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Review Article *Corresponding author Samuel Juni, Department of Applied Psychology, New York University, USA, Tel: (212) 998-5548; Email: sam : A Psychodynamic Submitted: 14 November 2016 and Behavioral Model Accepted: 18 January 2017 Published: 20 January 2017a Samuel Juni* Copyright Department of Applied Psychology, New York University, USA © 2017 Juni

OPEN ACCESS Abstract Keywords We are delighted that practitioners, theorists, and researchers have been following the clinical and diagnostic endeavors in of our team at NYU. In a • Neuropsychiatry recent set of publications delineating specific aspects of character disorders (Juni 2009, • Neuropsychology 2009a, 2010, 2014), a comprehensive psychodynamic model of psychopathy has • Psychopathy been emerging as clinical findings led us to reconceptualize symptom clusters. I have been asked by the editor of this journal to share a unified model of psychopathy and antisocial behavior which incorporates our findings and conceptualizations. This paper is descriptive, intended to present an abridged summary of our conceptual system as it has evolved to date. The theoretical development and clinical rationales of the elements in this model are detailed in our previous papers. Grounded in our publications to date, the model is made more robust by incorporating the Oppositional Defiant factor and fine-tuning the other categories based on more recent clinical insights. Culling the conclusions from our clinical research studies, we annotate and outline the key elements of recent diagnostic and theoretical expositions of psychopathy, while elaborating and refining constructs of personality and behavioral disorders. The model is offered as a uniform classification strategy to systematize and reconcile disparate clinical and research data in the fields of neuropsychiatry, neuropsychology, personality, forensics, and social psychology.

INTRODUCTION While psychopathy is often accompanied by antisocial behavior, the two phenomena are not equivalent. Psychopathy Psychopathic personality vs. Behavioral disorders is a disorder of personality. It may, or may not, be expressed in and controversial disorders of psychopathology [1]. The term has specific behavior patterns, and negative behavior – regardless beenPsychopathy further fractured has been by dualdescribed tracks as in one medicine of the mostand diagnostics ill-defined personality disorder (Footnote 1). of its intensity or pervasiveness – is insufficient evidence of a which focused inconsistently on psychodynamics and on overt Similarly, behaviors which are antisocial may be attributable behaviors. to causes other than psychopathy. This divergence has been The theoretical stance of this paper is not congruent with and clinical psychology, but has been steadily eroded by the the view of the antisocial personality disorder espoused in atheoreticalcommon sense transformation knowledge for decades of American in the fields of psychiatry into a the current version of the Diagnostic and Statistical Manual of behavioral-oriented discipline (evidenced in the gradual Mental Disorders [2]. Starting with the fourth edition in 2010, exorcising of psychodynamics in the progression of DSM DSM decided to substitute the term “antisocial” for the term editions) though the tide has been somewhat stemmed by the “psychopathic” in an effort to stress the behavioral, rather than valiant efforts of a consortium of psychoanalytic associations the dynamic, aspects of the disorder. This category is presented championing PDM. Ironically, DSM still uses the nomenclature of as a collection of behavioral anomalies which share antisocial Antisocial Personality Disorder though its elements are almost qualities – in a stark departure from the psychodynamic origins all circumscribed to habitual antisocial behavior. Psychopathy, of psychopathy postulated by Henderson [3] and Cleckley [4] and disorder and features traits and attributes that may – or may not –as engender defined conceptually antisocial behavior. in PDM, focuses primarily on personality fleshed out by Hare [5], and Meloy [6,7]. Our classification model of theWe Aggressive find the DSM Psychopath stance regarding elaborated behavioral in the Psychodynamic and antisocial disorders diagnostically unsound. By contrast, we find the criteria Our model is based on three postulates which differentiate between pathological personality factors and behavioral patterns as it retains the dynamic aspect of this disorder. Diagnostic Manual [8] to have a more sound definitional integrity

Cite this article: Juni S (2017) Psychopathy: A Psychodynamic and Behavioral Model. Ann Neurodegener Dis 2(1): 1021. Juni (2017) Email:

