Welcome to PsychEd, the psychiatry podcast for medical learners, by medical learners. In this episode, we present a broad overview of antisocial personality disorder and psychopathy with our guest expert — Dr. Donald Lynam. Dr. Lynam is a clinical psychologist by training, and professor at Purdue university, where he heads the Purdue's Developmental Psychopathology, Psychopathy and Personality Lab. While there may be some disagreement in the field, Dr. Lynam and I discuss how ASPD and psychopathy are two diagnostic constructs that are attempting to outline the same psychopathology, with the main difference being the degree of severity — for this reason, we use the terms antisocial and psychopathic interchangeably.

While not necessary, it may be of benefit for listeners to familiarize themselves with the DSM-V criteria for antisocial personality disorder, the psychopathy checklist (PCL), as well as the 5-factor model of personality. References for each are listed below in the references section, however, for a brief overview, one could do a quick google image search for each term (Wikipedia also has a succinct overview of the psychopathy checklist).

The learning objectives for this episode are as follows:

Develop a basic understanding of what is meant by antisocial personality and psychopathy
Be aware of some of the classic traits and characteristics of antisocial/psychopathic personalities, and the general functions of these behaviors
Describe the theoretical basis for the development of antisocial personalities

Guest Expert: Dr. Donald Lynam - Clinical psychologist, Investigator at Purdue University, Indiana

Produced and hosted by: Dr. Chase Thompson (PGY5 in Psychiatry)

Episode guidance and feedback: Dr. Gaurav Sharma (PGY4 in Psychiatry)

Interview Content:

0:50 - Learning objectives

1:40 - Dr. Lynam discusses his path to his current research interests

3:40 - Defining the terms antisocial personality disorder, sociopathy, psychopathy

8:30 - Discussing the possibility of antisocial behaviors without an antisocial personality

12:07 - Laying out the core features of antisocial individuals

18:20 - Antisocial personality from the perspective of the Big 5 personality model

22:00 - Discussion of the high-functioning psychopathy

25:06 - Prevalence of psychopathy

30:10 - Factors relevant to the development of psychopathy

39:30 - Prognosis and clinical trajectory

44:30 - Comorbid psychopathology

46:30 - Functions of antagonism or antisocial behaviours

49:30 - Treatment

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. 2013.
Broidy LM, Nagin DS, Tremblay RE, Bates JE, Brame B, Dodge KA, Fergusson D, Horwood JL, Loeber R, Laird R, Lynam DR. Developmental trajectories of childhood disruptive behaviors and adolescent delinquency: a six-site, cross-national study. Developmental psychology. 2003 Mar;39(2):222.
Babiak P, Hare RD, McLaren T. Snakes in suits: When psychopaths go to work. New York: Harper; 2007 May 8.
Hare RD. The psychopathy checklist–Revised. Toronto, ON. 2003;412.
Hare RD, Harpur TJ, Hakstian AR, Forth AE, Hart SD, Newman JP. The revised psychopathy checklist: reliability and factor structure. Psychological Assessment: A Journal of Consulting and Clinical Psychology. 1990 Sep;2(3):338.
Hare RD, Hart SD, Harpur TJ. Psychopathy and the DSM-IV criteria for antisocial personality disorder. Journal of abnormal psychology. 1991 Aug;100(3):391.
Jones SE, Miller JD, Lynam DR. Personality, antisocial behavior, and aggression: A meta-analytic review. Journal of Criminal Justice. 2011 Jul 1;39(4):329-37.
Lynam DR. Early identification of chronic offenders: Who is the fledgling psychopath?. Psychological bulletin. 1996 Sep;120(2):209.
Miller JD, Lynam DR. Psychopathy and the five-factor model of personality: A replication and extension. Journal of personality assessment. 2003 Oct 1;81(2):168-78.

CPA Note: The views expressed in this podcast do not necessarily reflect those of the Canadian Psychiatric Association.

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Dr. Chase Thompson:
Welcome to PsychEd, the Psychiatry Podcast for Medical Learners by Medical Learners. This episode covers the development of antisocial or psychopathic personalities and features our guest expert, Dr. Donald Lynam. Dr. Lynam is a clinical psychologist by training and professor at Purdue University, where he heads the Purdue's Developmental Psychopathology, Psychopathy and Personality Lab. He has written extensively on the topic of antisocial and psychopathic personalities. The learning objectives for this episode are as follows one Develop a basic understanding of what is meant by antisocial or psychopathic personalities two be aware of some of the core characteristics and traits of these personalities. Three Describe the theoretical basis for the development of these personalities, as well as their clinical trajectory over time. I just want to make a note to our listeners that we will be referring to the DSM five criteria for antisocial personality, as well as a psychopathy checklist or PCL. Dr. Lynam, is there anything you would add to that or anything you want to clarify?

