US Pharm. 2014;39(11):HS29-HS36.
ABSTRACT: Psychopathy is a personality disorder characterized by a profound deficit of empathy and conscience. These deficits result in a number of negative interpersonal and societal behaviors, such as pathological lying, lack of remorse, impulsivity, and poor behavior control. Psychopathy may have a genetic basis (primary psychopathy) or may be caused by early trauma or other sensitization forces (secondary psychopathy). Unlike primary psychopathy, secondary psychopathy generally includes the presence of neurosis. Psychopaths rarely seek treatment. Data are conflicting regarding the efficacy of counseling, and no proposed pharmacologic therapies show evidence of efficacy.
Psychopathy is a serious personality disorder that can have significant negative effects both on individuals and on society.1 Psychopathy was first described by Hervey M. Cleckley in his classic book The Mask of Sanity, published in 1941 and still used today for its detailed case studies of psychopathy.2 Psychopathy occurs worldwide and in all age groups, cultures, and ethnic groups, with a predominance in males. Although it is difficult to determine a precise figure, psychopaths constitute approximately 1% to 4% of the population.
Psychopathy should not be confused with psychosis. Psychopaths can clearly distinguish reality from fantasy, although their view of the world differs significantly from that of the rest of society. The public perception of the psychopath is usually that of a maniacal serial killer; however, many psychopaths do not commit crimes and they mingle freely in society. Psychopaths constitute a sizable share of the prison population (approximately 20%), however, and they are more likely than nonpsychopathic criminals to reoffend.3 It is highly probable that most people will encounter an individual with psychopathic traits sometime in their lives. Robert D. Hare, PhD, one of the foremost experts on psychopathy, has described the psychopathic personality as follows: “Psychopaths are social predators who charm, manipulate, and ruthlessly plow their way through life, leaving a broad trail of broken hearts, shattered expectations, and empty wallets. Completely lacking in conscience and in feelings for others, they selfishly take what they want and do as they please, violating social norms and expectations without the slightest sense of guilt or regret.”1
This review aims to provide pharmacists with an awareness of the clinical features of psychopathy, a summary of potential drug therapies for managing psychopathy, and an understanding of the impact of psychopathy on pharmacy practice.
Definition and Diagnosis
Psychopathy is not listed as a distinct diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).4 However, antisocial personality disorder (ASPD), as characterized by the DSM-5, is a broad term that encompasses psychopathy (FIGURE 1). Although not all patients diagnosed with ASPD are psychopaths, all psychopaths would fit under the ASPD diagnostic term. Inherent to ASPD are observable, behavioral, and objective elements characterized by antisocial and criminal behavior within a pervasive pattern of disregard for the rights of others.4 Psychopathy includes many of the observable components of ASPD along with subjective personality traits that are much more difficult to assess, such as glibness/superficial charm, grandiose sense of self-worth, conning and manipulative behavior, callousness, and lack of empathy.
The two predominant subtypes of psychopathy are primary and secondary psychopathy (FIGURE 1).5,6 Primary psychopaths are generally thought to have a genetic basis to their disorder, as opposed to secondary psychopaths (often referred to as sociopaths), whose psychopathic traits are thought to originate or be acquired from childhood trauma or other early socialization forces. These two subtypes can be further differentiated by the absence of neurotic issues in the primary psychopath, whereas the secondary psychopath often displays anxiety, hostility, and other neuroses. This review will describe the major characteristics of the primary psychopath.
The Psychopathy Checklist–Revised (PCL-R), developed by Dr. Hare, is a valid, reliable, and reproducible tool for identifying psychopathy in individual patients (TABLE 1).7 The PCL-R delineates the essential features of psychopathy, which include interpersonal and affective facets (e.g., superficial charm, grandiosity, pathological lying, conning and manipulative behaviors, lack of remorse, shallowness, callousness, and failure to accept responsibility) as well as lifestyle and antisocial facets (e.g., need for stimulation, impulsivity, irresponsibility, parasitic lifestyle, poor behavioral controls, and criminal versatility).
While these features describe the behaviors and personality elements of psychopathy, the dominant and seminal characteristic of the psychopath is a profound lack of conscience.1,3 Rather than feeling no emotion, psychopaths experience very shallow emotions. There is evidence that psychopaths can display deeper emotions if a particular feeling or emotion provokes more attention or provides an advantage. Psychopaths are known to mimic emotions and feelings as a manipulation technique. Lacking a conscience, psychopaths lie on a consistent basis, although they often sprinkle in some truth. Psychopaths are often described as being highly charming, part of the “mask of sanity” they use to deceive and con their targets. Most psychopaths are narcissistic and rarely accept responsibility for their bad actions, unless it is part of their manipulative scheme. Impulsive and irresponsible, psychopaths lack realistic, long-term goals. For example, the psychopath may voice dreams of becoming a physician, but have no idea how to achieve this goal and quickly become bored, moving on to something else.