Central Bringing Excellence in Open Access as follows: if the behavior is offensive to others. Psychopathic Personality Disorder is intrapsychic, and its Impulse control deficit: Here, too, there is no evidence of diagnosis is not obviated by a lack of antisocial behaviors. • Its criteria are emotional rather than behavioral. delay and a diminished capacity to clamp down on impulse personality pathology. There is an inability to delay gratification any incipient impulses which may arise for them, including (for example)expression. sexuality, Thus, suchappetite, individuals and thrill have seeking. difficulty Aggression controlling is but • Therefore,Antisocial Behaviordiagnosing patterns personality are typically disorders due in to general specific – an instance where control is lacking. While such individuals will anddeficits psychopathy in emotional in particularmodulation – basedand cognitive on overt anomalies. behavior express their aggression when frustrated, they have no particular is inappropriate. investment in belligerence, nor do they harbor an untoward DSM diagnostic criteria for Antisocial Personality degree of hostility or anti-social motivations. Disorder are primarily behavioral. As such, they are only Diagnostically, this pattern too is a behavioral style. It is • marginally relevant to Psychopathy. certainly not a personality disturbance, and has no implications The foundations of our conceptual strategy are anchored in of negative attitudes toward others. the differential seminal psychodynamic approaches of the classic Within the psychopathy category, we include the following: Oppositional defiant disorder: This is a new category we ourpsychopathy own studies. theoreticians Our system, -- Harepresented [5], Cleckley in Table [4], (1), and sorts Meloy the recently added to our model of psychopathy based on analyses various[6] -- as affective,elaborated relational, by elements and behavioralchampioned factors in DSM, into PDM, distinct and of patient protocols. categories which show minimal overlap. We demarcate between behavioral disorders and psychopathy. Within behavioral disorders, we feature the limitsTo thiscapture diagnosis the flavor to children of this distinct who defy psychopathic rules and regulations,orientation, following: arewe adapted deliberately the term contrary, Oppositional and show Defiant antisocial Disorder behaviors. from DSM. In DSM our use of the term, we recognize that some psychopathic adults have Social intelligence deficit: Many individuals are a characterological disposition to defy societal rules, authority and Psychopathy labels after inappropriate interpersonal psychiatrically and legally classified with Antisocial Behavior Tofigures, be sure, and we their accentuate regulations. the characterological We postulate this aspects pattern of the to these people have no intention of acting inappropriately and disordercomprise (in a distinctaccordance motif with in the the perspective classification of ofPDM) psychopathy. instead of certainlyinteractions no negativeor running emotionality afoul of the which law. motivatesWe repeatedly them. find Instead, that focusing on the overt behavioral DSM markers. Developmentally, such individuals bring with them a thatthey thosesimply acts lack would sufficient be perceived social intelligence as negative to or understand hostile. the perceived history of mistreatment by powerful others which meaning or significance of their acts and do not anticipate the fact Characteristically, such “perpetrators” are genuinely and to adopt an oppositional attitude and a combative stance prompted their very personalities to coalesce around defiance, believe that it was all just a big “misunderstanding” (which it individuals, oppositionalism is an end of its own, divorced from, indeedpuzzled is, at since the trouble they lack they the find social themselves intelligence in, to and understand honestly andtoward unrelated any directives to, context by superiors or situational or authority features. figures. For these the perceived meaning and consequences of what they did). Their understanding of social repercussions of behavior is Normal healthy development is predicated on the limited, rendering their judgment dysfunctional. Behavior which internalization of cultural norms and mores. Reasonable deviates from accepted social mores is thus unwitting. We state prosocial external restrictions and behavioral mandates, though emphatically that not only can such activities not be considered initially experienced as dystonic, gradually get incorporated pathological, but they cannot even be considered antisocial, even not experience this transition, and continue to perceive norms Table 1: Factors of Antisocial Behavior and Psychopathy. andinto rulesone’s asown infringements set of values. of Oppositionally their agency. Defiant Pathognomically, adults do I. Antisocial Behavioral Disorders