Dr. Lynam:
No, that sounds about right. I mean, I also work on sort of just personality disorders more generally and personality more generally, but that's a pretty good description.

Dr. Chase Thompson:
Dr. Lyneham Since is kind of an interesting area, we don't always ask our expert this, but I'm just curious how you how did you get interested in this area of personality and psychopathy more in general?

Dr. Lynam:
Sure. Well, I started my graduate training with Terrie Moffitt at University of Wisconsin, and her her main interest was kind of the longitudinal study of antisocial behaviour and folks who would become kind of severely antisocial later in adult. I mean, that's a huge issue kind of in that sort of research is that all adults who were antisocial were antisocial as kids, but not all antisocial kids grew up to be antisocial adults. So a lot of her work was about how can you identify kids who are at greatest risk for continuing kind of their delinquent or their antisocial behaviour into adulthood. So I kind of started there looking at early risk factors like IQ and neuropsychological deficits and problems. And while there, her husband, Aslam Caspi, also worked some with him, and he was more interested kind of in personality. So I added this kind of personality layer. And then I took several classes with Joe Newman, who's a psychopathy researcher. So I became very interested in psychopathy at that point. And so those those kind of interests began to merge. And my earlier work was sort of on trying to identify can you identify in early adolescence kids who look psychopathic and who might go on to become to be psychopathic in adulthood? So that was kind of my my earliest work. But then I was at University of Kentucky, and I began working or hanging out more with Tom Whitaker, who was a big five factor model of personality fan. And it's sort of at that point that I began thinking of psychopathy the way I do now as sort of this collection of personality traits that that if you're extreme enough and you have enough of these, you're going to be psychopathic. And so that's kind of the history of how I got involved in this. And ever since about whatever late nineties, I've been pursuing that line of research.

Dr. Chase Thompson:
I see. And I think we'll get into some of those points that you brought up a little bit later on. But I think maybe a good place for us to start would be sort of some definitions of the terminologies, because I think that's a source of confusion for myself at least. And I know some other learners in the areas of psychiatry and psychology. So maybe I'll just put it out to you. Like how would you sort of define the terms an antisocial personality, or how is that different or similar to a psychopathic personality?

Dr. Lynam:
Well, I think ultimately that they are referring to the same things. I mean, there's been a distinction. So there are three terms that get used. Psychopath, sociopath and antisocial personality disorder. And I think ultimately they're all referring to the same people, which typically is sort of folks who are seriously, consistently chronically antisocial. It's sort of what it's meant to capture. The distinction between APD and psychopathy was really about how they were operationalized. So so in DSM three, this distinction really began to emerge. DSM three adopted these very behavioural criteria that came out of Leigh Robins work. And so it was really just a series. It was like a behavioural checklist, right? And you just sum those up and check the things they had done and that was how the diagnosis of of APD or antisocial personality disorder was arrived at. Psychopathy was about was a bit different. It kind of grew out of work. It was more closely aligned with kind of beckley's clinical description. And it had a direct line through Bob Hare who was trying to take collect these description. He had this in-depth, in-depth descriptions of 16 folks that he thought were psychopathic, and he had a set of criteria. And Bob Hare was interested in using those criteria in prison settings, maybe to identify this this kind of very chronically and consistent antisocial group of folks.

Dr. Lynam:
And so he built the psychopathy checklist in that kind of forensic setting or that prison setting. And it was a bit more focused on sort of traits. Right. So callousness, lack of remorse, lack of guilt, irresponsibility. So it wasn't just this behavioural checklist. And so that was the initial big distinction between antisocial personality disorder and psychopathy across time, like DSM four DSM, four TR, the criteria for APD have moved much more much closer to psychopathy criteria, where now they're really just traits that are being assessed and rather than the close. So so APD and DSM three are used very close criteria. Right. Did they do this act? Did they do that act? Did they do this other act? The criteria now in the current DSM are much more open, like, does he does things? Do they do things that look like they lack remorse? So it's not just this like checklist of things that you had to check. And so those diagnoses are becoming much more closely aligned. And I think a big deal was made about how different they were early on, I think in part Bob Hare and colleagues, to try to highlight how good the psychopathy diagnosis was and why you might want to use that. Their big line was like virtually 90% of people in prisons will receive antisocial personality disorder diagnoses.

