The Paradox of Psychopathy

But what about psychopathic disorders? Persons with these disorders are usually considered untreatable and cannot be involuntarily admitted to a hospital. Yet psychopathy is the disorder that is most predictive of a person's future aggression and foreseeable harm to others.

Antisocial personality disorder is one of the few mental disorders for which aggressive behavior is a diagnostic criterion.¹ "Irritability and aggressiveness, as indicated by repeated physical fights or assaults," is 1 of 7 elective criteria of which 3 are required to establish the diagnosis.¹ A pattern of personal violence is widely recognized as a major predictor of future assaults. Because of its severe character pathology, psychopathy is, although limited, a better predictor of future violence than are other major mental illnesses.^2,3 High scores on the Hare Psychopathy Checklist (PCL) and on the Hare Psychopathy Checklist-Revised (PCL-R) have been shown to be strong predictors of criminal and especially violent recidivism among prisoners.^4,5

High scores on the short, screening version of the checklist (PCL-SV) are predictive of postdischarge violence among psychiatric patients^4,6 and civil psychiatric patients.^7,8 In the MacArthur study⁸ of posthospital discharge patients, a high score on the PCL-SV was a strong predictor of postdischarge violence-in fact, it was the strongest predictor of all variables studied. Even so, with a prevalence of 35.7%, more than half of patients with elevated psychopathy had no registered incidents of violence within 6 months following discharge. A history of serious child abuse and alcohol or drug abuse, together with elevated psychopathy and absence of suicidal behavior as the reason for hospital admission, raises the prevalence of violence to 58.5%.

In the 1970s, young age and male sex were considered more predictive of violence than was having any clinical condition. Because of their statistical strength-even if they were not strong predictors in themselves-such actuarial correlates were considered to be on firmer scientific ground than clinical factors and research on prediction headed toward actuarial determinations, as exemplified by the MacArthur study.⁸

However, the finding that psychopathy predicted future violence was an exciting revelation. Psychopathy carries not only predictive validity in assessing risk for future violence but also has construct validity. The PCL, in particular, identifies a disorder, condition, or dimension. Decisions need not be restricted to dichotomous options to protect the public. If something could be done that is appropriate to the condition (treatment would be ideal) then a clinical intervention offering hope for the afflicted person was conceivable and more consistent with clinicians' roles as helpers rather than as guardians of the public. Thus, research suggesting that treatment did not improve the behavior of psychopaths, and may in fact make it worse, was all the more disappointing.⁹ Obviously, society will not imprison all young males for its protection. The association between psychopathy and violence suggests a smaller, more manageable group with whom to be concerned; however, preventive detention without other beneficial goals is at the very least morally controversial.

Contrary opinion maintains that for public safety, if not for treatment (especially if the person has already victimized others), some preventive detention may be justified whether by imprisonment or hospitalization. Perhaps it is because of such a view that defendants have been acquitted based on insanity when the primary disorder is a personality disorder, despite insanity law to the contrary.¹⁰ Specific laws such as sexually violent predictor statutes allow civil commitment when the sole disorder is a personality disorder. We shall not delve into the debate over the appropriateness of civil or criminal preventive detention here, except to point out that views and laws pertaining to involuntary hospitalization for personality disorders are not as simple and settled as some commentators might suggest.

Treatment considerations with co-occurring disorders

Most important and often overlooked is that antisocial personality disorder or psychopathy in clinical settings often do not occur in the pure state. Commentaries typically discuss psychopathic disorders as if they existed in the absence of other more or less seriously disabling conditions. For example, conditions such as substance abuse and impulsive aggression may be conceptualized as either dimensions of the basic psychopathic disturbance or as distinct conditions that frequently co-occur with psychopathic disorders.

In any event, especially if the patient cooperates with treatment efforts, such conditions should not be overlooked, because a favorable response to therapeutic interventions can improve the patient's overall social functioning and decrease the risk of recidivism, even while other psychopathic traits persist. Co-occurring conditions in psychopathic criminal offenders and civil patients should not be overlooked. Whether these persons are on probation, parole, or incarcerated, failure to address co-occurring conditions therapeutically only strengthens the incorrigibility of the core psychopathic disturbance.

Persons who are antisocial and psychopathic can also have a major mental illness such as schizophrenia. If they manifest extreme aggression and difficult to manage behaviors, they may require intensive treatment in a maximum security hospital. Even aggression that is the result of psychosis can have impulsive features, such as in psychotic agitation and premeditated qualities when the act is planned but delusionally driven. Appropriate treatment of the psychosis with antipsychotic medication often serves to control aggression and other psychotic symptoms. Selected mood stabilizers or anticonvulsants can be added when antipsychotic medication alone does not control aggression.

