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Home , Enabling, Superficial charm

Incurable Psychopaths?

Marianne Kristiansson, MD

Treatment, comprising pharmacotherapy and an educational program based on cognitive behavior therapy, of four psychopathic, criminal men fulfilling the crite- ria for borderline and antisocial personality disorder is de- scribed. The diagnoses were made during a forensic psychiatric evaluation. An estimation of the capacity of the central serotonergic system was performed by analysing the platelet monoamine oxidase (MAO) activity. The pharmacotherapy was combined with an educational program involving strategies for developing better impulse control. All four men had earlier been regarded as resistant to conventional therapy. In the present cases, a combined psychosocial and biolog- ical approach seemed to be effective in developing an increased control of im- pulses, leading to improved coping strategies. Controlled studies are needed in order to clarify whether the described treatment program proves beneficial.

Psychopathy, as originally described by personality disorder according to DSM- Cleckley,' comprises a set of clinical 111-R.~ characteristics including superficial The possibility of curing or even trying charm, unreliability, untruthfulness, lack to treat criminal psychopathic individuals of or , failure to learn by is often looked upon as futile. Most treat- experience, incapacity for love, general ment programs involve various psycho- poverty in major affective relations, and social interventions and little effort has failure to follow any life plan. The impul- been made to investigate and stabilize a siveness sometimes associated with habit- possible biological vulnerability in these ually violent behavior, the decreased individuals. arousal often leading to of central In recent years an association between stimulant drugs, and the lack of a decreased capacity of the central sero- are important character features and are tonergic system and habitually impulsive probably associated with the risk of de- behavior has been ~uggested.~-~If impul- veloping criminal behavior. These indi- siveness is associated with a serotonergic viduals often meet the criteria for antiso- dysfunction in the brain, pharmacother- cial personality disorder andor borderline apy aiming at increasing the serotonin metabolism by administering antidepres- sants could be of value. Case reports re- Dr. Kristiansson is affiliated with the Department of garding borderline personality disorder6 Social and Forensic Psychiatry, Karolinska Institute, Huddinge, Sweden. Address correspondence to: Mari- and psychoactive substance use disor- anne Kristiansson, MD, Department of Social and Fo- rensic Psychiatry, Karolinska Institute, Box 4044, S-14 1 ders' are in line with this assumption. 44 Huddinge, Sweden. Mania may also be associated with de-

Bull Am Acad Psychiatry Law, Vol. 23, No. 4, 1995 555 Kristiansson creased ability to control impulses and Table 1 aggression. Lithium has become well es- Items in the Revised Checklist tablished as an effective and specific 1. Glibness/ treatment for mania.839Lithium may de- 2. Grandiose sense of self-worth 3. Need for stimulation/Proneness to boredom crease the frequency of aggressive anti- 4. social acts in male delinquents'' and re- 5. Conning/Manipulativeness duce violent incidents in chronically 6. Lack of remorse or 7. Shallow affect aggressive inmates. ' Lithium may have 8. Callous/Lack of empathy beneficial effects in hyperactive psycho- 9. Parasitic lifestyle pathic individuals with a tendency to ag- 10. Poor behavioral controls gressive outbursts. 11. Promiscuous sexual behavior 12. Early behavioral problems Serotonin is metabolised via deamia- 13. Lack of realistic, long-term goals tion by monoamine oxidase (MAO; E.C. 14. 1.4.3.4) to 5-hydroxyindoleacetic acid. 15. Irresponsibility The implications of platelet MA0 activity 16. Failure to accept responsibility for own actions 17. Many short-term marital relationships in various neuropsychiatric disorders 18. have been reviewed by Oreland.I2 Plate- 19. Revocation of conditional release let MA0 activity is to a certain extent 20. Criminal versatility genetically determined and is also sug- gested to reflect the functional capacity of the central serotonergic system." hyperactivity and perceptual dysfunc- The objective of this pilot study was to tions. A lack of adequate impulse control investigate whether it is possible to obtain and an antisocial/ be- noncriminal behavior in psychopaths us- came apparent in adolescence. ing a combination of pharmacotherapy Pharmacotherapy, as described in each and an educational program based on case example, was combined with an ed- cognitive behavior therapy. ucational program based on cognitive be- havior developing strategies Patients and Methods for obtaining more effective impulse con- Four patients, all white men meeting trol. The program comprised individual the criteria for borderline personality dis- sessions with the patients during which order and antisocial personality disorder information regarding brain-body interac- according to DSM-111-R,~are described. tions was given. They were asked to ana- The degree of psychopathy was scored lyse steps from thoughts to actions and using the Hare Psychopathy Check List- the importance of understanding connec- Revised (PCL-R).I4 The PCL-R consists tions between the past, the present, and of 20 items (Table l), with each item the future was pointed out. Various cop- scored 0, 1. or 2 (not true, uncertain, and ing strategies to stabilize impulse control true, respectively). A score higher than 30 in everyday life were taught. Exercises in indicates psychopathy. training anticipation and realizing conse- In childhood all patients had presented quences of different actions were per-