Dr. Lynam:
But but only a subset of those 20% will get diagnoses of psychopathy. So but but all psychopaths, also all individuals with psychopathy, will get diagnoses of APD. And that, I think, was mostly about threshold. I mean, so on the psychopathy checklist, to get a diagnosis of psychopathy, you need 30 out of a possible 40 points. And that's a pretty strict cut-off. But for APD, you needed three out of nine criteria. So so there's a huge difference in the threshold that led to that sort of subset finding or that sort of subgroup finding. And the other thing that gets used is a sociopath, and it's often contrasted with psychopath. And the idea there is that sort of there's a difference between why people got the way they did. And so there was an assumption that if you were for people who were psychopathic, they were sort of born that way or as innate or something internal to them. But the sociopath was created by his or her environment. They they grew up in a really poor environment which pushed them down that path. So they're still meant to refer to the same type of people. But there's a difference in the assumption about where it came from.

Dr. Chase Thompson:
And correct me if I'm misconstrued misconstruing what you're saying a little bit, but it sounds a little bit like the DSM version of antisocial personality is sort of a an outward checklist that tries to capture the person's outwardly manifesting behaviours. Sorry for listeners who don't have the DSM criteria in front of them, but basically they're mostly outward behaviours, except for, I believe, one which is lack of remorse for, for such behaviours. But I guess there's been concerns raised by some people that one could enact those certain antisocial behaviours. Say you're, you're experiencing poverty and you need to commit a certain amount of crimes to feed yourself and or you have a substance use disorder and you're sort of caught in this horrible cycle of trying to, to obtain substances for yourself that basically an individual without sort of a core of psychopathy could, could still end up meeting criteria for an antisocial personality disorder, but may have a different underlying subjective experiences. Is that a concern in terms of differences between those two constructs or.

Dr. Lynam:
I mean, it's possible. I mean, I think I think the DSM criteria have more kind of trait like things. So I'm staring at them now. So I can tell you, I mean, one is very behavioural failure to conform to social norms and so indicated by repeatedly performing acts that are grounds for arrest. Lots of reasons for for committing crimes, as you just outlined. I mean, deprivation need sort of know growing up in a culture where that's in a place where that's the only available way to get, get the things you want. But there are some others deceitfulness, impulsivity or failure to plan ahead, irritability and aggressiveness, reckless disregard for the safety of others, consistent irresponsibility, lack of remorse. So, I mean, those are a little more less behaviorally tied or less less specifically tied to the antisocial stuff. But but it is still a concern. But but it's also a concern for psychopathy. I mean, if you look at how the psychopathy checklist is scored, it's based on a semi-structured interview and a file review. Right. And there's a lot of emphasis placed on crimes committed. So so in fact, a lot of what they call factor two psychopathy is based kind of on criminal history. How much have you done? When did you start? Do you show remorse about those crimes? I mean, so so so those crimes sort of suffuse the psychopathy checklist as well. So so I do think that's a possible concern. I mean, I think it would be very hard to hit the tops of these scales just on the basis of having come from a really rough and deprived environment or disadvantaged environment. But but certainly sort of low to mid-level elevations would certainly be possible, I think, for reasons that didn't have to do with sort of the underlying personality that this person possesses.

Dr. Chase Thompson:
Got you. You know, in terms of when we think about, say, psychopathic individuals, maybe I'll draw a similarity to, say, borderline personality disorder, where we think of affective dysregulation. Is this core one of the core defining features of the disorder and some of the other aspects of the disorder kind of flow out from that core. Is there a sort of core characteristic or defining features of psychopathic individuals?

Dr. Lynam:
Sure. I mean, I think I think there's one big one and then sort of a fairly large secondary one. And the first is sort of this this interpersonal dimension that that if you want to talk about the negative pole, you call it antagonism. If you want to talk about the positive poll, you call it agreeableness. But this is sort of a basic measure of personality shows up in everybody's personality model. It shows up in these models of disordered personality and it's an interpersonal dimension and it's really about how you feel about other people. So it's separate from extroversion, which is like, how much do you like them, how warm you are, This is your orientation to them and you kind of at a very basic level, it's a nice versus mean dimension. Antagonistic folks are egocentric, they're lying and manipulative. They're callous. I mean, they really just don't care much about other people. And I think that accounts for almost all of the most of the symptoms that we that we use to define psychopathy. And in fact, if you take these sort of self-report measures of psychopathic personality. It's the glue that holds them together, both within an inventory and across inventory. So this is a feature that that is really shared across all various ways of assessing psychopathy.

