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Case: “He killed the cat!”

Chief complaint

• J. is a 8-yo boy brought to see you for killing the family pet.

Background:

• He and his 6-yo sister were adopted by loving middle class parents when he was aged 3, and his sister was aged 1.

Onset of issues:

• From the beginning, parents sensed that J. was different. He could be perfectly charming and friendly at times. However, he was often indifferent to the pain and suffering of others, often laughing when others were hurt. He appeared to be aware of others feelings (e.g. knowing that they were sad or upset), but simply didn’t appear to care about upsetting others. He appears to lack true remorse when his behaviours hurt others, other than remorse that he has gotten into trouble. Unfortunately, he appears to be learning the ‘right things to say’, but despite saying them, incidents continue to occur.

Now that he is in Gr. 3, there are more issues:

• Other students accuse him of bullying them. Teachers have had a hard time coming up with evidence, because the alleged bullying apparently happens only when adults aren’t around.
• There was an incident of violence at school, where he punched a teacher, because he felt the rules shouldn’t have to apply to him.

Treatment:

• He has seen two counselors so far, for help with managing his anger, however parents do not feel it was helpful at all. Parents report “he knows all the right things to say to the therapist, but nothing really changes at home.”

Parent interventions:

• Parents tell you that they have done parenting courses, and that they set clear limits and expectations, with clear consequences. “No matter how we consequence him, it doesn’t seem to work. We even took everything out of his room, but he doesn’t care.”

Last week, he put the family cat in the dryer, and killed it… He tells you matter of factly, “I was bored, and I was curious what would happen…”

What are you going to recommend?

Epidemiology

• Prevalence of psychopathy is ~ 1%
• Adult psychopaths comprise only a small percentage of the general population; nonetheless, they commit half of all violent crimes

Terms

There are many related terms used to describe people who have troubles with behaviours and empathy.

• Psychopathy: A mental condition where people have a lack of moral, ethical behaviour (i.e. lack of ability to show empathy, caring for others).
• Psychopath: A person who has psychopathy.
• Sociopath: Essentially the same thing as psychopath.
• Psychopathology: Psychopathology is the study of abnormal thoughts, feelings and experiences, which includes mental disorders (such as anxiety, depression, psychosis). Psychopathy is one type of psychology.
• Conduct disorder: In the DSM-5 (a manual of mental conditions), conduct disorder is a type of mental condition for those aged up to age 18, who have troubles with behaviours that violate the rights of others (e.g. aggression, deception, etc.)
• Antisocial personality disorder: In the DSM-5 (a manual of mental conditions), antisocial personality disorder (ASPD) is a mental condition for those 18 and above, who have troubles with behaviours that violate the rights of others (e.g. aggression, deception, etc.

Etiology

Research suggests that there are two main paths that lead to the development of psychopathy aka callous/unemotional traits:

• Nature: For some children, it is felt that their callous/unemotional traits are genetically determined and result from the way the child’s brain is ‘hard wired’. The typical profile will be that of a child with callous/unemotional traits even though the child appears to have been raised by ‘good enough’ parents in loving environments.
• Nurture: For other children, it is felt that their callous/unemotional traits are due to adverse childhood environments (Gullhaugen, 2011):
  • Abuse and/or neglect from parents
  • Growing up in poverty
  • Living in a violent neighborhood

Neurophysiologic features

There are various neural abnormalities in the psychopathic brain that help explain their behaviours:

• Limbic system
  • The limbic system is less functional (due to less gray matter with an undersized or underactive amygdala), which may explain why:
    • They may not be able to feel true empathy towards others,
    • They have troubles recognizing fear or distress in other people’s faces
    • They may not be able to refrain from violence
  • It is typical in social species (such as humans), that there are social hierarchies established in order to minimize conflict, with members in the classic dominant (“alpha”) role
  • Unfortunately, children/youth with psychopathy have troubles recognizing others’ distress cues (e.g. fear, sadness) which are a normal signal of submission and conciliation
  • As a result, they are more likely to be aggressive (or take advantage) of others

• Low resting heart rate
  • Individuals with psychopathy have low resting heart rates, which likely reflects lack of fear, which thus increases the person’s risk of engaging in violent acts.
  • Violent acts (e.g. crime, violence) may be seen as a way of self-regulation, in that it gives them that dopamine / adrenaline that they lack

• Overactive reward system
  • Individuals with psychopathy tend to be sensation seeking
  • E.g. at a basic sensory level, those with psychopathic traits are more likely to prefer black coffee than those without
  • On the other hand, their brains do not respond to the usual punishments, or “brakes” that inhibit other people’s activity
    • In one study, children played a computer game programmed to allow them to win early on, and then begin to lose
    • Whereas neurotypical kids would “cut their losses” and stop playing in order to keep their wins, psychopathic children kept playing until they lost everything
  • Parents often anecdotally note this when they report
    • “When he was a toddler, time outs didn’t do anything. Now he’s older, and we’ve punished him by taking away things from his room, but now his room is completely empty but it still hasn’t helped his behaviours."
• The implications of the research are thus to create an approach which
  • Relies on positive rewards (for their overactive reward system) 
    • E.g. “Of all the things we’ve tried, it’s having a reward system with hockey cards, which seems somewhat helpful."
  • Relies less on negative reinforcement such as punishment (as they are less concerned about negative consequences of their actions).
    

