in the case of evaluation of routine

THE PUZZLE OF PSYCHOPATHY 14 clinical services. So political will to provide targeted funding would be helpful, but it is not necessary; the only necessary thing is the will of scientists and practitioners. The solutions for the puzzle of psychopathy will not be easy to find, but they’ll most certainly do exist. Keep searching; don’t despair. Remember these words, by the Indian writer, Sapran Saxena, from his novel Finders, Keepers : Every chaos has an order hidden in it. What we see as a chaos, is actually driven by a very disciplined and dedicated order of things. What we need to do is focus on the stuff before us, make our way through this chaos, and that order will sort itself out for us. Additional Readings Hart, S. D., & Cook, A. N. (2012). Current issues in the assessment and diagnosis of psychopathy (psychopathic personality disorder). Neuropsychiatry , 2, 497-508. Reidy, D. E., Kearns, M. C., DeGue, S., Lilienfeld, S. O., Massetti, G., & Kiehl, K. A. (2015). Why psychopathy matters: Implications for public health and violence prevention. Aggression and Violent Behavior, 24 , 214-225. World Health Organization. (2008). The global burden of disease: 2004 update . Geneva: Author.

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THE PUZZLE OF PSYCHOPATHY 15 References Babiak, P., & Hare, R. D. (2009). Snakes in suits: When psychopaths go to work . New York: Harper Collins. DeLisi, M., Dooley, B. D., & Beaver, K. M. (2007). Super-predators revisited. In K. T. Froeling (Ed.), Criminology research focus (pp. 21-30). New York: Nova Hare, R. D. (1993). Without conscience: The disturbing world of the psychopaths among us . New York: Pocket Books. Hare, R. D. (1996). Psychopathy a clinical construct whose time has come. Criminal Justice and Behavior, 23 , 25-54. Lynam, D. R. (1996). Early identification of chronic offenders: Who is the fledgling psychopath? Psychological Bulletin, 120 , 209-234. Mealey, L. (1995). The sociobiology of sociopathy. An integrated evolutionary model. Behavioral and Brain Sciences , 18 , 523-599. Saxena, S. (2015). Finders, keepers . Navi Mumbai: Leadstart. View publication stats