Abnormalities in the Psychopathic Brain
A number of anatomical and physiological derangements have been identified in psychopaths, as well as in subjects exhibiting psychopathic or related traits. These have been verified by the PCL-R. TABLE 2 summarizes known derangements or abnormalities and whether these findings have implications for the pharmacologic management of psychopathy.8-17
Treatment of Psychopathy
Psychopaths rarely seek treatment; in fact, most believe that their personality affords them a significant advantage and do not perceive psychopathic traits and behaviors as a disorder. Historically, psychological counseling and psychotherapy have yielded little evidence of effectiveness. Indeed, early studies suggested that counseling provided the psychopath with new tools to use in manipulating others. More recent data suggest that counseling may be effective to some extent; however, long-term effects are unknown.1,3,18
TABLE 3 lists the potential pharmacologic treatment modalities that have been explored or theorized to help psychopathic individuals.19-30 None of the proposed therapeutic agents currently shows evidence of efficacy. Most pharmacotherapy outcomes have evaluated surrogate markers, such as reduction in illicit drug use or reduced recidivism rates. Obviously, more stringent outcome measures, such as a decrease in PCL-R scores, would be preferable.31
Psychopaths have a significant negative impact on individuals and on society. Assuming that effective combinations of psychotherapy and pharmacotherapy can be developed to successfully treat such a disorder, can a treatment regimen be forced upon a person who perceives no personal benefits in the treatment? Can society require compliant drug therapy to treat these antisocial individuals when psychopaths actually perceive a benefit in their current attributes and personality? These are intriguing questions that remain to be answered.
Implications for the Pharmacist
Even trained mental-health professionals can be deceived and manipulated by a psychopath. Dr. Hare described being taken in by psychopaths during his many years of studying this disorder.1 The advantage that psychopaths hold over others is that most people cannot conceive that anyone can be totally devoid of a conscience and empathy. Psychopaths capitalize on this by using victims’ empathy, sympathy, compassion, and mercy against them to keep them off-balance, rendering them unable to perceive the psychopath’s underlying true agenda.
Recognizing a psychopath is the best defense against becoming a victim.31 This can be difficult because of the charm and confidence psychopaths exude and the manipulative behavior they employ. Psychopaths have difficulty verbalizing emotional issues; for them, it is almost like having to speak a foreign language.32 As a result, they often use exaggerated hand movements when discussing emotions or relationships. Psychopaths may also have a reduced capacity to discriminate between and identify smells, but whether this will prove helpful in differentiating them from nonpsychopaths is unknown.33 Finally, psychopaths are often characterized as having a predatory stare; some authors have described it as a reptilian stare: lifeless, emotionless eyes with nothing behind them.4,34,35
The pharmacist may encounter a psychopath as a drug-seeking patient. Drug addiction and psychopathy show a high correlation because both conditions have common traits.36 Defining traits possessed by psychopaths and drug addicts include novelty-seeking behavior and lack of impulse control. Impulsivity is deeply rooted in the brain’s dopaminergic pathways. Psychopaths appear to have hypersensitivity and excessive activation of the mesolimbic dopamine system.13 Impulsivity and novelty-seeking, often resulting from boredom, render psychopaths susceptible to drug-seeking behavior.
The pharmacist also may come across a psychopath in a possible business deal or financial arrangement.37 However, psychopaths are equally likely to be encountered as employees, pharmacy technicians, customers, sales representatives, or healthcare professionals. It is important to remember that not all psychopaths are inevitable criminals destined for incarceration.38 Because of their compulsive lies and narcissistic confidence, psychopaths can effectively portray themselves as highly successful, well-educated, well-adjusted individuals. Doing a thorough background check, checking references, and verifying credentials are excellent ways to identify a potential psychopath. Diligent, detailed checks must be performed because psychopaths are known to cleverly falsify credentials and work history. Psychopaths frequently switch careers, change relationships, or relocate. Such a history, combined with the trail of destruction that many psychopaths leave behind, is often a clue to identification.
It is critical to realize that many people may exhibit psychopathic traits or behaviors at times, whether it is an occasional lie, a momentary lack of empathy, or a temporary dearth of conscience. This does not make us all psychopaths. Pharmacists should not label every patient or associate who treats us poorly as a psychopath. Psychopaths are fundamentally different from other humans and are essentially unalterable in their disposition and destiny. Although they can don their mask of sanity for a period of time, psychopaths ultimately fall back on primal and ingrained instincts that cause them to seek power and domination by means of lies and manipulation.
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