Once the overt psychosis is controlled, aggression may or may not dissipate. For some inpatients, aggression associated with psychopathic disturbance may persist. In addition to maintenance antipsychotic pharmacotherapy, an anticonvulsant or mood stabilizer may further improve aggression that is predominately impulsive. In contrast, organized, premeditated antisocial aggression will not be altered with pharmacotherapy. Depending on the severity of the patient's core psychopathy, psychosocial rehabilitation and cognitive or behavioral therapy may be helpful with continuous treatment following discharge.

Treatment of the inpatient who is psychopathic must involve fair, reasonable, and consistent limit setting, and the patient's attempts at manipulation must be confronted and dealt with therapeutically. At first glance, this approach may seem at odds with contemporary approaches to inpatient hospitalization, which emphasize respect for the patient's wishes and de-emphasize the use of controlling and coercive measures, constant one-to-one observation, seclusion, and restraint. Indeed, every reasonable effort must be made to avoid provoking potentially aggressive patients and to use the least intrusive and restrictive measures to ensure safety. Of course, even in patients with major mental illnesses who are sufficiently disturbed and require inpatient care, titration of the ratio of individual freedom to support and control should be ongoing in their recovery process.

Transfer, prosecution, and discharge

When the guiding principles of inpatient hospitalization address the needs of those with major mental illnesses but not those of patients who are psychopathic, the latter may need to be transferred, discharged, or prosecuted in order to maintain the integrity of noncontrolling programming. Taken to an extreme, the scapegoating and exiling through the prosecution of every patient who does not conform constitutes an abusive practice. If used judiciously, prosecution actually respects a patient's autonomy by holding the person accountable for his conduct. One must remain ever mindful, however, that when successful, prosecution is a far more controlling, coercive, and punishing measure than any of the temporary protective measures customarily used in hospital treatment.

Arguments exist for and against the continued hospitalization of a patient whose symptoms of serious mental illness have been controlled but who remains dangerous to others as a result of psychopathy. Again, the greater the risk of future violence, the greater the justification for preventive detention, if one accepts the controversial view that preventive detention for public protection is a worthy social policy. But, the greater the psychopathy, the poorer the prognosis with hospital treatment and, therefore, the weaker the treatment becomes as a justification for hospitalization.

The issue is not simply a debate between the conflicting justifications of public protection and effective treatment. Regardless of whether a patient is psychopathically disturbed, traditional justification for discharge is that the patient has achieved optimal benefits from hospitalization. A minimal justification, favoring cost containment, is that the crisis or acute condition that precipitated hospitalization has subsided to the extent that the patient no longer presents a significant risk of harming himself or others in the near future. A compromising justification between these options is substantial reduction in the probability that rehospitalization will be necessary soon.

Many would advocate a laissez-faire approach to persons with psychopathic disorders. If they do not appear to be suffering and motivated, attempts to treat these patients might be wasted efforts. Civil commitment is inappropriate because the disorder does not cognitively disturb their ability to consent. In Foucha v Louisiana,¹¹ a psychopathically disordered insanity acquittee had to be released from involuntary hospitalization because, even if dangerous, he lacked a mental illness for which continued hospitalization would be justified. If, however, a person with psychopathy violates criminal law, he is subject to punishment, including imprisonment, just as any other person. Incarceration to punish the person and protect society is preferred over treatment and civil commitment. Criminal intervention is reactive, not proactive, and retributive justice is blind to whether the person has a personality disorder.

Capacity to consent and to benefit from treatment

Involuntary hospital commitment is most easily justified when the unwilling patient has a mental disorder that deprives him or her of the capacity to consent, is amenable to psychiatric treatment, and creates a serious risk of harm to himself or others. Psychopathy alone statistically elevates the risk of harm to others but does not result in incapacity to consent and is not generally considered responsive to standard psychiatric treatments.

In Zinermon v Burch,¹² the US Supreme Court noted that Burch was voluntarily admitted to a hospital and no attempt was made to ascertain whether he was competent to sign the voluntary admission forms. This and the resultant deprivation of liberty was sufficient to state a claim in Federal Court. Of course, those with psychopathy alone should be competent to voluntarily agree to hospitalization. The US Supreme Court's Burch decision¹² notwithstanding, many patients have historically been and many continue to be hospitalized voluntarily and involuntarily without having been found legally incompetent to make treatment decisions. Those who are hospitalized involuntarily show a wide range of decisional capabilities.

Most committed patients eventually benefit from treatment sufficiently to qualify for hospital discharge. Depending on jurisdictional law, some persons with developmental disabilities and sexual offenders are subject to long confinement with little to suggest the possibility of recovery as a result of treatment. Historically, persons with mental illnesses were sometimes committed for life, before the advent of effective psychotropic medicine. Whether the patient is likely to respond to inpatient treatment is an important consideration for civil commitment, but amenability to treatment per se is not necessarily dispositive.

