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1. frontpage A comprehensive developmental view of psychopathic personalities David X. Swenson PhD LP Gerald Henkel-Johnson PsyD LP MnATSA Conference April 6, 2006 Minneapolis, MN

2. objectives Agenda • Why this workshop? • Meet the psychopath (video vignettes) • Diagnostic criteria for ASP & the “antisocial spectrum” • Incidence of antisocial behavior • Family attachment • Developmental pathways • Brain research • The cost of antisocial behavior

3. Drivers Current Issues in ASP Diagnosis • Drivers of the Psychopathy Model • Popularity of psychopathic media themes • Need to distinguish between low and high risk offenders, especially if violent; Crisis in prediction of “super-predators,” • Prevent juvenile exposure to adult sanctions epidemic of juvenile violence; grounds for transfer to adult system • Origins of condition (possible organic bases); fMRI • Available diagnostic test to distinguish (e.g., PCL-R, PCL-YV) • Risks • Remanding youth to the court prematurely • Giving up on the youth as incorrigible • Inconclusive data supporting psychopathic diagnosis in youth • Risk that psychopathic label is not used to indicate need for further assessment, but are used for disposition of adults Laurence Steinberg, The Juvenile: fads, fictions, & facts about identification and treatment of serious juvenile offenders.

4. Defining Antisocial Spectrum "When I'm good, I'm very good. When I'm bad, I'm better." (Mae West)

5. DSM • The DSM-IV, describes Antisocial Personality Disorder (301.7) as a pervasive pattern of disregard for and violation of the rights of others, as indicated by three (or more) of the following: • failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest; • deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure; • impulsivity or failure to plan ahead; • irritability and aggressiveness, as indicated by repeated physical fights or assaults; • reckless disregard for safety of self or others; . • consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations; • lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. • The individual is at least 18 years, there is evidence of Conduct Disorder with onset before age 15 years, and the occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.

6. The Family of Antisocial Personalities Character Neurosis Super-Ego Lacunae Primary Psychopath Common Sociopath Alienated Sociopath Aggressive Sociopath Dyssocial Sociopath Punishment Seekers Secondary Psychopath Adolescent Rebellion Distempered Psychopath Paranoid Personality Charismatic Psychopath Inadequate Personality “A rose by any other name…” Sociopathic Personality Psychopathic Personality • Epileptic Equivalent • Choleric Type • Hypersexed Type • Pathological Cravings • Hysterical Type • Disaffiliated Type • Disempathetic Type • Hostile Type • Cheated Type Lykken, D. T. (1995). The antisocial personalities.

7. Hare characteristics Hard core: The psychopathic personality (PCL-R) • Glibness/superficial charm (1) • Grandiose sense of self-worth (1) • Pathological lying (1) • Cunning/manipulative (1) • Lack of remorse or guilt (1) • Shallow affect (1) • Callous/lack of empathy (1) • Failure to accept responsibility for own actions (1) • Need for stimulation/proneness to boredom (2) • Parasitic lifestyle (2) • Poor behavioral controls (2) • Early behavior problems (2) • Lack of realistic, long-term plans (2) • Impulsivity (2) • Irresponsibility (2) • Juvenile delinquency (2) • Revocation of conditional release (2) • Promiscuous sexual behavior (T) • Many short-term relationships (T) • Criminal versatility (Hare, 1986) (T) Factor 1: Callous emotional and interpersonal detachment; unrelated to environmental factors (e.g., dysfunctional family), lifetime stability; correlated with narcissistic, histrionic personality & machiavellianism, negatively correlated with anxiety and empathy Factor 2: Chronic and unstable lifestyle; socially deviant antisocial behaviors; tends to extinguish about age 40; correlated with criminal behavior

8. Psychopathy & APD in Offender Populations (Hare, 2006) All offenders (100%) APD (50%+) PCL-R Psychopaths (10-20%) White Collar “Successful Psychopaths” ? Many treatable with current programs Difficult to treat with current programs

9. PCL-YV Psychopathy Checklist: Youth Version Factor 1 Factor 2

10. 1% PDD 1-20% ADHD 1% FAS/FAE 4-6% Bipolar 2-8% LD Antisocial “Spectrum” 40-50% of CD becomes ASP 2-16% 6-16% boys 2-9% girls 3% males 1% females PDD ADHD FAS/FAE Bipolar LD etc… 1% Oppositional Defiant Disorder Antisocial Personality Disorder Psychopathic Personality Disorder Conduct Disorder Stimulus seeking Lack goals Parasitic Predatory Violent Criminal acts Impulsiveness Disregard safety Irresponsibility Lack remorse Aggression Destruction Deceitfulness Rule violation Manipulation Hostile Defiant Negative Inattention Poor social skills Learning deficits 80% of kids with ADHD as children carried it into adolescence, and 60% of those had developed ODD or CD. 100% of antisocial personality disorder have Dx as CD as youth.