556 Bull Am Acad Psychiatry Law, Vol. 23, No. 4, 1995 Incurable Psychopaths?

Table 2 four to six months, according to official Brief Description of the Educational arrest records. Program Blood samples (5 ml) for analysis of Mechanisms contributing to control of an platelet MA0 activity were obtained in act. Steps from impulse to act (via cognitive processing and experience of emotion) are the morning after eight fasting; analysed.~esponsessuch as "Everything these were taken by venipuncture using happened so fast" and "I did not think citrated vacutainer tubes (Becton Dickin- before I acted" are scrutinized. Physiology including brain-body interactions, son, Grenoble, France). Within 18 hours aggressiveness, depression, discomfort, of venipuncture the tubes were centri- sexuality. fuged at 200 X g for 10 minutes and Impulse control in everyday life. about 1 ml of platelet-rich plasma was Treatment and coping strategies aiming at improved impulse control (e.g., acupuncture, removed by careful suction. The platelet hypnosis, pharmacotherapy). count was measured by a Coulter Counter Society and the individual. (Dunstable, United Kingdom) and the Detailed analysis of earlier committed plasma frozen at -70°C until analysis. crimes (e.g., pros and cons, alternatives to crime, the feelings of the injured person). After thawing, MA0 activity was esti- Drugs, alcohol, anabolic androgenic mated as described by Hallman et a1. l7 by steroids. using phenyletylamine as substrate. MA0 How to be conscious of emotions-learn activity was expressed as nanomoles of how to manage and express them in an appropriate and well-balanced manner. The substrate oxidized per minute per 10" importance of transferring emotions to platelets. The obtained values were com- words is emphasized. pared to a reference limit of low activity.

Case Reports formed. In Table 2 a brief review of var- Case I A 38-year-old man presented ious steps of the educational program are with motor restlessness, hyperactivity, given. and aggressive outbursts since early Official arrest records were used to re- childhood. He had been convicted 13 ceive information about relapses in crin- times for crimes involving property and inal behavior. The frequency of criminal violence (assault). The history was activities was supposed to reflect coping positive for type I1 and possi- strategies. With regard to the complexity bly mild mental retardation. Immediately of the psychopathology of psychopaths, it after military service he started to use seemed not possible or reliable to make narcotics; initially he used amphetamines, an evaluation of factors (eg, reliability but after a few years he showed a prefer- and capacity to develop empathy and es- ence for heroin and alcohol, which made tablish relationships). All of the men had him calm. He had repeated periods, most earlier presented frequent relapses in often during late spring and summer, of criminality and during the period of the wide-ranging criminal behavior, in- last 10 years they had all, after release creased sexual activities, sleep distur- from prison, relapsed to criminality after bances, and marked motor restlessness.