Risk of violence

To address the risk of personal violence or harm to others, 3 qualities must be assessed: the seriousness of the risk, its likelihood, and its proximity in time.¹³ Even if unlikely to occur immediately, a risk that appears serious and near-certain must be considered grave. If violence is about to occur, its seriousness need not be extremely catastrophic to justify intervention.

When the risk is secondary to psychotic agitation associated with schizophrenia, the application of these 3 considerations: treatment decision capacity, treatment amenability, and risk-is straightforward for purposes of addressing the overall appropriateness and specific jurisdictional legal criteria for involuntary hospitalization. For the remitting patient with schizophrenia who is also psychopathic, the matter becomes more complicated. If he is no longer considered high risk, the patient may not qualify for involuntary hospitalization. However, if the patient with schizophrenia is also psychopathic, psychopathy cannot be overlooked because psychopathy may increase the risk of present and future aggression more than schizophrenia alone.

Joyal and colleagues¹⁴ suggest that many index crimes, even when perpetrated by patients with schizophrenia, are actually driven by aspects of their disordered personality. Any significant aggression during active psychosis can reasonably be attributed to the psychosis for purposes of justifying civil commitment, even if the exact causal mechanism cannot be demonstrated and psychopathy may have contributed. Once the psychotic and other schizophrenic symptoms have dissipated, the risk of aggression due to psychopathy in the distant future would not justify continued commitment under the standard civil commitment law for mental illness.

A gray area is the impulsive aggression that can persist after psychotic symptoms have subsided. Conceptually, such aggression can represent incomplete control of schizophrenic symptoms, such as persistent impairment of frontal lobe functions, the impulsive aggression seen in psychopathy, or a third comorbidity such as intermittent explosive disorder. Regardless, it can be difficult to sort out the exact origin in the patient with both schizophrenia and psychopathy. Because the aggression is out of the patient's control and can reasonably be expected to respond to appropriate treatment, we recommend erring in the direction of hospital treatment, supported by involuntary court order if necessary.

Hospital discharge planning must take into account environmental factors that can interact with psychopathic features with resultant recurrence of aggressive and antisocial behaviors and psychotic decompensation. Such risk-enhancing factors include availability of weapons, street drugs, and adversely influencing people such as members of criminal gangs. To be optimally effective, any therapy or programming begun in the hospital should be continued in the community following discharge.

Conclusion

Much remains to be learned through basic and clinical research about developing strategies to help those with psychopathic disorders lead more constructive and meaningful lives, or at least to minimize the risk of harming others and inviting harm to themselves. Paradoxically, persons who have psychopathic disorders may well be more "predictably" aggressive than those with other disorders, yet their reputation for untreatability and uncommitability is not without foundation. Nonetheless, the assessment of psychopathy can be useful in establishing a total treatment context for addressing common co-occurring conditions such as substance abuse and impulsive aggression, as well as major mental illness such as schizophrenia.

References:

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised Text. Washington, DC: American Psychiatric Publishing; 2000.
2. Hare RD. The Hare Psychopathy Checklist-Revised. Toronto: Multihealth Systems; 1991.
3. Hare RD, Clark D, Grann M, Thornton D. Psychopathy and the predictive validity of the PCL-R: an international perspective. Behav Sci Law. 2000;18:623-645.
4. Hart SD, Kropp PR, Hare RD. Performance of male psychopaths following conditional release from prison. J Consult Clin Psychol. 1988;56:227-232.
5. Serin R, Amos NL. The role of psychopathy in the assessment of dangerousness. Int J Law Psychiatry. 1995; 18:231-238.
6. Strand S, Belfrage H, Fransson G, Levander S. Clinical and risk management factors in risk prediction of mentally disordered offenders-more important than historical data? Legal and Criminological Psychology. 1999; 4:67-76.
7. Douglas KS, Ogloff JR, Nicholls TL, Grant I. Assessing risk for violence among psychiatric patients: the HCR-20 violence risk assessment scheme and the Psychopathy Checklist: screening version. J Consult Clin Psychol. 1999;67:917-930.
8. Monahan J, Steadman HJ, Silver E, et al. Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence. New York: Oxford University Press; 2001.
9. Rice M, Harris G, Cormier C. An evaluation of maximum security therapeutic community for psychopaths and other mentally disordered offenders. Law Hum Behav. 1992; 16:399-412
10. Reichlin SM, Bloom JD, Williams MH. Post-Hinkley insanity reform in Oregon. Bull Am Acad Psychiatry Law. 1990;18: 405-412.
11.Foucha v Louisiana, 112 Ct 1780 (1992).
12.Zinermon v Burch, 494 US 113 (1990).
13. Felthous AR. Personal violence. In: Simon RI, Gold LH, eds. Textbook of Forensic Psychiatry. Washington, DC: American Psychiatric Publishing; 2004:471-500.
14. Joyal CC, Putkonen A, Paavola P, Tiihonen J. Characteristics and circumstances of homicidal acts committed by offenders with schizophrenia. Psychol Med. 2004;34: 433-442.