Dr. Lynam:
There's another important part which which is sort of this low conscientiousness or lack of constraint or disinhibition that also seems to be in there. And so this is that poor impulse control, this lack of self discipline, this lack of this irresponsibility bit that sort of has. And when you put those two things together, I mean, you just have a person, I think, who is free to do whatever pops into their head because they're not constrained by by what the effect their actions have on others or what other people expect. So boom, they can do whatever they want there. And and they're probably not constrained by consideration of future consequences either. And so. Yeah, they just they lack these internal constraints that most of the rest of us have. If an antisocial impulse pops into our head, we think, well, I could get in trouble. That might hurt that other person. They might be really hurt. What would that do to my social? I mean, there are all these things that we think about that kind of keep us in line. But if you start peeling those off, you get a person who's pretty much capable of doing almost whatever they please.

Dr. Chase Thompson:
And along those lines, like lack of remorse is sort of one of the criteria as well. And I think, you know, when you you hear about psychopaths talked about in the media or or among just in general conversation, it commonly comes up that they don't they lack empathy. I mean, part of the reason I bring this up is because lack of empathy is a feature that occurs across numerous different disorders in psychology and psychiatry, including it's like a schizoid personality or pathological narcissism or. So on, but you don't necessarily see these like very antisocial acts among in these other sort of diagnostic entities. So are you sort of suggesting that it's this antagonism and lack of restraint that is sort of the the thing that separates them and sort of drives the antisocial behaviours?

Dr. Lynam:
Or in part, I mean, I think I think I mean, narcissism and psychopathy are pretty closely related. I mean, we we do research on narcissist, I do research on narcissism as well with my collaborators. And the core feature to lots of narcissism is this very similar antagonism dimension. I mean, that seems to be what's what, why these two things are so highly correlated with each other. If you look at kind of relations between psychopathy and narcissism is they both share this sort of antagonistic core of I'm better than others. And I'm I don't really care what my what what effect my actions have on you because frankly, you're not important. Right. And so so that is a common theme there. I mean, I think what you get for psychopathy is maybe it's a little more broad. You add that deceptive Ms.. And that willingness to manipulate other people and and use them, there may be a little bit absent in narcissism. But the other big part is narcissism is not associated with this control or disinhibition. Right? I mean, it doesn't have that sort of poor impulse control piece to it. So I do think that's important for separating out psychopathy from narcissism.

Dr. Lynam:
The other role it serves, too, is you'll hear people sort of talk about successful psychopaths often. And what I think people mean when they say that is they mean people who are antagonistic but can still hold it all together. Right. So they've got impulse control. I think they have enough impulse control to contain to to get advanced degrees. They have enough impulse control not to punch somebody when they feel like it. Right. And so but but that kind of callousness and that coldness and that lack of concern for other people lets them do lots of stuff that is not very nice. Right? Cheating, manipulating, using. I mean, this is where all the financial or some of the financial crimes come from, right? They don't care about the people whose money they're taking. Right. It's all about sort of them. And so those folks get called successful because they haven't been arrested. They don't have a long rap sheet. But but but they're really just sort of these incomplete manifestations of psychopathy because they've got some of the some of the traits, but not the others.

Dr. Chase Thompson:
This is sort of touch on what you talking about is psychopathy being sort of a cluster of specific traits. I'll just put it to you. Like, what are the traits? Is it you mentioned antagonism and impulsivity.

Dr. Lynam:
Right. So I work from this this big five model, A personality, which is sort of the current coin of the realm. And it suggests there are these five broad traits that you can use to describe everybody that are relatively universal and extroversion. So one's orientation to others, whether you really like being around others or you prefer to be alone neuroticism, which should be very familiar to anybody working with psychopathology, right. Sort of high levels of negative affect that are experienced easily, often, and take longer to subside versus kind of an emotional stability. There's this openness to experience idea that people are open or close to new experiences. And then you've got the two that I'm most interested in, which is the one is that antagonism dimension or that agreeableness dimension, which is really that other interpersonal dimension about how you are oriented to others or whether you care about them or you don't, whether you're nice or whether you're a jerk. And then the last one is this conscientiousness domain, which has a couple of pieces to it, but it's like organisation and impulse control and that's sort of what it gets at. And so I work with them. I work with a slightly bigger model because the specific five factor model that I work with has six subscales for each one of those. And you can get this very kind of well articulated profile of psychopathy across them. One of the things that comes out is they are low on every aspect of agreeableness. So they are they are distrustful, They are lying and manipulative, They are selfish, they are noncompliant, they are immodest and they are callous.