11. Oppositional Defiance Conduct Disorder Psychopathy • Glibness/superficial charm (1) • Grandiose sense of self-worth (1) • Failure to accept responsibility for own actions (1) • Pathological lying (1) • Cunning/manipulative (1) • Lack of remorse or guilt (1) • Shallow affect (1) • Callous/lack of empathy (1) • Parasitic lifestyle (2) • Poor behavioral controls (2) • Early behavior problems (2) • Lack of realistic, long-term plans (2) • Impulsivity (2) • Irresponsibility (2) • Need for stimulation/proneness to boredom (2) • Juvenile delinquency (2) • Revocation of conditional release (2) • Promiscuous sexual behavior (T) • Many short-term relationships (T) • Criminal versatility (Hare, 1986) (T) • Bullies, threatens, & intimidates • Initiates physical fights • Used weapon that can cause serious physical harm • Physically cruel to people • Physically cruel to animals • Stolen while confronting victim • Forced sexual activity • Deliberately engaged in fire setting with intentional damage • Deliberately destroyed property • Broken into someone’s house, building, car • Lies to obtain goods or favors or avoid obligations • Stolen nontrivial items without confronting victim • Stays out at night despite parental prohibitions • Run away from home overnight twice while living in parent/surrogate home • Truant from school • Loses temper • Argues with adults • Actively defies or refuses to comply with adults requests or rules • Deliberately annoys people • Blames others for his/hers mistakes • Touchy or easily annoyed • Angry or resentful • Spiteful or vindictive

12. incidence Incidence of Psychopathy • ASP M=3%, F=1%; Psychopathy = 1% gen. population • 15-20% of prisoners • Across all races, cultures & ethnic groups • Common among drug dealers, spouse and child abusers, swindlers and con men, high-pressure salesmen and stock promoters, gang members, mercenaries, corrupt politicians, unethical lawyers and doctors, terrorists, cult leaders, and black marketeers. • Recidivism 2x other offenders; violent recidivism 3x • 4x more likely to commit violent offense after treatment release from intensive treatment community • Treated psychopaths are more likely than untreated to commit crime (develop better manipulations & deceptions) • Court mandated therapy for spouse abusers are ineffective for 25-35% who are psychopaths • Base rates of psychopaths among is 6-10% for pedophiles, 35% for rapists, and 64% for those who sexually perpetrate against both children and adults

13. What we know about antisocial behavior among youth • Persistent aggression after third grade (age 8) is predictive of continued aggressiveness; its stability is similar to that of intelligence; the more severe the more stable • 40% of 8 year-olds with conduct disorder are repeatedly convicted of theft, vandalism, & assault in adolescence • Conduct problems can be predicted with 80% accuracy 5 years later based on social skills, negative/aggressive behavior, and disciplinary contacts • Drop-out rate is 12% for at-risk youth and 62% for antisocial youth • Three years after leaving school, 70% of antisocial youth have been arrested at least once. • Forty percent of the offenders who victimized children under age 6 were juveniles • ½ of all adult offenders had at least one deviant interest before age 18

14. Student risk screening • Stealing • Lying, cheating, sneaking • Behavior problems • Peer rejection • Low academic achievement • Negative attitude • Aggressive behavior Student Risk Screening Scale

