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Altered Performance Monitoring in Psychopathy: A Review of Studies on Action Selection, Error, and Feedback Processing

Current Behavioral Neuroscience Reports volume 3, pages 19–27 (2016)Cite this article

Abstract

Psychopathy is a serious personality disorder characterized by a range of affective and behavioral adaptation deficits. Behavioral adaptation and individual as well as social functioning require monitoring of one’s behavior, i.e., performance monitoring. Performance monitoring has been associated with specific neurophysiological processes, for instance, an astoundingly uniform sequence in the human EEG. In this review, I will present evidence for altered and likely deficient performance monitoring processes in psychopathy, which can explain a range of behavioral deficits. Previous research, however, is also characterized by inconsistent findings and possible reasons will be discussed. Among some proposals for advancement of the field, applying a multidimensional and not unitary construct perspective of psychopathy may allow detection of unique or differential effects of psychopathic traits and therefore represents a particularly useful approach for future research. Neural responses related to performance monitoring are well-validated units of measurement, and recent research also highlights their value as targets and tools of intervention.

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Fig 1

Notes

  1. To this end, reported effects were first converted into effect sizes d and their standard errors using conversion formulas [see 55]. The converted effects were from Munro et al. [32] for the correlation between PCL-R scores and ERN amplitude at electrode site Cz (d = .847 [95% CI = −.499, 2.193]) and from Brazil et al. [33] for the group difference (d = .516 [95% CI = −.168, 1.2]). Second, OpenMetaAnalyst [54] was used to estimate the combined effect size and its confidence interval, using a random-effects model [DerSimonian-Laird approach; 56]. The resulting estimate was marginally significant (d = .584 [95% CI = −.026, 1.194], p = .061), indicating that there might be a reduced ERN in psychopathic offenders. This particular analysis was restricted to these two comparable studies, because the other studies reviewed either used different tasks or experimental contexts or investigated psychopathy from a different construct perspective.

  2. Interestingly, in one of the mentioned studies with non-significant findings [32], only file information was used to determine PCL-R scores, which seem to better capture impulsive-antisocial (factor 2) than interpersonal-affective features (factor 1; [58]). Hence, the marginal meta-analytic effect might also be associated with impulsive-antisocial features.

  3. In this regard, the experimental paradigm used in [74] might be of special interest for future research to disentangle otherwise integrated processes.

References

  1. Hare RD, Neumann CS. Psychopathy as a clinical and empirical construct. Annu Rev Clin Psychol. 2008;4:217–46.

    Article  PubMed  Google Scholar 

  2. Cleckley H. The mask of sanity. Educational and psychological measurements. St. Louis: Mosby; 1941.

    Google Scholar 

  3. Salekin RT, Worley C, Grimes RD. Treatment of psychopathy: a review and brief introduction to the mental model approach for psychopathy. Behav Sci Law. 2010;28:235–66.

    Article  PubMed  Google Scholar 

  4. Hemphill JF, Hare RD, Wong S. Psychopathy and recidivism: a review. Leg Criminol Psychol. 1998;3:139–70.

    Article  Google Scholar 

  5. Hall JR, Benning SD. The “successful” psychopath. Adaptive and subclinical manifestations of psychopathy in the general population. In: Patrick CJ, editor. Handbook of psychopathy. Guilford Press; 2006. P. 459–78.

  6. Gao Y, Raine A. Successful and unsuccessful psychopaths : a neurobiological model. Behav Sci Law. 2010;28:194–210.

    PubMed  Google Scholar 

  7. Lykken DT. A study of anxiety in the sociopathic personality. J Abnorm Psychol. 1957;55:6–10.

    Article  CAS  PubMed  Google Scholar 

  8. Newman JP, Kosson DS. Passive avoidance learning in psychopathic and nonpsychopathic offenders. J Abnorm Psychol. 1986;95:252–6.

    Article  CAS  PubMed  Google Scholar 

  9. Holroyd CB, Coles MGH. The neural basis of human error processing: reinforcement learning, dopamine, and the error-related negativity. Psychol Rev. 2002;109:679–709.