regulationsthey “carry (to the the torch” point of of defiance seeking toout a confrontations) pathological degree, even asin 1. Social Intelligence Deficit they become preoccupied with defying authority figures and II. Characterological2. Impulse PsychopathyControl Deficit situationsPervasive where aggression: conflict is easilyAlthough avoidable. DSM subsumes (Footnote individuals 2) with excessive aggression under the diagnostic category of 1.2. OppositionalPervasive Aggre Defiantssion Disorder Conduct Disorders, we classify them as psychopathic because their behavioral pathology derives from abnormal drive levels. 4. Sadism We refer here to individuals who show a marked proclivity for 3. Superego Deficit aggressive behavior. They get into altercations even with minimal a. Characterological Cruelty or no frustration. Fights are not means to achieve an end. Rather, b. Reenactment Complex they are enjoyable in themselves. Their aggressive behavior is not

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Central Bringing Excellence in Open Access derived, and that the disorder entails the displacement of are often good friends, and the friendship is not disrupted by the eroticism from sexuality to aggression in a process of pathological necessarily linked to anger or hatred. Their fighting “adversaries” fusion. It is for this reason that the enjoyment of cruelty may be conceptualized psychoanalytically as related to fetishism. evenphysical when altercations. they get seriously Moreover, hurt. the They intent will of feel fighting uneasy is notwhen to It is important to stress that Sadism without reenactment interactionswin the fight. are Many not problematic, individuals and in this often category go out of enjoy their fighting way to features is “reality oriented” since it does not engender seek out a brawl. deterioration in reality testing. Habitual aggressive behavior is arguably a diagnostic enigma. Reenactment Complex: Individuals in this sub-category as compulsive, because they often feel compelled to act out. merely exhibit characterological cruelty. What is distinct about Descriptively,Individuals who they are also excessively fall with the aggressive criteria of mayConduct be Disorder. classified reenactmentshare the pathological sadists is adevotion pattern ofto ritualisticpain infliction acting with out thoseof historic who However, we believe that categorizing this pattern solely as a behavioral abnormality or conceptualizing it as a compulsion acts of the reenactment sadist (often featuring sexual violence) both miss the dynamic basis of the disorder. Furthermore, aretrauma relational and perceived in nature. injustice. The emotional Clinically, reactions we find of that the sadistthe brutal and these individuals cannot be diagnosed as evincing Antisocial the victim are key to understanding the intent of the attack. In the Personality Disorder, since their repertoire does not entail perpetrator’s mind, the attack is construed as an interaction into negative or hateful attitudes toward others or toward society. In which he or she projects a distinct relational tone. As the planned fact, the social attitudes of these individuals are psychologically attack script unfolds, it is a psychopathic sequel to an unresolved intact, and their cognition is not disturbed as a rule. historic trauma suffered by the perpetrator, intended to “solve” The fact that habitual excessive aggression often yields the trauma by enacting a corrective redress. The pathology in Reenactment Sadism shows a range of diagnosis, since behavioral abnormality is not necessarily symptomatology with borderline features which sometimes indicativesignificant harm of personality to others is disorder. not sufficient Although to merit the a psychopathic judgment of usurp reality testing. Reenactment has the earmarks of such individuals is usually suspended when they act out, they do compulsion – especially when it repeated serially – featuring appreciate the negative repercussions of their behavior pattern precise rituals in which victims are forced to participate and when not involved in aggressive frenzies. Psychodynamically, typically combine aggressive and sexual features. however, it is clear that the behavioral disturbance in such individuals -- which derives from a miscalibrated innate Neurodegenerative Diseases, Psychopathy, and Antisocial Patterns (Footnote 3) aggressive drive -- justifies the classification of psychopathy. Recent studies have shown a general linkage between Superego deficit: The superego of normal individuals is neurodegenerative disorders, antisocial personality, and effective only insofar as it has recourse to inculcate guilt in the behavior patterns. We highlight a representative sample. individual. Lack of remorse and absence of guilt is a diagnostic In a comprehensive review of the link between psychopathy individuals as callous. to the cognitive and affective functions of the prefrontal cortex, marker of Superego Deficit, hence the common depiction of such Koenigs [9] outlines the projected analysis of PhineasGage’s The avoidance of guilt is accomplished by massive emotional brain by Damasio et al. [10], the personality changes in patients repression and reaction formation. Other affect is often also with brain damage involving ventral PFC [11], Damasio’s repressed as the effects of this self-protective defensive process subsequent analyses zeroing in on the ventromedial prefrontal solidify. It is this generalization from guilt negation to the cortex, and a number of follow-up studies highlighting a variety blockage of other emotions which renders psychopaths with of traits and characteristics which may be associated – centrally (Footnote 4) or peripherally – with psychopathy. superegoIt is important deficit shallow. to note that a large proportion of psychopathic Using DSM-IV criteria for Anti-Social Personality Disorder, personalities actually succeed – and even excel – in vocational Gregory et al. [12], and societal interaction. Particularly, those with high social bilaterally in the anterior rostral prefrontal cortex and temporal intelligence understand others’ feelings and expectations and poles. Based on a content report review significantly of a large reduced number GM of volumesmedical then play along manipulatively. In such cases, their superego records looking for indications of criminality, Lijergen et al. [13], concluded that neurodegenerative diseases can disrupt self-serving manner without personal discomfort. neural structures responsible for executive function, emotional deficit and lack of guilt is often an asset, enabling them to act in a Sadism: Sadistic psychopaths engage in aggression only processing, judgment, and self-awareness, and that resulting because they enjoy the pain they cause others. With Sadism, we dysfunction can translate into antisocial acts and criminality. have two diagnostic categories, the second being a subset of the Blair ( [14] reviewed a number of studies linking antisocial behaviors to the amygdala as the neural nexus of instrumental learning and aversive conditioning, including Blair et al. [ ], first.Characterological cruelty: The pathognomic marker of Kiehl et al. [ ], LeDoux, [ ], Tiihonen et al. [18], and others who 15 Psychoanalytically, we believe that this enjoyment is erotically highlight the medial orbitofrontal cortex, since it is involved in sadism is the enjoyment experienced when inflicting pain. 16 17

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Central Bringing Excellence in Open Access response reversal – in addition to instrumental learning [19,20]. technique of summing all items (across the factors) into a single psychopathy index which blurs crucial inconsistencies among the Aggressiveness is a diagnostic behavioral marker of certain varieties of the disorder. neurodegenerative and trauma based disorders [21,22]. Besides characterological psychopathy, our model also offers a more The clinical and classic analytic literature is replete with inconsistent features of psychopathy. We argue that much of construct of aggression per se. specific classification differential which is applicable to the of diagnostically distinct psychopathic categories. We see the Differentiating between antisocial behavior and psychopathic inconsistency is a reflection of the clinically faulty over-lapping aggression can be a crucial aspect in guiding diagnostics detrimental to studies of characterological pathology which are and treatment as well as the proper elucidation of personalitydearth of consistent based, while operational they also definitions hamper -of to psychopathy a serious degree most and other neurological disorders – let alone sociological and -- studies of neurodegenerative diseases and aggressive patterns epidemiological analysis of violence. which hinge on psychopathic and antisocial behaviors. A major stumbling block to the elaboration and charting of It is suggested that utilizing the model proposed in this paper structural, neurological, and trauma-based effects on