Signs/Symptoms of a Psychopath

Infancy

• As infants, individuals with psychopathy show neurologic differences. In one study, babies (aged 5-weeks) were tested to see if they preferred looking at a person’s face or a red ball. Those who preferred the ball showed more psychopathic traits 3 years later.

Toddlers

• When neurotypical toddler see another child in distress, they may try to provide comfort or leave. 
• Toddlers with psychopathic traits appear to show a chilly detachment; if they do get upset, it is that the other child is being loud, but without an empathic understanding that the other child is distressed.

School-age children

• The child commits a crime or transgression while alone, without the pressure of peers (Kiehl, 2015).
• The fact that the act is committed while alone reflects a tendency towards harm.

School-age / high school

• Aggression is a red flag, especially towards adults. In some cases, the aggression is quite severe which reflects the severe lack of inhibitions, e.g. “I beat my teacher unconscious” (Kiehl, 2015)
• Note as well that lack of aggression does not rule out psychopathy.

Despite the above symptoms however, in many children/youth, traits of psychopathy can go undetected because the children/youth are smart enough to mimic others and blend in.

Red Flags

Consider screening for conduct disorder (and psychopathy) when the following risk-taking behaviours are seen in a child or younger adolescent (e.g. between age 10-14) (Searight, 2001)

• Alcohol Use
• Substance use 
• Sexual activity
  

Screening and Assessment

Sample interview questions for parents

Given that youth are often reluctant to talk to authority figures about their difficulties, depending on how much time one has, it may be more high yield to simply ask parents first, or talk alone with the parents.

• Does your child have troubles following rules?
• Has your child ever had problems with the police? What happened?
• Any problems with getting physically aggressive? Towards people?
  • For psychopathy, aggression towards adults (e.g. teachers) and cruelty to animals is a particular red flag
• Any problems at school? E.g. Have there been any suspensions or expulsions from school? What happened?
• Has there been any running away from home? Overnight? How many times?
• Does your child smoke, drink alcohol or use other drugs? How often? Does this cause any problems?
• Is your child sexually active?
• After there has been an incident, does your child show any remorse or empathy?

Parental supervision

• What is the child’s routine?
• How does your child spend his/her time after school?
• Is your child doing activities with adult supervision, or is your child tend to be doing activities without adult supervision?

Sample Interview questions for a youth

It’s not always easy being a young person, because there are all these rules that you have to follow, and there are so many ways to get into trouble…

• Do you find it hard to follow rules?
• Ever get in trouble with the police? What happened?
• Ever gotten into a physical fight with someone else? What happened?
• Have you ever gotten any detentions, been suspended or expelled from school? What happened?
• Have you ever run away from home? Overnight? How many times?
• Do you smoke, drink alcohol or use other drugs? What drugs? How often?
• Are you sexually active?

References: Searight, 2001.

DSM-5 Diagnosis

DSM-5 does not have an official diagnosis for psychopathy or sociopathy. However, under the DSM-5 diagnosis of conduct disorder, there is a specifier for “callous and unemotional traits”, which appears to be the closest match for psychopathy.

Studies on adult prison inmates show that:

• 80% meet criteria for antisocial personality disorder (ASPD),
• 20% meet for psychopathy (as defined by various psychopathic checklists).

Differential Diagnosis and Comorbidity

Many conditions and situations can lead to aggression towards others which include (but are not limited to) the following:

• Autism spectrum disorder (ASD): Troubles with narrow range of interests; troubles with theory of mind and seeing other’s perspectives; difficulty understanding social situations. In contrast, individuals with psychopathy can often be very aware of social situations and other’s feelings, but unfortunately, they use this ability to take advantage of others.
• Non-verbal LD (NVLD): Difficulties reading social cues.
• Intellectual Disability: Individuals with intellectual disabilities have troubles engaging with school and peers, which can lead to frustration.
• Attention deficit hyperactivity disorder (ADHD): Individuals with ADHD have troubles focusing and paying attention.
• Schizophrenia / Psychosis: Individuals with psychosis may become paranoid, and as a result of trying to defend themselves, in rare situations, may end up committing crimes.
• Substance Use Disordres
  • Psychopathy and substance use disorders are highly comorbid
  • Psychopaths appear to abuse drugs for different reasons than non-psychopaths, which may reflect their differences in how their reward systems are wired.
  • Psychopaths do not typically experience withdrawal and craving upon becoming incarcerated.