    Article  PubMed  Google Scholar 

  10. Ullsperger M, Fischer AG, Nigbur R, Endrass T. Neural mechanisms and temporal dynamics of performance monitoring. Trends Cogn Sci. 2014;18:259–67. This review provides a rich body of information about performance monitoring, describing astoundingly uniform sequences in the human EEG, and discussing open questions in the field.

    Article  PubMed  Google Scholar 

  11. Silvetti M, Alexander W, Verguts T, Brown JW. From conflict management to reward-based decision making: actors and critics in primate medial frontal cortex. Neurosci Biobehav Rev. 2013;46:44–57.

    Article  PubMed  Google Scholar 

  12. Amodio DM, Bartholow BD, Ito TA. Tracking the dynamics of the social brain: ERP approaches for social cognitive and affective neuroscience. Soc Cogn Affect Neurosci. 2014;9:385–93.

    PubMed Central  Article  PubMed  Google Scholar 

  13. Nigbur R, Ivanova G, Stürmer B. Theta power as a marker for cognitive interference. Clin Neurophysiol. 2011;122:2185–94.

    Article  PubMed  Google Scholar 

  14. Cavanagh JF, Zambrano-Vazquez L, Allen JJB. Theta lingua franca: a common mid-frontal substrate for action monitoring processes. Psychophysiology. 2012;49:220–38.

    PubMed Central  Article  PubMed  Google Scholar 

  15. Cavanagh JF, Cohen MX, Allen JJB. Prelude to and resolution of an error: EEG phase synchrony reveals cognitive control dynamics during action monitoring. J Neurosci. 2009;29:98–105.

    PubMed Central  Article  CAS  PubMed  Google Scholar 

  16. Debener S, Ullsperger M, Siegel M, Fiehler K, von Cramon DY, Engel AK. Trial-by-trial coupling of concurrent electroencephalogram and functional magnetic resonance imaging identifies the dynamics of performance monitoring. J Neurosci. 2005;25:11730–7.

    Article  CAS  PubMed  Google Scholar 

  17. Hauser TU, Iannaccone R, Stämpfli P, Drechsler R, Brandeis D, Walitza S, et al. The feedback-related negativity (FRN) revisited: new insights into the localization, meaning and network organization. Neuroimage. 2014;84:159–68.

    Article  PubMed  Google Scholar 

  18. Jodo E, Kayama Y. Relation of a negative ERP component to response inhibition in a Go/No-go task. Electroencephalogr Clin Neurophysiol. 1992;82:477–82.

    Article  CAS  PubMed  Google Scholar 

  19. Falkenstein M, Hoormann J, Hohnsbein J. ERP components in Go/Nogo tasks and their relation to inhibition. Acta Psychol (Amst). 1999;101:267–91.

    Article  CAS  Google Scholar 

  20. Donkers FCL, Van Boxtel GJM. The N2 in go/no-go tasks reflects conflict monitoring not response inhibition. Brain Cogn. 2004;56:165–76.

    Article  PubMed  Google Scholar 

  21. Smith JL, Smith EA, Provost AL, Heathcote A. Sequence effects support the conflict theory of N2 and P3 in the Go/NoGo task. Int J Psychophysiol. 2010;75:217–26.

    Article  PubMed  Google Scholar 

  22. Falkenstein M, Hohnsbein J, Hoormann J, Blanke L. Effects of crossmodal divided attention on ERP components: error processing in choice reaction tasks. Electroencephalogr Clin Neurophysiol. 1991;78:447–55.

    Article  CAS  PubMed  Google Scholar 

  23. Gehring WJ, Goss B, Coles MGH, Meyer DE, Donchin E. A neural system for error-detection and compensation. Psychol Sci. 1993;4:385–90.

    Article  Google Scholar 

  24. Miltner WHR, Braun CH, Coles MGH. Event-related brain potentials following incorrect feedback in a time-estimation task: evidence for a “generic” neural system for error detection. J Cogn Neurosci. 1997;9:788–98.

    Article  CAS  PubMed  Google Scholar 

  25. Overbeek TJM, Nieuwenhuis S, Ridderinkhof KR. Dissociable components of error processing: on the functional significance of the Pe vis-à-vis the ERN/Ne. J Psychophysiol. 2005;19:319–29.

