To treat a psychopath


Some people are now quite optimistic about the possibility of treating psychopathy with drugs that directly modulate brain function. I argue that this optimism is misplaced. Psychopathy is a global disorder in an individual’s worldview, including his social and moral outlook. Because of the unity of this Weltanschauung, it is unlikely to be treatable in a piecemeal fashion. Recent neuroscientific methods do not give us much hope that we can replace, in a wholesale manner, problematic views of the world with more socially desirable ones. There are, therefore, principled reasons that psychopathy is so singularly treatment resistant.

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  1. 1.

    Serotonin reuptake inhibitors (SSRI) and serotonin and norepinephrine reuptake inhibitors (SNRI).

  2. 2.

    In what follows, I am following PCL-R except where noted. That is, I reference emotional and other disorders that are not part of the diagnostic criteria but that have nevertheless been documented by at least some important researchers in the field.

  3. 3.

    Some studies have found that psychopaths have problems recognizing the expression of fear in people’s faces [12], others that they have special problems identifying disgust, but not fear [13]. Sadness recognition might also be a problem, but only in adolescent psychopaths [14]. Vocal affect is another area that has been studied and it would appear that here, too, psychopaths are impaired, but again, only with respect of certain emotions. Bagley and colleagues, for instance, only found evidence for general impaired vocal-semantic sadness recognition (with some difference between primary and secondary psychopaths for other emotions) [15].

  4. 4.

    I simplify Mealey here a bit. She thinks primary psychopaths are genetically disposed to become psychopaths, whereas the expression of secondary psychopathy is more environmentally determined.

  5. 5.

    But probably this is primarily true for male psychopaths. Since women traditionally do most of the child rearing and psychopaths are notoriously irresponsible, female psychopaths may not fare particularly well in terms of fitness. The prevalence rate of psychopathy among women is much smaller than among men, however [23].

  6. 6.

    Here Chartrand quotes directly from the DSM-IV [8, p. 649].

  7. 7.

    Antisocial personality disorder is a very disputed diagnosis, particularly among psychopathy researchers. Around half of the prison population meets the diagnostic criteria, adding credence to critics who regard it as a thinly veiled “criminality” classification (only a slight advance on “moral insanity”). And many young people, who would have received the diagnosis at one point or other, end up as productive members of society [17]. However, Hare judges that most psychopaths meet the antisocial personality disorder diagnosis [31, p. 92]. Hart and colleagues found that 79.2 % of psychopaths had a diagnosis of antisocial personality disorder, whereas only 30.2 % of inmates with this diagnosis also met the diagnostic criteria for psychopathy (PCL-R) [32].

  8. 8.

    The matter is more complex than it seems at first. The evidence that empathy reduces violence is mixed [3638]. For instance, violent sex offenders often have intact empathy [39]. There is also the additional question of what exactly we mean by “empathy.” In the psychopathy literature, as in many other places, “empathy” may refer to sympathy, empathy, personal distress, emotional reactivity, or emotional contagion [38]. This gives rise to considerable confusion, particularly when considering how to conceptualize the moral impairments of psychopaths [40].

  9. 9.

    In the Ultimatum Game, a certain amount of money is provisionally allocated to two people who may share it under the following conditions. Person 1 is to make an offer of how to split the money, e.g., 70/30, and person 2 must either accept or reject that offer. Only if person 2 accepts person 1’s offer, does either of them receive any money.

  10. 10.

    Personal harms are harms that involve physical contact with the victim, e.g., one pushes another to his or her death. They contrast with impersonal harms where, for instance, one dispatches the victim by pulling a lever or pushing a button. The scenarios are supposed to involve a moral dilemma between harming the one and saving the many.

  11. 11.

    A couple of points bear mentioning here. First, Cima et al. [43] found no statistically significant difference between psychopaths and nonpsychopaths on moral dilemmas of the type used by Koenigs et al. [42] and Crockett et al. [1], though they did use a lower cut-off point for psychopathy (26 vs. 30 points). Koenigs and colleagues also do not find a difference between the two groups on personal harm dilemmas unless they divide the psychopaths into high-anxious and low-anxious groups. Interestingly, even low-anxious psychopaths find personal harm scenarios unacceptable almost half of the time (0.58 vs. 0.46 for nonpsychopaths). Second, both groups of psychopaths in the Koenigs et al. study were more likely to endorse impersonal harms to save the many. Third, though the studies show a statistically significant difference between psychopathic and nonpsychopathic responses, it is hardly as dramatic as one would expect given the current hype about psychopaths.

  12. 12.

    The Interpersonal Reactivity Index [45], which is used by the authors to establish the level of empathy of their subjects, is a hodgepodge of measures that include one’s tendency to take others’ perspective, feel sympathy for them, experience emotions in response to their emotions, experience distress at their distressing situation, or engage with fictional characters.

  13. 13.

    Gregor Hassler and colleagues have recently reported success modulating behavioral responses with cathecolamine depletion [3]. By administering alphamethyl-paratyrosine (AMPT), which inhibits tyrosine hydroxylase, essential for the formation of cathecolamines (e.g., epinephrine, norepineprhine, and dopamine), the authors produced reduced adaptive responses in a couple of simple learning tasks. In certain parts of the probabilistic reversal learning and passive avoidance learning tasks, AMPT drugged subjects performed worse than controls. This supports the literature that suggests that dopamine plays an important role in various forms of learning [46]. Upon finding abnormal responses to negative reinforcement in passive avoidance learning tasks in youths with psychopathic tendencies, Finger et al. [2] suggest that treatment with dopamine or cathecolamine enhancing drugs increases reinforcement learning, and should therefore be considered as a treatment option for psychopathy or psychopathic tendencies. The focus of this treatment intervention is no longer the modulation of emotions that increase social and moral concern, but on psychopaths’ deficient learning. Though not often recognized, psychopaths have significant practical reasoning deficits [47]. Could one fix those deficits, one would have important and enduring effects on their behavior. But these deficits are unlikely to exhaust their socio-moral impairments. And as I have already argued, without a more encompassing change of orientation towards how to lead one’s life, such interventions will not have the desired effect.


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Correspondence to Heidi L. Maibom.

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Maibom, H.L. To treat a psychopath. Theor Med Bioeth 35, 31–42 (2014) doi:10.1007/s11017-014-9281-9

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  • Psychopathy
  • Moral treatment
  • Drug enhancement
  • Weltanschauung