15. Developmental Considerations

16. Development arrow Development of behavior disorders in youth • Infancy • Prematurity • low birth weight • brain injury • FAS/FAE • ADHD • attachment • hyperreactive • “colicky” • unhealthy • disability • pain • multiple placements • Environmental • pop. density • poor housing • mobile residents • discrimination • media violence • cultural norms • no support svc. • discrimination • crime rate • Peers • delinquent/deviant peers • antisocial sibs • bullying • rejection by norm group • attention/recognition • belonging • act out • revenge PROBABLE OFFENSE • Family • cohesion • flexibility • poor boundaries • inconsistent discipline • poor supervision • marital relationship • handle emotions • poor role modeling • criminality • physical, emotional, • sexual abuse • explicit sexuality • disorganization • cold, rejecting • large family • father absence • long unemployment • Personality-- What prevents you from offending? • values (“It’s wrong”) • empathy (“it would hurt others”) • consequences (“I’d get in trouble”) • ego dystonic (“that’s not me”) • shame/embarrassment (“what would other think”) • esteem (I’d feel awful”) • identification (“wouldn’t want that to happen to me”) • personal responsibility (“I would be responsible”) • self monitoring & control (“I’d stop myself”) • coping (“other ways to deal with tension”) • Pre-family • poverty • single • unwanted • MI (depression) • AODA • teen/immature • abused • antisocial • divorce • assortative mating • transgenerational problems

17. Nature nurture Nature or nurture?– yes! • heritability of ASP (as well as prosocial behavior) estimated at 50% • trauma modifies the risk • incompetent parenting further modifies the risk

18. ~~Attachment~~ Family Considerations: Attachment Theory & Offender Development

19. Normal attachment Normative Healthy Attachment • eye contact • cooing • crying • smiling • reaching • grasping • approaching • following • discomfort • hot/cold • hungry • happy • afraid • angry • tired • wet Availability Sensitivity Responsiveness Consistency • prolonged gazing • kissing • cuddling • fondling • high voicing • rocking • rhythmic contact • seek closeness & reciprocity • frustration tolerant • high intimacy • long lasting relationships • high levels of commitment • high relationship satisfaction • stress resilient • fewer physical & psychological problems • less aggressive, more cooperative • high belonging • Secure attachment • trust • safe/secure • regularity • easier to comfort • more affectionate

20. Poor attachment • mental illness • postpartum depression • attachment disordered • chemical abuse • physical illness • multiple caretakers • frequent moves • criminal behavior • preoccupation • separation/divorce • death • PDD Attachment Problems • Unresponsive to Comforting • severe illness • premature birth • surgeries/pain • hyperactive • hospitalizations • colicky • autistic • FAS/FAE • physical abuse • domestic violence • absence • neglect • inconsistency • over/under stimulate • over/under attentive • rejecting • Insecure Attachment • untrusting • fearful • angry

21. Effects of multiple caretakers The effects of multiple caregivers • Insecure attachment– unstable image of caregiver • Confusion over different caregiver & household rules • Poor, variable boundaries • Conflicted guilt over attachment to foster parents vs. parents • Mistrust, caution (due to previous abuse) • Displace anger onto new caregivers from past resentments • Learn superficial charm to manipulate others • Play people off against each other • Continuous testing to see if they are rejected • Fear of removal, loss, grief; closeness means pain • Preoccupation with fantasy of returning to family of origin

22. Self _ + + Others _ Adjustment: low self efficacy, low confidence, emotionally expressive & labile, intense, too close too fast, inconsistent, dominating, controlling, unsatisfactory intimacy, jealousy, obsessive, compulsive, idealizing, oversensitive, shame prone, deficient problem solving, dislike authority & rules, self-defeating, Offenders: nonthreatening, seek immature victims, groom over time, quasi-romantic relationships, (borderlines, bipolar) Internal Working Model & Types of Attachment Preoccupied Anxious- Ambivalent Secure Available, responsive, nurturing, consistent Neglecting, avoidant, indifferent Avoidant- Dismissive Avoidant- Fearful Ambivalent, inconsistent, over/under responsive Violent, abusive, threatening, punitive, rejecting Adjustment: self blame, not seek or accept help, fear rejection, fear disclosure & closeness, lack trust, emotionally aware but unexpressive, passive, superficial intimacy, not recall childhood, hypervigilant (depressive, schizoid) Offendersengage in impersonal, single contact sex, acquaintance rape, cruising Adjustment: uncaring, avoid closeness, non-disclosing, high confidence, aloof, indifferent, impatient, shallow, vain, hostile, arrogant, grandiose, reject treatment, selfish, controlling, AODA, vengeful (narcissistic, psychopathic) Offenders: coercive & assaultive, no guilt, remorse, shame (Bartholomew, Shaver, et al.)

