Thursday, May 7, 2009


The terms "psychotic" and "psychopathic" are commonly confused, even in reputable media. But while it may not seem like a big deal to mislabel a "psychotic killer" a "psychopath," we'll see that understanding their differences is crucial for solving the problems caused by the conditions. Moreover, as we'll see again and again in coming posts, empathy -- the ability to see the world from another's perspective -- may aid us in coping with the harmful consequences of sometimes unfathomable decisions made by others.

Today let's focus on psychopathy (used in a specific sense, as opposed to general psychological pathology). In order to qualify as a "psychopath," a person must be incapable of feeling guilt, empathy, compassion, remorse, shame, and a host of other social emotions that keep most of us in line. (Technically, to differentiate it from similar antisocial diagnoses, other traits such as grandiosity and manipulativeness are required, but let's focus on the above for now.)

Through employing a variety of psychophysiological testing (such as heart rate and skin resistance monitoring, and more advanced methods like fMRI brain scans), we know that psychopaths process emotional stimuli very differently than the rest of humanity. And critically, to the best of psychiatric understanding today, psychopaths are born, not made.

Why should any of this matter? Consider the following quote from a psychologist treating a psychopathic child.
I remember a conversation where he told me, "People know when something is wrong because it feels wrong. I have to remember or be reminded that stealing from someone is wrong. I don’t feel bad if I take something."

Meeting this young boy changed my opinion of a psychopathic personality. Why? Because children with this condition are "emotionally blind." And while I do not excuse cruelty or criminal behavior, I have sympathy and appreciate how hard it is for some people to learn how to act responsibly.
Another theme we'll come across again: while practical measures such as incarceration may still be warranted, malicious feelings that often accompany a thirst for vengeance are often counterproductive. In the case of psychopaths, the response you're most likely to evoke by expressing indignation is probably amusement or satisfaction. By coming to understand the perspectives of our perceived enemies, we may be able to better deal with our own painful feelings of resentment and bitterness, and eventually come to recognize them as vestiges we're better off without.

Estimates of psychopathic prevalence put the figure at ~1% of the population. If we group it with similar conditions such as Antisocial Personality Disorder, that number goes up to maybe 5%. So, what about "the rest of us?" As we'll see, the mere existence of the brain structures that give rise to compassion -- the ones that reveal our shock at seeing a dog kicked, even if we try to hide it -- are cause for hope.



  1. Maybe I'm not clear on definitions here.

    On my psychiatry rotation, we treated the term psychopath as synonymous with anti-social personality disorder.

    "...the ones that reveal our shock at seeing a dog kicked, even if we try to hide it "

    I think it's safe to say that you're making a case for a biological basis of compassion or empathy. In your mind does the evidence argue for a similar biological basis for shock?

    I ask this because it feels like we don't just stop appearing shocked in med school. It feels like we stop being shocked.

    Maybe you have reason to think that I'm just wrong on this point. Either way, I'm curious.

  2. Glad to hear your questions, Whitecoat! :)

    I'm referring to the definition of "psychopath" as diagnosed by Dr. Robert D. Hare's Psychopathy Checklist-Revised (PCL-R), which I understand is used more by researchers than physicians.

    It is true that in the DSM-IV, "psychopathy" is considered an obsolete term for Antisocial Personality Disorder. In the ICD-10, it most closely matches Dissocial Personality Disorder. Anyway, murky waters, as I'm sure you're aware.

    On your second point: check out some of the studies on the startle reflex. It was widely considered impossible to suppress, until a monk recently demonstrated the ability. I'll be posting more on this later.

  3. So it would appear that you'll build a more nuanced case then.

    Something along the lines of a strong biological contribution with some environmental or conditioning factors included.

    That may fit much more with what my perceptions have been.

    I'll stop trying to predict your future work, I await your future posts, so far you're highly entertaining.