Bull Am Acad Psychiatry Law, Vol. 23, No. 4, 1995 557 Kristiansson

After being suspected of severe assault, His PCL-R score was 38. The investi- he was admitted for a forensic psychiatric gation suggested a dysfunction of the cen- evaluation. tral serotonergic system as reflected by a His PCL-R score was 36. The investi- platelet MA0 activity level of 3.48 (the gation suggested increased basal activity corresponding reference limit for low ac- of the serotonergic system. His platelet tivity was 8.46). He was treated with cita- MA0 activity level was 15.6 (the corre- lopram, a selective serotonin reuptake in- sponding reference limit for low activity hibit~r.~Doses were increased from 10 was 8.46). In addition to an antisocial mg daily to 40 mg daily over a period of personality disorder, hypomaniclmanic 14 days. After seven days of treatment, he episodes, including lack of adequate real- declared that he was feeling "mentally ity testing, were diagnosed. Treatment healthy for the first time in my life." After with lithium (168 mglday) was initiated. four months he used amphetamine intra- A positive effect was reached at a lithium venously, but then experienced unpleas- concentration of 0.4 mmol per liter. For ant feelings. After 10 months of treat- 16 months this man was able to work and ment, no relapse in criminal behavior has have a stable relationship with a woman. occurred. His proneness to boredom and His criminal activities decreased and constant need of stimulation has de- were restricted to illegally driving a car, creased, which has made it possible for for which he was sentenced to prison. In him to reach a better level of concentra- prison the medication was disrupted. Af- tion, thereby him to start estab- ter 10 days he presented with hyperactiv- lishing long-term goals. ity, sleep disturbances at night, and re- Case 3 A 40-year-old man presented peated aggressive outbursts. After with mood disturbances, including de- another three months he was released pressive/aggressive periods marked with from prison. He continued to present the either passivity. sleep disturbances, and same mood disturbances as in prison and anxiety or periods of abusing amphet- relapsed into criminal activities (assault), amines and criminal behavior that often for which he was again sentenced to comprised violent acts. He had 36 earlier prison. After being released from prison, convictions, mostly involving crimes of he once again entered an educational pro- violence. gram in combination with lithium treat- His PCL-R score was 38. His platelet ment. He has not relapsed into criminal MA0 activity level was 2.98 (the corre- activities for 16 months. sponding reference limit for low activity Case 2 A 50-year-old man presented was 8.46). Citalopram, a selective seroto- with feelings of discomfort and uneasi- nin reuptake inhibit~r,~reduced his pas- ness since youth. For 35 years he had sivity and seemed to increase his arousal, regularly used amphetamines. He exhib- resulting in a diminished need for central ited repeated relapses into criminal be- stimulant drugs. His impulse control was havior. He had been convicted 32 times stabilized, resulting in a better cognitive for crimes involving property. capacity to manage aggressiveness. Since

558 Bull Am Acad Psychiatry Law, Vol. 23, No. 4, 1995 Incurable Psychopaths? he was released from prison 20 months relapse into criminal behavior has oc- ago, he has not committed any new curred. crimes. He has been able to finish basic school work and has now started voca- Discussion tional training. He manages to live in an Psychopathy involves various person- apartment by himself and pays his rent ality traits that constitute a complex psy- regularly. chopathology, causing lack of empathy Case 4 A 38-year-old man presented and impulse control. The crucial point is. with atypical, depressive symptoms, however, the association of psychopathy which he tried to manage by using am- with frequent relapses into criminal be- phetamine; however, this resulted in re- havior and incapacity to profit from ad- peated psychotic episodes during which verse experiences, especially . he showed marked agitation, hyperactiv- The implications of criminal behavior, in- ity, perceptual dysfunctions (possibly in- cluding its costs, to society must also be volving hallucinations), and criminal be- kept in mind. havior. He had five earlier convictions for From a clinical point of view, it is crimes involving damage to property as difficult to present factual measures of well as for violence. He was admitted to improvement with regard to the person- the clinic of forensic psychiatry during ality traits. The frequency of criminal ac- such a psychotic episode and was initially tivity is possible to measure and may treated with high doses of zuclopenthixol. reflect not only the social functioning His PCL-R score was 30. The forensic level but also such characteristics as im- psychiatric evaluation suggested a mod- pulsivity, aggressiveness, and capacity erate reduction of the serotonergic system for empathy. with a MA0 activity level of 3.62 (the These case reports represent individu- corresponding reference limit for low ac- als with repeated relapses into criminal tivity was 8.46). In addition to the low behavior. Since early childhood they had dose of zuclopenthixol, medication with presented conduct disorders in combina- moclobemid, a MAO-inhibitor,'' was tion with hyperactivity. The relationship started. Gradually, over a period of four of criminality to psychiatric status has months, an affective stability developed. been a matter of discussion among re- The dosage of zuclopenthixol was tapered searchers. Children with diagnosed atten- to 2 mg daily. He remained in the hospital tion deficit disorder and hyperactivity another 10 months, and during that period might be at an increased risk for criminal no agitation or aggressive outbursts oc- activities according to Mannuzza et a1. l9 curred. The craving for amphetamine The authors in this study also found, how- seemed to be reduced. He started to re- ever, that the association between arrest establish contact with relatives. For two history and childhood hyperactivity was months he has been on leave and is show- almost entirely mediated by the occur- ing improved coping strategies, including rence of antisocial disorders in young a capacity to manage daily activities. No adulthood. These suggestions are re-