24. Developmental Pathways for Conduct Problems

25. CD ODD Destructive A Property Violations B Aggression Animal Cruelty Assault Stealing Spiteful Blaming Cruel Vandalism Fighting Fire setting Lying Bullying Covert Overt Annoying Swearing Temper Runaway Defiance Rule Breaking ODD Truancy Arguing Angry Stubborn Substance use Touchy C Status Violations D Oppositional Nondestructive CD ODD

26. Early/adolescent onset

27. Neurological Research

28. The Male Brain and ASP

29. The case of Phineas Gage Phineas gage • Gage was a railroad construction supervisor in 1848 when a tamping rod was driven through his skull by an explosion • The tamping rod severed the connections in the frontal area • Prior to the accident he was a moral, hardworking, sensitive, conscientious, intelligent, and well liked • Following the accident, his personality changed: lying, swearing, fighting, drinking, extravagance, seizure prone, and antisocial

30. Pruning MRI Time-lapse imagery of brain age 5 to 20 Use it or lose it! Note: red shows more gray matter while blue shows less gray matter. Gray matter wanes as the brain matures and neurons are pruned. Areas for basic function mature early; higher executive functions later.

31. Stroop color word test Undersocialized subjects have more difficulty than control subjects in naming the color, suggesting frontal lobe involvement (Waid & Orne, 1982)

32. Frontal brain Brain “CEO”: Forebrain or Prefrontal Area • Planning • Attention • Judgment • Reflection • Prioritizing • Self control • Strategizing • Sequencing • Anticipation • Organization • Impulse control • Second thought • Working memory • Modulating mood • Response flexibility • Goal-directed behavior • Foresee consequences

33. Stress Effects of Stress & Trauma on the Brain • Long term exposure to stress & violence produces high level of fear hormone, cortisol (reduces connections & may shrink hippocampus) • High stress homes, & multitasking technology (computer games) more often produce short attention (ADHD) • Verbal abuse (repeated yelling, scolded, criticized) has adverse effects on the limbic (emotional) system, likely through stress pathways • Physical and/or sexual abuse increases limbic system dysfunction including olfactory hallucinations, visual disturbances, déjà vu, jamais vu • Repeated recollection and obsessing can intensify the stress effects • Physical/sexual abuse or neglect is associated with decrease in the size of the hippocampus (working memory) in adulthood • Stress tends to short-circuit frontal lobe processing (what little there is) and switch to emotional processing (resulting in over-sensitivity) • Such impairments may make the challenges of school even more stressful– a vicious cycle

34. Reading emotion Reading Emotion— Normal Youth • Youth seem to do nothing but socialize, yet are poor readers of emotion • Undeveloped prefrontal cortex plays role in assessment of social relations, planning, and impulse control in social relations • Compared with adults (100%), teens (50%) have greater difficulty correctly identifying emotional facial expression • This confusion may lead to misinterpretation & inappropriate reaction • Girls somewhat more accurate than boys; boys misinterpret cues • Deep emotional relationships comes from ability to read subtle cues • When one observes a close friend receiving a shock, although the sensory cortex does not activate, the emotional one does When reading emotion, teens (left) rely more on the amygdala, while adults (right) rely more on the frontal cortex. • Conduct Disordered Youth: • Errors in evaluating motive and intent • Misinterpret social cues • Attribute hostile intentions • Tease others but respond negatively to others • Abnormal standards and expectations regarding own behavior

35. Psychopath brain The Brain of the Psychopath • 64% of violent people have abnormal frontal lobes, 50% brain atrophy, 40% EEG abnormalities • 84% victims of severe physical or sexual abuse • Ratio of brain abnormalities of violent to normals is 31:1 • Normal people blink to a startling noise when viewing an unpleasant picture compared to a pleasant one– psychopaths don’t • Brains may not be able to construct an emotional facsimile (empathy) of others’ discomfort • Less able to process deep semantic meaning of words & emotional significance of events • Show less response to startle, lower GSR to expected painful stimuli, less fear of common hazards, higher pain thresholds, less avoidance of shock-punished errors in learning task

36. Brain serotonin Antisocial behavior & the brain • Impulsive, violent emotions appears to be a failure of emotional regulation • ASP shows impairment in the orbito-frontal cortex (impulse control, judgment, tact) and its connections with anterior cingulate cortex (conflict coping) & amygdala (fear & anger) • Abnormalities in serotonin function • Early neglect (sensory deprivation) trauma & abuse affects the development of the brain • During 1st three years the brain grows rapidly, later “prunes” unused areas • Result: poor impulse control, lack of socialization, poor empathy, reactivity