Dr. Lynam:
And so across the board, that's true. And so that's a huge feature. And the other bit is you get within conscientiousness like it order doesn't matter, right? So one of the aspects of order is like, how neat is your room? That doesn't seem to be very psychopathy, but the things that are like dude awfulness like I do, what I'm supposed to do is self discipline. I finish stuff, I start and then sort of deliberation, I think things through. So those are the big pieces. And then there's this little mix of stuff on extroversion and neuroticism, the kind of up and down. So within neuroticism, they have a lot of hostility, but they don't have much self-consciousness, they're not depressed, they're not anxious. And then in extroversion, they are not warm, but they are sort of gregarious and assertive. So it's kind of this little mix profile. And that extroversion neuroticism piece gets clumped together in some inventories and it gets called boldness or fearless dominance. So those are the big three pieces of psychopathy. And I know there's debate about how important that boldness piece is. I mean, I think it's window dressing, right? I don't think it does anything really for for the kinds of stuff we care about in psychopathy. But but those are, I would say, the big three pieces. And so the more of those pieces you have, the more psychopathic you are kind of in my model because it's nothing more than just this collection of extreme traits.

Dr. Chase Thompson:
Yeah. And I think going back to the impulsivity thing and talking about the high functioning psychopath versus the lower functioning or someone we might imagine is in a lower socioeconomic status group and maybe more involved with the criminal justice system. It almost seems that the the ones who do have some restraints on their impulsivity and who are of more ability to carry out their goals is maybe as aligned as they are, almost seem to be more harmful in some sense. Like, I don't know, I guess I'm thinking of people like Bernie Madoff. I think he was assessed and not actually found to have psychopathic personality by whoever assessed him because he didn't meet sort of the other external behaviours. But I guess it seems like there's like this problem of maybe overdiagnosis in people who are more, more actively involved in in criminal acts versus those who are sort of high functioning and sitting in, in a high up office downtown somewhere.

Dr. Lynam:
I mean, I think that's definitely a risk. I mean, but, you know, that's an issue with white color crime anyway, right? I mean, people regarded differently than kind of non white color crime, right? It gets overlooked a lot or that's not real crime or I don't know how people feel about it, but but that's just my kind of my general sense is that people don't think of white color. Crime quite in the same way they think of other types of crime. And so, I mean, but I mean, Bernie Madoff defrauded. Tons of people out of lots of money. But I mean. But but, but, but he but he wasn't violent, right? And he didn't have a huge, you know, a long, long rap sheet, which will elevate your psychopathy checklist scores because that's a huge focus of of of what they're assessing in prison settings. So, yeah, I mean, but the other thing that happens to I mean is that people want to call Bernie Madoff psychopathic. Right? And they want to call the person who's called psychopathic because it's like a curse word, you know? You know, and it's like we don't like that person. That person's not good. But but you have to be a little careful about how you throw the label around, because it is more than just that callousness. It does include these other pieces. And sometimes people will shrink the entire idea down to just one trait, coldness or lack of empathy or fearlessness or whatever it is. But these are all just kind of sub manifestations of the much bigger construct.

Dr. Chase Thompson:
Right. As in people who are not necessarily psychopaths can still do some pretty bad things.

Dr. Lynam:
Right. Exactly. I mean, you know, the the the individuals of psychopathy don't have sort of the corner on the market of antisocial behaviour. Right.

Dr. Chase Thompson:
Maybe just changing gears a bit. Can we talk a bit a little bit about how common is the problem of psychopathy? How how many people in broader society or kind of experiencing what we're talking about here?

Dr. Lynam:
It's funny, I've had a back and forth for three weeks now with one individual wanting me to try to tie me down to, well, exactly how many are there. And I think that's I think that's hard to do, because I really do think this is something that is continuously distributed in lots of ways. So my response to this person was, well, how many tall people are there in the world? Right. And that's the problem you run into. At what point do we decide to call somebody tall? And at what point do you decide to call somebody psychopathic or give them a diagnosis of psychopathy? I mean, the psychopathy checklist has a pretty explicit criteria. It's 30 out of 40 on their scale. That'll probably identify less than 1% of the population is my guess. If you could assess everybody on the psychopathy checklist, which you probably can't because you need to file a review and it takes forever. But but they have a pretty strict criteria. So kind of if you use that criteria, it's about 1%. If you do something like I think APD criteria is 3 to 5%, something like that. But again, if you change the threshold, how many do you need? How many? What's the score on the psychopathy checklist? Well, instead of 30, let's make it 25, because those guys are pretty bad, too. Then all of a sudden your prevalence rate increases. And with APD, we'll just require a set of three of three of them or four of them require five or six, and then your prevalence will decrease dramatically.