    Article  Google Scholar 

  26. Nieuwenhuis S, Ridderinkhof KR, Blom J, Band GP, Kok A. Error-related brain potentials are differentially related to awareness of response errors: evidence from an antisaccade task. Psychophysiology. 2001;38:752–60.

    Article  CAS  PubMed  Google Scholar 

  27. Van Veen V, Carter CS. The timing of action-monitoring processes in the anterior cingulate cortex. J Cogn Neurosci. 2002;14:593–602.

    Article  PubMed  Google Scholar 

  28. Kiehl KA, Smith AM, Hare RD, Liddle PF. An event-related potential investigation of response inhibition in schizophrenia and psychopathy. Biol Psychiatry. 2000;48:210–21.

    Article  CAS  PubMed  Google Scholar 

  29. Munro GES, Dywan J, Harris GT, McKee S, Unsal A, Segalowitz SJ. Response inhibition in psychopathy: the frontal N2 and P3. Neurosci Lett. 2007;418:149–53.

    Article  CAS  PubMed  Google Scholar 

  30. Maurer JM, Steele VR, Edwards BG, Bernat EM, Calhoun VD, Kiehl KA. Dysfunctional error-related processing in female psychopathy. Soc. Cogn. Affect. Neurosci. 2015;1–10

  31. Verona E, Sprague J, Sadeh N. Inhibitory control and negative emotional processing in psychopathy and antisocial personality disorder. J Abnorm Psychol. 2012;121:498–510.

    Article  PubMed  Google Scholar 

  32. Munro GES, Dywan J, Harris GT, McKee S, Unsal A, Segalowitz SJ. ERN varies with degree of psychopathy in an emotion discrimination task. Biol Psychol. 2007;76:31–42.

    Article  PubMed  Google Scholar 

  33. Brazil IA, de Bruijn ERA, Bulten BH, von Borries AKL, van Lankveld JJDM, Buitelaar JK, et al. Early and late components of error monitoring in violent offenders with psychopathy. Biol Psychiatry. 2009;65:137–43.

    Article  PubMed  Google Scholar 

  34. Bresin K, Finy MS, Sprague J, Verona E. Response monitoring and adjustment: differential relations with psychopathic traits. J Abnorm Psychol. 2014;123:634–49. This study investigated behavioral adjustment and error monitoring in psychopathy in three experiments, applying a multidimensional perspective of psychopathy that allowed observing differential relationships.

    PubMed Central  Article  PubMed  Google Scholar 

  35. Brazil IA, Mars RB, Bulten BH, Buitelaar JK, Verkes RJ, De Bruijn ERA. A neurophysiological dissociation between monitoring one’s own and others’ actions in psychopathy. Biol Psychiatry. 2011;69:693–9. This study investigated error monitoring in psychopathy by including a social context. Specifically, error monitoring related to one’s own behavior and related to observation of others’ behavior was compared.

    Article  PubMed  Google Scholar 

  36. Steele VR, Maurer JM, Bernat EM, Calhoun VD. Error-related processing in adult males with elevated psychopathic traits. personal. Disord. Theory, Res. Treat. 2015.

  37. Heritage AJ, Benning SD. Impulsivity and response modulation deficits in psychopathy: evidence from the ERN and N1. J Abnorm Psychol. 2012;122:215–22.

    Article  PubMed  Google Scholar 

  38. von Borries AKL, Brazil IA, Bulten BH, Buitelaar JK, Verkes RJ, de Bruijn ERA. Neural correlates of error-related learning deficits in individuals with psychopathy. Psychol Med. 2010;40:1559–68.

    Article  Google Scholar 

  39. Varlamov A, Khalifa N, Liddle PF, Duggan C, Howard R. Cortical correlates of impaired self-regulation in personality disordered patients with traits of psychopathy. J Pers Disord. 2011;25:75–88.

    Article  PubMed  Google Scholar 

  40. Salim MAM, van der Veen FM, van Dongen JDM, Franken IHA. Brain activity elicited by reward and reward omission in individuals with psychopathic traits: an ERP study. Biol Psychol. 2015;110:50–8.

