Treatment for people with psychopathic personality disorder needs to change to be effective, says research

Current treatment for adults with psychopathic personality disorder needs to change if it is to be effective, as those with the condition process information related to punishment and reward differently, researchers have found.

The functional Magnetic Resonance Imaging (fMRI) study by scientists from King’s College London and the University of Montreal, published in Lancet Psychiatry, found that men with psychopathic personality disorder have functional differences in their brains.

Most violent crimes are committed by people with anti-social personality disorder (ASPD). Half the UK prison population meet the diagnostic criteria for this disorder. Such individuals are ‘hot headed’: reactively aggressive, impulsive, and poor decision-makers. One third of those in prison with ASPD also meet the diagnostic criteria for psychopathy. Such individuals are ‘cold-hearted’: callous, lacking in empathy, grandiose and instrumentally aggressive, that is, using aggression in a planned way to get what they want. Psychopathy is persistent across the lifespan and is thought that children with callous and unemotional traits go on to develop psychopathic personality disorder as adults.

Senior author Dr Nigel Blackwood from King’s College London said: “We know that men with antisocial personality disorder and psychopathy respond poorly to punishment across their lives: they seem to struggle to use punishment to change their behaviour. Until now we did not know why. The key is in their altered information processing system for punishment and reward information in comparison to antisocial men without psychopathy. This is the first study to show these differences in functional terms.”

By studying how adults with ASPD with and without psychopathy approached a punishment and reward task in an fMRI scanner, researchers were able to identify differences in the way they processed information and their ability to adapt their behaviour according to its consequences.  

The study comprised 12 violent offenders with ASPD and psychopathy; 20 violent offenders with ASPD but not psychopathy and 18 non-offenders. They completed a ‘reinforcement learning’ task in the fMRI scanner and researchers assessed their ability to adjust their behaviour (‘adaptive decision-making’) when the consequences of their responses changed from reward to punishment. 

“We were particularly interested in the areas of the brain that track change in reward or punishment and what we found was a markedly different response in those with ASPD and psychopathy,” added Blackwood. “At the point at which something previously rewarded was now punished we found abnormally increased activity in the posterior cingulate cortex and the anterior insula. 

“Crucially, our findings suggest that offenders with psychopathy do not simply show reduced neural sensitivity to punishment, they show altered organisation of the information processing system responsible for reversal learning and adaptive decision making. This is similar to the findings with children with callous and unemotional traits. In childhood, however, diagnostic schemes such as DSM-V already recognise the callous unemotional group of children, but adult diagnostic schemes do not, lumping all such men together as antisocial personality disordered.  This means that in treatment terms we have a ‘one size fits all’ approach. This is wrong.”

Fellow study author, Professor Sheilagh Hodgins from the University of Montreal’s Department of Psychiatry, added: “Our studies are providing insights into the neural mechanisms at work in adult violent offenders that may be used, along with other findings, to design treatment to reduce reoffending. Conduct problems and the antecedents of psychopathy emerge early in life when learning-based interventions have the potential to alter brain structure and functioning. Future studies could focus on the development of psychopathy in children with callous and unemotional traits and hopefully improve childhood interventions to prevent violence and create behavioural therapies which in turn could significantly reduce violent crime.”

Reference

Gregory S, Blair RJ, ffytche D, Simmons A, Kumari V, Hodgins S and Blackwood N (2015) Punishment and the psychopath: an fMRI investigation of reinforcement learning in violent antisocial personality disordered men. Lancet Psychiatry. Available at:  http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(14)00071-6/abstract.