Dr. Lynam:
Mine is always about sort of I think this is this is you can you can see this as not relatively normally distributed in the population. You have some people who are basically anti psychopathic, right. They are they have great impulse control and they're really agreeable. So they're like negative, psychopathic. And then you've got most of us who are somewhere in the middle and then you've got a bunch of folks out on the far end. And how far out do you want to draw that? I mean, two standard deviations above the mean prevalence rate of two and a half percent. So something along those lines. So that's how I think about it. I mean, the really, really extreme folks are relatively rare, but it depends on what criteria and what what threshold you're going to use. So it's sort of hard to put a number on that. But if you went with the psychopathy checklist, you're going to tell you about less than 1% at the very, very, very extreme end. And that's comforting unless you think that, you know, the person with a 29 is basically as bad as the person with a 30, and so is the person with 28, that it is continuous, that there's no point at which this seems to become qualitatively different. And so that's the issue you face anytime you're dealing with something that's continuously distributed like that is prevalence depends on where you want to draw your cut point.

Dr. Chase Thompson:
Right. Right.

Dr. Lynam:
That may not be what you wanted, but that's all I got.

Dr. Chase Thompson:
Sorry. No, fair enough. I don't know if this is known, but is it is it expected that the prevalence is sort of the same across different populations?

Dr. Lynam:
I think there's been some research suggesting well, some research suggesting that say the items on the PCLR don't function the same in certain groups. And so so that's a bit problematic. And that gets back to your idea about are these scores going to be elevated for people from disadvantaged backgrounds? And so there's some evidence that at least on some of the symptoms that are used in the psychopathy checklist, that that is problematic. And I think it's probably around most of the antisocial items because there are a lot there are multiple pushes to making people antisocial. And so if you grow up in an environment where you're experiencing a lot of those, you're you're going to elevate a little bit on the antisocial related facets. But but in terms of I mean, mostly men score higher than women, as you might imagine. And that's actually you can actually predict that just from the basis of what we know about the traits that are involved and the gender differences there. So that's one thing that you could certainly say with, I think, some authority, although there are some folks who disagree a bit saying, well, we should change the criteria. If you change the criteria and had different criteria, they would be more equal. That's that's possibly true. But but but in general, actually, it's interesting. Among all the personality disorders so kind of attend DSM, PDS and psychopathy if you sort of calculate gender differences on the basis of gender differences in the traits that they contribute to them, psychopathy by far has the largest sort of male to female ratio, but it should be the most male disorder of them all.

Dr. Chase Thompson:
What do we know about the development of psychopathic personalities in terms of like, is it genetic, environmental and.

Dr. Lynam:
Well, I think like most things, I mean, it's, you know, what is it, 40 to 40 and 50% of the variance seems to be heritable, you know, or 40 or 50% of the variation in the population seems to be due to genetic variation. And that's that's true for for lots of lots of these sorts of things. What we do know is, is that that that this adult manifestation has kind of adolescent and childhood precursors. I mean, if you look at if you look at kind of conduct disorder diagnosis in the DSM, there's a specify that is called callous unemotional traits. And that's basically Paul Frick's version of psychopathy in a lot of ways. And I had a version, too. We called it the childhood psychopathy scale, but it was much the same as kind of what what Paul's done, which is that sort of you can identify early on folks who are callous and impulsive and don't seem to care about other people and and all these traits. And there is some stability across time. And so it's not surprising that the kind of the child who's going to grow up to receive a diagnosis of psychopathy, of psychopathy, or who's going to look psychopathic in adulthood is also looking psychopathic in childhood and adolescence.

Dr. Lynam:
Do we know how that comes about? Not really. Really? Well, I mean, I think Paul has done some work sort of on on on on parenting. And there seem to be some parenting styles that are associated with with those sorts of traits in kids in adolescence. But the problem with those studies, it's awfully hard to know. I mean, parents are also reactive to kids, and that's been shown again and again, right? Difficult kids who are difficult end up with parents who have certain parenting styles. And it may not be the parenting styles that come first. So it's really kind of a thorny thing to try to figure out about how does this develop. We do know there's a genetic component. We also know that 50% of the at least 50% of the variation is not genetic. And that's the hardest piece to get on. And, you know, and again, we didn't know what the genes what the what the genetics of it are at all. Anyway, These are global estimates, and our ability to identify any specific genes is really lousy. So I'm not sure that those numbers ever help us a whole lot.