37. serotonin

38. Lykken study startle Normal people show fear, startle, and avoidance reactions to painful stimuli– psychopaths don’t

39. Non-reactivity to Emotional Stimulation

40. Socialization

41. Less easily-socialized youth require more competent parenting to avoid personality disorders

42. Moral self core Essential Components of a Moral Self Core Empathy (2-7 yrs): see from other’s perspective Sympathy: sorrow for another person’s distress Remorse: regret & sadness at one’s role in another’s pain Guilt (3-4 yrs): signal to repress impulses so not to offend or upset another; includes regret over actions Anxiety (5-11 yrs): apprehension about violation of other’s standards Shame (1-2 yrs): Inner sense of not meeting expectations Embarrassment (3 yrs): expansion of shame involving standards of others and fear of judgment

43. Development of empathy Development of Empathy • Year 1: Global Distress • chain reaction when other infants cry • Year 1-2: Egocentric Empathy • Imitative distress & behavior of another child; concern for others & try to comfort them • Year 2-3: Empathy for Other’s Feelings • Empathy with distress, disappointment, fear, surprise, sadness, anger, enjoyment • Year 3-8: Empathy for Other’s Life Conditions • Imagine pain/pleasure of remote persons & groups

44. Emotional intelligence Emotional Intelligence Skills (Goleman) • Self Awareness: Knowing one’s internal states, resources, and limitations • Emotional awareness: recognizing one’s emotions and their effects • Accurate self assessment: knowing one’s strengths and limits • Self confidence: strong sense of self worth and capabilities • 2.Self Regulation: Managing one’s internal states, impulses and resources • Self control: keeping disruptive emotions and impulses in check • Trustworthiness: Maintaining standards of honesty and integrity • Take responsibility for personal performance • Adaptability: Flexibility in handling change • Innovation: Being comfortable with new ideas • 3.Motivation: Emotional tendencies that guide or facilitate reaching goals • Achievement drive: striving to improve • Commitment: aligning with the goals of the agency or group • Initiative: Readiness to act on opportunities • Optimism: Persistence in pursuing goals

45. Emo IQ cont’d • 4. Empathy: Awareness of others’ feelings, needs, perceptions and concerns • Understanding others: Sensing others’ feelings and concerns • Identifying their development needs: bolstering their abilities • Service orientation: recognizing and meeting users’ needs • Political awareness: Reading a group’s emotional currents and powerrelationships • 5. Social Skills: Ability to induce desirable responses in others • Influence: ability to persuade • Communication: listening openly • Conflict management: negotiating and resolving disagreements • Change catalyst: Initiating and managing change • Building bonds: nurturing key relationships • Collaboration and cooperation: working with others towards shared goals • Team capabilities: Creating group energy in pursuing collective goals

46. System map of traits Possible pathways among traits Stimulation seeking Low fear, anxiety High pain threshold Low motivation to anticipate consequences Opportunist (versatility) Inability to anticipate, learn, insight Poor planning, present orientation, unrealistic Predatory Limited cognitive capacity, inattention Impulsiveness Early behavior problems Poor identification with others Parasitic Irresponsible Aggressive Callous No remorse, shame, guilt, embarrassment Narcissism grandiosity Poor social attachment Superficiality Promiscuity Short term relations Charm glibness Verbal fluency Manipulation Lying

47. The cost of antisocial behavior • Young people who represent only 20% of the population produce 40% of reported crimes • Out of district juvenile placement can cost about $200,000/year • By the time youth are finally referred to day treatment programs they have already cost $250,000 in services • By age 28, the costs for public service for individuals with conduct disorder were 10 times higher than non-CD persons, especially related to crime (Scott, et al., 2001) • Antisocial persons have longer and more periods of unemployment • The cost of incarceration per prisoner per year is $20,000-$50,000 • Recurrent or lifetime incarceration costs about $3 million per person NOT counting the indirect costs of adjudication, damage to victims, and related costs over the years • Execution is more expensive than lifetime incarceration: Execution can be from $2.1 (CA) to 3.2 million (FL), and incarceration from $600K (FL) to $1.4 million (CA) • Net annual direct & indirect cost of criminal behavior in the US is estimated at $1 trillion (Journal of Law & Economics, 1999) • High quality early childhood development programs have high cost-benefit ratios of $3 for every $1 invested (Lynch, 2004) • early invention programs can prevent as many as 250 crimes per $1 million spent while the same amount spent in prisons would prevent only 60 such crimes a year(Rand Corp, 1997)