Bull Am Acad Psychiatry Law, Vol. 23, No. 4, 1995 559 Kristiansson

flected in the present case examples. All The patients had earlier been subjected individuals had a history of conduct dis- to several years of treatment either in order combined with hyperactivity in psychiatric hospitals or in prisons. Except early childhood. for neuroleptics (Case 4) the treatment In the present cases the platelet MA0 had earlier been restricted to various psy- activity was measured in an attempt to chosocial interventions. Each patient was estimate the capacity of the central sero- regarded as impossible to treat. A thor- tonergic system. In three individuals a ough investigation of the histories of the low MA0 activity level was found. In a patients implies the importance of not study of a group of mentally disordered neglecting hypomanic (Case I), depres- offenders, those who had committed vio- sivelaggressive (Cases 2 and 3), and lent crimes had the lowest platelet MA0 schizophrenia-like symptoms (Case 4) as- activity.20 Assuming that low platelet sociated with the primary personality dis- MA0 activity is associated with a de- order; this may possibly facilitate the creased capacity of the central serotoner- choice of treatment. Recently published gic system, serotonin-enhancing drugs data suggest a certain comorbidity be- might be beneficial. The results from tween antisocial personality disorder and these case studies are in line with that mania.22 assumption. Further randomized con- In the present treatment program, phar- trolled studies are needed, however. macotherapy seemed to be the prerequi- A comparatively high platelet MA0 site for the patients' being able to partic- activity level (Case 1) is more difficult to ipate in the educational program, and interpret. It might be that the serotonergic from a clinical point of view, the com- system contributed to a lesser extent to bined psychosocial and biological ap- the symptoms as compared for example proach appeared to increase the level of with norepinephrine. The noradrenergic social functioning. Earlier they had been system, however, was not monitored in subjected to milieu therapy, but after two Case 1. One might speculate that the ob- to four months they always lost their ca- served comparatively high platelet MA0 pacity to fulfill the environmental de- activity level could be a compensation mands and ceased to cooperate. This is in mechanism for controlling the hypoma- line with recent research regarding milieu niclmanic and psychotic disorders. It is therapy with psychopaths. One study conceivable that this compensation mech- even suggests that milieu therapy, when anism could fail during stress. It is well used exclusively, may increase the risk of known that stress and trauma give rise to psychopaths relapsing into criminal be- synthesis and release of corticosteroids. ha~ior.~~The importance of getting be- Biegon2' has discussed possible effects of yond countertransference when treating steroid hormones on the serotonergic sys- psychopaths has been emphasized by tem, including a possible depressant ef- Maier,24 among others. A structured ed- fect of corticosteroids on the serotonergic ucational program based on cognitive be- system. havior therapy, combined with appropri-