    Article  PubMed  Google Scholar 

  41. Schulreich S, Pfabigan DM, Derntl B, Sailer U. Fearless dominance and reduced feedback-related negativity amplitudes in a time-estimation task—further neuroscientific evidence for dual-process models of psychopathy. Biol Psychol. 2013;93:352–63. This study investigated feedback processing in psychopathy, applying a multidimensional construct perspective, which allowed observation of differential relationships for different psychopathic traits.

    PubMed Central  Article  PubMed  Google Scholar 

  42. Hare RD. The hare psychopathy checklist-revised. 2nd ed. Toronto: Muliti-Health Systems; 2003.

    Google Scholar 

  43. Hart SD, Cox DN, Hare RD. The hare psychopathy checklist: screening version. 1st ed. Toronto: Muliti-Health Systems; 1995.

    Google Scholar 

  44. Patrick CJ, Curtin JJ, Tellegen A. Development and validation of a brief form of the multidimensional personality questionnaire. Psychol Assess. 2002;14:150–63.

    Article  PubMed  Google Scholar 

  45. Patrick CJ. Operationalizing the triarchic conceptualization of psychopathy: preliminary description of brief scales for assessment of boldness, meanness, and disinhibition (unpublished manuscript). Minneapolis, MN: University of Minnesota; 2010

  46. Lilienfeld SO, Andrews BP. Development and preliminary validation of a self-report measure of psychopathic personality traits in noncriminal population. J Pers Assess. 1996;66:488–524.

    Article  CAS  PubMed  Google Scholar 

  47. Alpers GW, Eisenbarth H. Psychopathic personality inventory—revised. Goettingen: Hogrefe; 2008.

    Google Scholar 

  48. Fowles DC, Dindo L. Temperament and psychopathy: a dual-pathway model. Curr Dir Psychol Sci. 2009;18:179–83.

    Article  Google Scholar 

  49. Patrick CJ, Fowles DC, Krueger RF. Triarchic conceptualization of psychopathy: developmental origins of disinhibition, boldness, and meanness. Dev Psychopathol. 2009;21:913–38.

    Article  PubMed  Google Scholar 

  50. Patrick CJ, Drislane LE. Triarchic model of psychopathy: origins, operationalizations, and observed linkages with personality and general psychopathology. J. Personal. Adv. online Publ. 2014.

  51. Patrick CJ, Bernat EM. Neurobiology of psychopathy: a two-process theory. In: Berntson GG, Cacioppo JT, editors. Handbook of neuroscience for the behavioral sciences. NY: John Wiley & Sons; 2009. P. 1110–31.

  52. Vilà-Balló A, Hdez-Lafuente P, Rostan C, Cunillera T, Rodriguez-Fornells A. Neurophysiological correlates of error monitoring and inhibitory processing in juvenile violent offenders. Biol Psychol. 2014;102:141–52.

    Article  PubMed  Google Scholar 

  53. Eisenbarth H, Angrilli A, Calogero A, Harper J, Olson LA, Bernat E. Reduced negative affect response in female psychopaths. Biol Psychol. 2013;94:310–8.

    PubMed Central  Article  PubMed  Google Scholar 

  54. Wallace BC, Dahabreh IJ, Trikalinos TA, Lau J, Trow P, Schmid CH. Closing the gap between methodologists and end-users: r as a computational back-end. J. Stat. Softw. 2012;49:1–15. Download from: http://www.cebm.brown.edu/open_meta/ September 2015

  55. Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. Introduction to meta-analysis. Chichester: Wiley; 2009.

    Book  Google Scholar 

  56. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177–88.

    Article  CAS  PubMed  Google Scholar 

  57. Hall JR, Bernat EM, Patrick CJ. Externalizing psychopathology and the error-related negativity. Psychol Sci. 2007;18:326–33.

    PubMed Central  Article  PubMed  Google Scholar 

  58. Grann M, Långström N, Tengström A, Stålenheim EG. Reliability of file-based retrospective ratings of psychopathy with the PCL-R. J Pers Assess. 1998;70:416–26.

