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 personality disorder 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 remorse or shame, 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 abuse of central In recent years an association between stimulant drugs, and the lack of empathy 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 Psychopathy Checklist tablished as an effective and specific 1. Glibness/Superficial charm 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. Pathological lying social acts in male delinquents'' and re- 5. Conning/Manipulativeness duce violent incidents in chronically 6. Lack of remorse or guilt 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. Impulsivity 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. Juvenile delinquency 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/conduct disorder 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 family history was activities was supposed to reflect coping positive for alcoholism 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