Dr. Chase Thompson:
Sometimes you commonly hear that, for example, an individual who has severe a personality disorder, that there tends to be some sort of contribution of early life trauma. Is that something that's relevant in psychopathic personality disorders?

Dr. Lynam:
I'm not I'm not sure. I'm not sure about that. I'm not sure that's been as strongly demonstrated for psychopathy as, say it has been for some some other sort of disorders. So I would I'm not going to go out on a limb and say anything about that. Sorry, I just I just don't know.

Dr. Chase Thompson:
Yeah, no worries. And you mentioned something about children showing some there being some stability of psychopathic traits over time, even from early childhood. What are some of the early signs that you tend to see in children?

Dr. Lynam:
A lot of them are just sort of just the similar manifestations as what you find in in adults. So my earliest work was taking the psychopathy checklist and trying to operationalise it in a group of 13 year old boys using sort of archive data. And so so you could find things like they lie a lot, right? They're aggressive, they're in trouble a lot, but they don't seem to feel bad after misbehaving. They've got impulse control problems, you know, they steal. So it's a lot of the same sorts of traits. I mean, they're not stealing cars, right? But they are stealing food or things like that that are a little more developmentally normative. But sort of those same traits seem to be present earlier on as well, that they look slightly different, but they seem to mean the same thing. Yeah. So, you know, they seem to be they seem to be callous, they seem to be selfish. And one of the concerns was some of that stuff is, well, aren't all kids callous and selfish and and things like that. But but it's really a matter of degree, you know, like these folks are these these kind of kids who will grow up to show more psychopathic features are even more callous and even more self-centred and lie even more.

Dr. Lynam:
And so it's about sort of elevations across all of those things that seems to predict higher levels of psychopathy. I mean, we did one study where we had those 13 year old boys that we had that we had assessed using this kind of childhood psychopathy scale, and we followed them up 11 years later in the young adulthood and gave them the the PCLSB, which is a psychopathy checklist screening version. And across those 11 years, I mean, the stability wasn't high, but it was a correlation of about 0.35, which is not awful when you consider it's 11 years. And these are different instruments being used. And there's mother ratings at time one and it was interviewer ratings at time, too. So there's definitely some degree of stability in all of that. And again, it's sort of like predicting like it's, it's the same sorts of behaviours, early predicting the same sorts of behaviours later on.

Dr. Chase Thompson:
So what about in the DSM for antisocial personality? One of the criteria is that there's some evidence of conduct disorder behaviour in the past, and at the beginning we were talking about the concept of a sociopath or someone who might be like a it's an acquired antisocial personality. I guess I'm wondering how do you reconcile those things or is acquired sort of antisocial personality, not really a thing or or what's going on there?

Dr. Lynam:
I mean, are you thinking that sort of those who acquire this antisocial personality won't show that sort of early evidence of conduct disorder? I'm not sure quite what you're.

Dr. Chase Thompson:
Yeah. I mean, I guess I'm wondering, like if you have an adult who has what seems to be really antisocial behaviours, but as far as you can tell, there isn't clear evidence from, from the parents or on review of their development that there was clear conduct disorder behaviour.

Dr. Lynam:
There have been a couple attempts to look at that. I mean there have been a couple this was years ago that I read on it, but there have been some people arguing that you can have kind of antisocial personality disorder in the absence of evidence of of earlier conduct disorder that you can sort of meet these other criteria and that it's still sort of meaningful and important. So I do think that's possible. I mean, I think there's a whole issue of sort of a lot of times like psychopathy checklist is used to predict future violence or it's used to predict recidivism, things along those lines. But there is an issue about the assessment being saturated with the behaviour you want to predict later on. So one of the reasons that the psychopathy checklist might serve so well as a predictor of future antisocial behaviour is because, boy, it's certainly built on past antisocial behaviour in a lot of ways because that file review just just bleeds into lots of those criteria. And so if you have lots of anti sociality in your background, in your file, you're going to elevate that psychopathy checklist purely on the basis of the past behaviour. So of course that's going to predict future behaviour very well.

Dr. Lynam:
One of the ways we've tried to move away from that is trying to move to a much more pure personality assessment. And there have been some other folks too in the adult military who are working around the psychopathy checklist saying we should try to exclude antisocial behaviour so we eliminate that kind of contamination and we're getting more at sort of pure personality. There's something that's a little bit separate from the behaviour that we're interested in and care about, and that's almost what you'd be doing with the APD if you eliminated childhood conduct problems because that's the most antisocial or the most, frankly, anti-social criteria in that set. But I mean, I think it's I think it's meaningful to to have these characteristics in the absence of I mean, I think they I think a lot of times antisocial behaviour will follow from having this collection of traits because again, I think it's about the removal of of internal controls that let you do almost anything. And so I think anti-social behaviour is a pretty probable outcome if you have these traits. But, but again, doing away with previous childhood conduct problems is probably might not be a bad idea for for the APD criteria. Mm hmm.

