How Psychopaths Work

Diagnosing and Treating Psychopathy

Psychopathy is incurable. No one knows how to repair the damaged areas of the brain largely responsible for the disorder. But thanks to advancements in diagnosis and treatment, there may be hope for some improvement, particularly if the condition is detected early in life.

The big breakthrough in diagnosis came in 1980, when psychologist Robert Hare developed the Psychopathy Checklist (PCL), a list of 20 traits he attributed to psychopathy. This is how it works: Psychologists ask patients a series of questions to determine whether they possess the traits. If the trait is present, they get two points, and if it's not, they get zero. If the psychologist isn't sure, they get 1 point. The max score is 40, but anything over 30 means the patient is a psychopath.

The test, which was revised in 2003 and is now known as the PCL-R, works surprisingly well. One study showed that while 80 percent of high-scoring criminals reoffended within four or five years, the percentage dropped to 20 or 25 percent among low-scoring criminals. That success, however, has a potential downside: The PCL-R is now used in the parole process to predict whether a criminal will reoffend, keeping otherwise well-behaved criminals in prison indefinitely. It's a use bemoaned by many mental health professionals, including Hare himself [source: Spiegel].

Once someone is diagnosed with psychopathy, treatment options are limited, but not non-existent. In the past, traditional methods like group therapy not only haven't worked, but they've made the problem worse. Surgery, electroshock and drugs were hardly better, producing wildly mixed results. Recent experiments, however, have shown some success, particularly among children.

One promising method, known as decompression treatment, is based on the notion that psychopaths respond better to rewards for good behavior than punishment for bad behavior. In this technique, which involves daily, hours-long sessions of close supervision, psychologists gradually increase rewards for good behavior in an effort to speak to the psychopath's desire to win — and it seems to work. One study of incarcerated boys showed that after two years, only 52 percent of those receiving decompression treatment reoffended compared to 73 percent who received traditional group therapy [source: Kiehl and Hoffman].

Still, there are limitations to treatment. Because the greatest successes seem to come from treating younger patients, older psychopaths are left with few options. And even if there were more options, it's unclear how you would get psychopaths outside the prison system to seek treatment. In their minds, they don't need help; their personality actually makes them better than everyone else.

Author's Note: How Psychopaths Work

Psychopaths can be terrifying. That's why people use the term (often incorrectly, I should note) to refer to anyone who is acting really crazy. So it was particularly revealing when, in the course of writing this article, I realized that psychopathy is caused by a structural problem in the body. In that sense, it's just like any other disorder. To make this point, one article suggested that asking someone with psychopathy to show empathy is like asking someone with color blindness to see color. It's just not happening. And it's not like they chose to be that way. So should we ignore the lies, manipulation and murder that is often associated with psychopathy? Certainly not. But this fact will make us all a little more supportive of research into treatment of this horrific condition.

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  • Barker, Eric. "Here's How to Deal With Psychopaths and Toxic People." The Week. Nov. 9, 2016. (Dec. 21, 2016)
  • Editors. "John Wayne Gacy." Nov. 10, 2015. (Jan. 6, 2017)
  • Brogaard, Berit. "The Making of a Serial Killer." Psychology Today. Dec. 7, 2012. (Dec. 19, 2016)
  • Bushak, Lecia. "What It Really Means To Be Psychotic: The Difference Between Psychosis and Psychopathy." Medical Daily. June 18, 2015. (Dec. 20, 2016)
  • Harpur, Timothy J. and Robert D. Hare. "Assessment of Psychopathy as a Function of Age." Journal of Abnormal Psychology. Vol. 103, No. 4. November 1994. (Dec. 24, 2016)
  • Harrold, Alice. "Is Your Child a Psychopath? Study Reveals the Warning Signs and How Early You Can Spot Them." The Independent. Dec. 5, 2015. (Dec. 23, 2016)
  • Hirstein, William. "What Is a Psychopath?" Psychology Today. Jan. 30, 2013. (Dec. 20, 2016)
  • Johnston, Joni E. "Female Psychopaths." Psychology Today. May 2, 2012. (Dec. 23, 2016)
  • Kiehl, Kent A. and Joshua W. Buckholtz. "Inside the Mind of a Psychopath." Scientific American Mind. Sept. 1, 2010. (Dec. 18, 2016)
  • Kiehl, Kent A. and Morris B. Hoffman. "The Criminal Psychopath: History, Neuroscience, Treatment, and Economics." Jurimetrics. 2011. (Dec. 20, 2016)
  • Leistedt, Samuel J. and Paul Linkowski. "Psychopathy and the Cinema: Fact or Fiction?" Journal of Forensic Sciences. Vol. 59, Iss. 1. Dec. 13, 2013. (Dec. 18, 2016)
  • Lynn, Richard. "Racial and Ethnic Differences in Psychopathic Personality." Personality and Individual Differences. Vol. 32, Iss. 2. Jan. 19, 2002. (Dec. 23, 2016)
  • McLain, Tiffany. "Can a Child Be a Psychopath?" Psychology Today. March 30, 2014. (Dec. 22, 2016)
  • Morin, Amy. "5 Surefire Signs You're Dealing With A Psychopath." Forbes. Jan. 30, 2016. (Dec. 22, 2016)
  • Ossola, Alexandra. "Can a Child Be a Psychopath?" Newsweek. May 18, 2015. (Dec. 22, 2016)
  • Psychology Today. "What Is Psychopathy?" 2016. (Dec. 21, 2016)
  • Silver, James. "Is Wall Street Full of Psychopaths?" The Atlantic. March 29, 2012. (Dec. 21, 2016)
  • Silver, James. "The Startling Accuracy of Referring to Politicians as 'Psychopaths.'" The Atlantic. July 31, 2016. (Dec. 22, 2016)
  • Spiegel, Alix. "Can A Test Really Tell Who's A Psychopath?" NPR. May 26, 2011. (Dec. 19, 2016)
  • Sprague, Jenessa et al. "Borderline Personality Disorder as a Female Phenotypic Expression of Psychopathy." Personality Disorders: Theory, Research, and Treatment. Vol. 3, No. 2. April 2012. (Jan. 6, 2017)
  • Wallisch, Pascal. "Psychopaths in Our Midst – What You Should Know." Elsevier. Nov. 17, 2014. (Dec. 18, 2016)
  • Wynn, Rolf et al. "Psychopathy in Women: Theoretical and Clinical Perspectives." International Journal of Women's Health. 2012. (Dec. 24, 2016)
  • Zuckerman, Marvin. "Are There Racial and Ethnic Differences in Psychopathic Personality? A Critique of Lynn's (2002) Racial and Ethnic Differences in Psychopathic Personality." Personality and Individual Differences. Vol. 35, Iss. 6. October 2003. (Dec. 23, 2016)

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