    Article  CAS  PubMed  Google Scholar 

  59. Riesel A, Weinberg A, Endrass T, Meyer A, Hajcak G. The ERN is the ERN is the ERN? Convergent validity of error-related brain activity across different tasks. Biol Psychol. 2013;93:377–85.

    Article  PubMed  Google Scholar 

  60. Weinberg A, Dieterich R, Riesel A. Error-related brain activity in the age of RDoC: a review of the literature. Int. J. Psychophysiol. Elsevier B.V.; 2015;March.

  61. Meyer A, Riesel A, Proudfit GH. Reliability of the ERN across multiple tasks as a function of increasing errors. Psychophysiology. 2013;50:1220–5.

    Article  PubMed  Google Scholar 

  62. Ross SR, Benning SD, Patrick CJ, Thompson A, Thurston A. Factors of the psychopathic personality inventory: criterion-related validity and relationship to the BIS/BAS and five-factor models of personality. Assessment. 2009;16:71–87.

    Article  PubMed  Google Scholar 

  63. De Pascalis V, Varriale V, D’Antuono L. Event-related components of the punishment and reward sensitivity. Clin Neurophysiol Int Fed Clin Neurophys. 2010;121:60–76.

    Article  Google Scholar 

  64. Verona E, Vitale J. Psychopathy in women: assessment, manifestations, and etiology. Handb. psychopathy. 2006. P. 415–36.

  65. Buckholtz JW, Treadway MT, Cowan RL, Woodward ND, Benning SD, Li R, et al. Mesolimbic dopamine reward system hypersensitivity in individuals with psychopathic traits. Nat Neurosci. 2010;13:419–21.

    PubMed Central  Article  CAS  PubMed  Google Scholar 

  66. Bjork JM, Chen G, Hommer DW. Psychopathic tendencies and mesolimbic recruitment by cues for instrumental and passively obtained rewards. Biol Psychol. 2012;89:408–15.

    PubMed Central  Article  PubMed  Google Scholar 

  67. Pfabigan DM, Alexopoulos J, Bauer H, Lamm C, Sailer U. All about the money—external performance monitoring is affected by monetary, but not by socially conveyed feedback cues in more antisocial individuals. Front Hum Neurosci. 2011;5.

  68. Anderson NE, Stanford MS, Wan L, Young KA. High psychopathic trait females exhibit reduced startle potentiation and increased P3 amplitude. Behav Sci Law. 2011;29:649–66.

    Article  PubMed  Google Scholar 

  69. Benning SD, Patrick CJ, Iacono WG. Psychopathy, startle blink modulation, and electrodermal reactivity in twin men. Psychophysiology. 2005;42:753–62.

    PubMed Central  Article  PubMed  Google Scholar 

  70. Dikman ZV, Allen JJB. Error monitoring during reward and avoidance learning in high- and low-socialized individuals. Psychophysiology. 2000;37:43–54.

    Article  CAS  PubMed  Google Scholar 

  71. Coles MG, Scheffers MK, Holroyd CB. Why is there an ERN/Ne on correct trials? Response representations, stimulus-related components, and the theory of error-processing. Biol Psychol. 2001;56:173–89.

    Article  CAS  PubMed  Google Scholar 

  72. Endrass T, Klawohn J, Gruetzmann R, Ischebeck M, Kathmann N. Response-related negativities following correct and incorrect responses: evidence from a temporospatial principal component analysis. Psychophysiology. 2012;49:733–43.

    Article  PubMed  Google Scholar 

  73. Holroyd CB, Pakzad-Vaezi KL, Krigolson OE. The feedback correct-related positivity: sensitivity of the event-related brain potential to unexpected positive feedback. Psychophysiology. 2008;45:688–97.

    Article  PubMed  Google Scholar 

  74. Baker TE, Holroyd CB. Dissociated roles of the anterior cingulate cortex in reward and conflict processing as revealed by the feedback error-related negativity and N200. Biol Psychol Elsevier BV. 2011;87:25–34.

    Article  Google Scholar 

  75. Luu P, Tucker DM, Makeig S. Frontal midline theta and the error-related negativity: neurophysiological mechanisms of action regulation. Clin Neurophysiol. 2004;115:1821–35.