Prognosis

The bad news is that children/youth with callous/unemotional traits are more likely than others (three times more likely in one study) to become criminals or have psychopathic traits later in life.

The good news is that even psychopaths can be steered towards healthier outcomes

• Psychopaths generally have the following character traits
  • Self-confident, cold-hearted, manipulative, fearless, charming, cool under pressure, egocentric, carefree
• Psychopathic traits can be helpful in the right situations
• For example, the following professions have been reported to have the highest rates of psychopathy
  • CEO, lawyer, media (TV/Radio), salesperson, surgeon, journalist, police officer, clergy person, chef, civil servant
  • It can be appreciated that these traits would be helpful in certain professions, e.g. the ability to stay calm (and not be distracted by emotions and feelings) is very helpful to a trauma surgeon coping with a severe trauma
• By comparison, the following are professions with the lowest rates of psychopathy:
  • Health care aide, nurse, therapist, craftsperson, beautician/stylist, charity worker, teacher, creative artist, doctor (i.e. non-surgical specialties), accountant
  • These are all professions where a high level of compassion and caring is required. While it is good to be compassionate and caring, some data suggest that being too compassionate can contribute to burnout, stress and mental health issues.

Management: Parenting Interventions

Do’s

• Ensure that parents are providing ‘good enough’ parenting -- sufficient love and limits
• Ensure that parents are not practicing extremes in parenting such as
  • Neglect (i.e. no control at all), or
  • Authoritarian (i.e. too much control) (Gullhaugen, 2011).

Are parents having difficulties with their child’s behaviours?

• Recommend parents start with positive parenting programs such as
  • Triple P, or
  • Circle of Security

• Let parents know that while these programs are necessary as a starting point, they will not necessarily be sufficient -- more specialized strategies may be required with a child with antisocial or psychopathic traits.

Management: Medications

Unfortunately, there does not yet appear to be any “empathy cure”.

Stimulants

• Some studies suggest that callous/unemotional children may respond to stimulant medication treatment (Blader, 2013)

MDMA

• There is interesting data from self-report surveys that show higher frequencies of MDMA use were associated with proportionately more ASPD and AD/H (Falck, 2006).
• There is treatment data for octopuses -- one study showed that when the usually antisocial octopus was given MDMA, it led the ‘antisocial’ octopus to reach out for hugs from other octopuses.
• Unfortunately, there is no treatment data yet for human beings.

Where to Refer?

Patients (and their families) with psychopathic traits will most likely benefit from specialized mental health interventions. Even if the patient themself does not benefit from classic types of counseling/therapy, treatment and support for the family will be helpful. 

Recommendation

• Refer your patient to local mental health services in your area. 
  • Refer your patient to local mental health services in your area. Most areas do not have specialized treatment for psychopathy specifically. However there will most likely be treatments and programs for children/youth with externalizing behaviours, and/or through the justice system. At a primary care level however, it is reasonable to start by referring to your local mental health service.

References

Blader et al.: Callous-Unemotional Traits, Proactive Aggression, and Treatment Outcomes of Aggressive Children with Attention-Deficit/Hyperactivity Disorder, J Am Acad Child Adolesc Psychiatry. 2013 Dec; 52(12): 1281–1293.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530123/

Cope L et al.: Psychopathic traits module brain responses to drug cues in incarcerated offendres, Front. Hum. Neurosci., 24 February 2014.

http://journal.frontiersin.org/article/10.3389/fnhum.2014.00087/full

Dutton K: The Wisdom of Psychopaths, Sci. American, Oct 2012.

Falck RS et al.: Psychiatric disorders and their correlates among young adult MDMA users in Ohio. J Psychoactive Drugs. 2006 Mar;38(1):19-29.

Gullhaugen et al.: Looking for the Hannibal Behind the Cannibal: Current Status of Case Research, Int. Journal of Offender Therapy and Comparative Criminology, 2011, 55(3): 350-369.

Hagerty B: When Your Child Is a Psychopath. The Atlantic. June 2017. Retrieved May 29, 2017 https://www.theatlantic.com/magazine/archive/2017/06/when-your-child-is-a-psychopath/524502/

Hare R: WIthout Conscience: The Disturbing World of the Psychopaths Among Us.

Kiehl, K: The Psychopath Whisperer: The Science of Those WIthout Conscience, 2015.

About This Document

Written by Dr. Michael Cheng and Michael Malik. Reviewed by members of the eMentalHealth.ca Primary Care team including Drs. Farad Motamedi; Mireille St-Jean; Eric Wooltorton.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace, the information from a qualified professional.

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