560 Bull Am Acad Psychiatry Law, Vol. 23, No. 4, 1995 Incurable Psychopaths? ate pharmacotherapy, may be one way to psychopharmacologica1 approach to the treat- ment of mania. J Neuropsychiatry 1:229 -4 1, reach that goal. 1969 In summary, the present case reports 9. Schou M, Juel-Nielsen N, Stromgren E, suggest that a combined psychosocial and Voldby H: The treatment of manic psychoses by the administration of lithium salts. J Neurol biological approach may make it possible Psychiatry 17:250-60, 1954 to treat even individuals with strongly 10. Sheard MH: Lithium in the treatment of ag- marked criminal behavior associated with gression. J Nerv Ment Dis 160:108-18, 1975 11. Tupin JP, Smith DB, Classon TL, Kim LI, borderline/antisocial personality disorder Nugent A, Groupe A: Long-term use of lith- and a high degree of psychopathy. In ium in aggressive prisoners. Compr Psychia- try 14:311-17, 1973 some cases biological tests may yield fur- 12. Oreland L: Monoamine oxidase in neuropsy- ther information regarding a choice of chiatric disorders, in Monoamine Oxidase: pharmacotherapy. A conceivable rela- Basic and Clinical Aspects. Edited by Yasu- ham H, Parvez SH, Oguchi K, Sandler M, tionship between brain pathology and im- Nagatsu T. Utrecht: VSP, 1993, pp 219-47 pulsive behavior associated with such be- 13. Oreland L, Hallman J: Blood platelets as a havior as violent crime25 may have peripheral marker for the central serotonin system. Nord Psykiatr Tidsskr 43:43-51, implications for both forensic psychia- 1989 try26 and treatment programs for "incur- 14. Hare RD: The Hare - able psychopaths." The potential benefits Revised. Toronto: Multi-Health Systems, 1991 to society. including a diminished need of 15. Beck AT: Cognitive therapy: Nature and re- institutional care and therefore decreased lation to behavior therapy. Behav Ther 1: 184- 200, 1970 costs, should be kept in mind. 16. Beck AT: Cognition, affect and psychopathol- ogy. Arch Gen Psychiatry 24:495-500, 1971 17. Hallman J, Oreland L, Edman G, Schalling D: References Thrombocyte monoamine oxididase activity and personality traits in women with severe 1. Cleckley H: (5th ed). St. Louis: Mosby, 1976 premenstrual syndrome. Acta Psychiatr Scand 2. Committee on Nomenclature and Statistics: 76:225-34, 1987 Diagnostic and Statistical Manual of Mental Freeman H: Moclobemide. Lancet 342: Disorders (ed 3 rev). Washington, DC: Amer- 1528-9, 1993 ican Psychiatric Association, 1987 Mannuzza S, Gittelman Klein R, Horowitz 3. Virkkunen M, Linnoila M: Serotonin in early Konig P, Giampino TL: Hyperactive boys al- onset male alcoholics with violent behaviour. most grown up. Arch Gen Psychiatry 46: Ann Med 22:327-3 1, 1990 1073-9, 1989 4. MacCulloch M: Violence. Curr Opin Psychi- Belfrage H, Lidberg L, Oreland L: Platelet atry 3:732-8, 1990 monoamine oxidase activity in mentally dis- 5. van Praag HM: Serotonergic dysfunction and ordered violent offenders. Acta Psychiatr aggression control. Psycho1 Med 21 : 15-19, Scand 85:218-21, 1992 1991 Biegon A: Effects of steroid hormones on the 6. Kallioniemi H, Syvalahti E: Citalopram, a serotonergic system. Ann NY Acad Sci 600: specific inhibitor of serotonin re-uptake in 427-32, 1990 treatment of psychotic and borderline patients. Fogarty F, Russell JM, Newman SC, et al.: Nord J Psychiatry 47(suppl 28):79 - 84, 1993 Mania (epidemiology of psychiatric disorders 7. Sellers EM, Higgins GA, Tomkins DM, Ro- in Edmonton: phenomenology and comorbid- mach MK, Toneatto T: Opportunities for ity). Acta Psychiatr Scand 89:16-23, 1994 treatment of psychoactive substance use dis- Rice ME, Harris GT, Cormier CA: An eval- orders with serotonergic medications. J Clin uation of a maximum security therapeutic Psychiatry 52: 12:49-54, 1991 community for psychopaths and other men- 8. Gershon S, Yuwiler A: Lithium ion: a specific tally disordered offenders. Law Hum Behav

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16:399-412, 1992 diurnal activity rhythms in alcoholic violent 24. Maier GJ: Psychopathic disorders: beyond offenders, fire setters and healthy volunteers. counter-transference. Curr Opin Psychiatry Arch Gen Psychiatry 51:20-7, 1994 3:766-9, 1990 26. Fenwick P: Brain, mind and behaviour: some 25. Virkkunen M, Rawlings R, Tokola R, et al.: medico-legal aspects. Br J Psychiatry 163: CSF biochemistries, glucose metabolism and 565-73, 1993

Bull Am Acad Psychiatry Law, Vol. 23, No. 4, 1995