psychopathy will go a long way to providing a template for neuroscientists, clinicians, researchers, and social psychologists alike. This will Different scales and measures are used by various researchers, is the inconsistency of definition of the latter between studies. enable consistent cataloging of the personality, characterological, and behavioral effects of a number of developmental neurological and methodologically unsound as they combine or confuse diseases and traumas (as well as developmental and personality aggressiveand the very tendencies, measures criminalwhich are behavior, used are moralconceptually shortcomings, flawed sadism, and poor social intelligence. progress in the context of descriptive clarity and common The negative diagnostic, clinical, and research repercussions disorders) so that the respective fields can enjoy scientific psychopathy and antisocial behavior have been egregious. But SUMMARYdefinitional language. theof the problem misdefinition is much oflarger a host than of this. marginally We have related argued factorsfor years in research data we have accumulated in our work with individuals diagnosedThe comprehensive with aggressive model character presented disorders. reflects Our the appreciation clinical and psychopathy,that the qualitative which divergencehas been a hindranceamong theoreticians to clinical and reflected research in of the psychodynamics of the disorders has led to a departure endeavorsthe literature in muchhas spawned of personality a host and of inconsistent social psychology definitions as well. of from its DSM diagnostics. Differentiating between behavioral and descriptions in [2,23]. While others stress emotionality [24] or within each of these by highlighting their respective pathognomic Some researchers and classification systems stress behavioral features.personality disorders, this model specifies diagnostic categories personality dynamics [25,26]. Examples of, the and latter callousness include thrill[31]. FOOTNOTES seeking [27], fearlessness and impulsivity [28], deceptiveness [29], charisma [25], absence of guilt [30] Footnote 1 This definitional hodge-podge has virtually stymied unified It is noteworthy that PDM does not classify most psychopaths research in this domain, yielding unrelated, misdefined, and as antisocial. Instead, it presents them as preoccupied by irreconcilableThe most widelyfindings. used contemporary measure of anti-social pronounced needs for interpersonal power, which prompts them behavior is Hare’s [32]. Psychopathy Checklist-Revised (PCL-R), to act manipulatively and to avoid the emotional repercussions of a scale including lack of remorse or guilt, callousness, emotional interpersonal interactions. shallowness, and lack of empathy. Analyzed initially into two factors, the “core factor” incorporates extraversion and positive Footnote 2 affect, which can be adaptive in behaviors which are decidedly Conceptually, there is a pathological developmental antisocial personality disorder, featuring reactive anger, anxiety, suicidality,non-criminal impulsive [5], while violence, the other and criminality. factor is associated with an one’scontinuum entire from moral, Oppositional ethical, and Defiantprosocial Psychopathy values – which to Superego includes complianceDeficit. The with superego social representsmores and obedience the internalized to well-intentioned structure of [33] revision of the Psychopathic Personality Inventory (PPI-R). ThisThe scale other includes popular traits index such in the as field egocentricity, is the Lilienfeld social & potency,Widows a tendency to resist rules and authority, they still do have poor planning, fearlessness, lack of stress, impulsivity, and cold- someauthority internalization figures. While of those morality with and oppositional values; they defiance merely evince see heartedness. by contrast, do not have internalized values and also do not experiencethe gatekeepers guilt as as a rule. problematic. Those with superego deficit, clustering of symptoms conceptually unsound, and no more veridicalOur analysis than many of psychopathy of the unscaled finds both “professional the PCL and judgments” the PPI Footnote 3 psychopathy types, some peripheral, and some incidental. Most A pathological level of aggressive behavior – regardless of egregious,used by clinicians however, andis the researchers. clinically-inappropriate We find some psychometric central to of a personality disorder. We argue, moreover, that excessive how disturbing it may be -- is not sufficient to merit a diagnosis Ann Neurodegener Dis 2(1): 1021 (2017) 4/6 Juni (2017) Email:

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