    Article  PubMed  Google Scholar 

  76. Bernat EM, Nelson LD, Steele VR, Gehring WJ, Patrick CJ. Externalizing psychopathology and gain/loss feedback in a simulated gambling task: dissociable components of brain response revealed by time-frequency analysis. J Abnorm Psychol. 2011;120:352–64.

    PubMed Central  Article  PubMed  Google Scholar 

  77. Pascual-Marqui RD. Standardized low-resolution brain electromagnetic tomography (sLORETA): technical details. Methods Find Exp Clin Pharmacol. 2002;24(Suppl D):5–12.

    PubMed  Google Scholar 

  78. Alexander WH, Brown JW. Medial prefrontal cortex as an action-outcome predictor. Nat Neurosci. 2011;14:1338–44.

    PubMed Central  Article  CAS  PubMed  Google Scholar 

  79. Sambrook TD, Goslin J. A neural reward prediction error revealed by a meta-analysis of ERPs using great grand averages. Psychol Bull. 2015;141:213–35.

    Article  PubMed  Google Scholar 

  80. Wessel JR, Danielmeier C, Morton JB, Ullsperger M. Surprise and error: common neuronal architecture for the processing of errors and novelty. J Neurosci. 2012;32:7528–37.

    Article  CAS  PubMed  Google Scholar 

  81. Talmi D, Atkinson R, El-Deredy W. The feedback-related negativity signals salience prediction errors, not reward prediction errors. J Neurosci. 2013;33:8264–9.

    Article  CAS  PubMed  Google Scholar 

  82. Danielmeier C, Ullsperger M. Post-error adjustments. Front Psychol. 2011;2:1–10. This study gives an overview of different kinds of post-error behavioral and neural adjustments and presents data on post-error slowing and its relation to post error accuracy, highlighting the need to distinguish these adjustments.

    Article  Google Scholar 

  83. Schroder HS, Moser JS. Improving the study of error monitoring with consideration of behavioral performance measures. Front Hum Neurosci. 2014;8:8–11.

    Article  Google Scholar 

  84. Wilkowski BM, Robinson MD. Putting the brakes on antisocial behavior: secondary psychopathy and post-error adjustments in reaction time. Personal Individ Dif. 2008;44:1807–18.

    Article  Google Scholar 

  85. Dutilh G, Van Ravenzwaaij D, Nieuwenhuis S, van der Maas HLJ, Forstmann BU, Wagenmakers E-J. How to measure post-error slowing : a confound and a simple solution. J Math Psychol. 2012;56:208–16.

    Article  Google Scholar 

  86. Konicar L, Veit R, Eisenbarth H, Barth B, Tonin P, Strehl U, et al. Brain self-regulation in criminal psychopaths. Sci Rep. 2015;5:9426. This study is one of the first applying a neurobiologically-based treatment (neurofeedback) of psychopathy, combined with behavioral measures and electrophysiological measures of performance monitoring to assess intervention outcomes.

    PubMed Central  Article  CAS  PubMed  Google Scholar 

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Acknowledgments

This work was supported by the Excellence Initiative of the German Federal Ministry of Education and Research through the German Research Foundation (DFG Grant EXC 302).

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Authors and Affiliations

  1. Cluster of Excellence “Languages of Emotion”, Freie Universität Berlin, Habelschwerdter Allee 45, 14195 Berlin, Germany

    Stefan Schulreich

  2. Department of Education and Psychology, Freie Universität Berlin, Habelschwerdter Allee 45, 14195, Berlin, Germany

    Stefan Schulreich

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Schulreich, S. Altered Performance Monitoring in Psychopathy: A Review of Studies on Action Selection, Error, and Feedback Processing. Curr Behav Neurosci Rep 3, 19–27 (2016). https://doi.org/10.1007/s40473-016-0061-x

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Keywords

  • Psychopathy
  • Performance monitoring
  • Behavioral adaptation
  • Error monitoring
  • Feedback processing
  • ERP
  • EEG
  • N2
  • ERN
  • FRN
  • Pe
  • Antisocial
  • Externalizing