Dr. Chase Thompson:
What can we say about the prognosis or long term clinical trajectory of individuals with psychopathic personalities?

Dr. Lynam:
Years ago, they thought they would talk about them being untreatable, right? You couldn't do anything with psychopathy, with individuals, with psychopathy. And they pointed to a couple treatment studies that looked just like things went terribly. There was no help at all. But but more recent scholars have looked at those and said those were crazy treatments you were trying. And sort of more recent stuff suggests that they're about as treatable as anybody with a personality disorder, which is so you can treat some, but it's not great, right? I mean, I think psychopathy may be a particularly difficult disorder to treat because there's not a lot of distress. I mean, like borderline right, individuals, borderline PD. I mean, they are remarkably distressed, right? I mean, they are not happy with how stuff's going. Right. But I think I think for folks with who are high in psychopathy or anybody who's high in antagonism generally, like they don't feel a lot of distress. They're like they're not anxious and worried and really, really sad. I mean, the pissed off and it's not their fault either. Right. I mean, it's your fault for for being so soft or it's it's the cop's fault for coming along at an inopportune time or it's the victim's fault for falling and hitting your head more severely.

Dr. Lynam:
I never intended for her to get hurt that bad, You know, this sort of things like that. And so I think it may be harder to get a lever. What do you grab to try to convince somebody to change? And Reed Molloy years ago was talking about kind of what he tried to do and was try to make them understand that you are not happy now. Jail sucks. Jail is not fucking right. What can we do to keep you out of ending up here again? And so it kind of it's an appeal to a certain amount of selfishness that sort of you might be happier if you could avoid prison or if you could sustain a relationship or. And so I think I think that's an issue for for psychopathy is sort of where do you grab on to? What kind of handle can you get? Because that big handle of subjective distress and you feel terrible, let's figure our way out of this just is not as available as it is in other places.

Dr. Chase Thompson:
Right. Right. I think there's also been some areas I've read around kind of like a burnout effect of antisocial behaviour as as individuals hit their midlife. Is that a phenomenon that that you recognize?

Dr. Lynam:
Well, one of the things that seems to happen a lot I mean, is this sort of crime decreases, our crime changes at least. So if you chart sort of the changes in levels of the psychopathy checklist factors, they break them into two factors. One, they I think erroneously call personality and the other they call antisocial behaviour. And it's more about for me, it's more about pure antagonism and then a mix of antagonism and conscientiousness. But what you see is that that factor one stuff changes a little bit, maybe decreases a little bit, but it's really the factor two stuff that drops off. And that's probably due to the kind of the way in which it's assessed and the reliance on crime. I mean, at 50, you just can't fight as much. You can't you can't break stuff and climbing windows anymore. I mean, it's sort of I think the burnout is more about the sort of crimes that are being committed. And so so those are definitely dropping off because I think they're hard to sustain as you get older. So I do I do think that that part's definitely a real thing. We're about to start looking at, at least in an older age cohort, just sort of psychopathy assess purely on the basis of personality. So not including the really antisocial stuff to look and see what does happen across 15 year old, 15 year span from, say, 60 to 75. Are the traits themselves changing very much at that point, or is it reasonable to believe that all the change people are reporting on is really this this drop off in antisocial stuff?

Dr. Chase Thompson:
So if I can try and paraphrase you it's it's it's that the outward behaviours decline, but maybe the inner subjective world remains the same.

Dr. Lynam:
Yeah, I think that's fair.

Dr. Chase Thompson:
Okay. Psychiatry and psychology. We always see a lot of comorbidity. And what are the common comorbid issues that people with psychopathic personalities run into?

Dr. Lynam:
I mean, you know, one is, is it really a kind of a close cousin personality disorder, which is narcissism. So you end up with narcissism is highly correlated with psychopathy. Substance abuse and substance use problems are highly correlated with psychopathy as well. I mean, there are diagnoses, but but aggression is a problem. Relationships are a problem. But but again, because they tend to lack this subjective distress, it's not as comorbid with other forms of psychopathology as, say, borderline personality disorder is right, which is co morbid with almost everything, because they all have this big piece of of emotional reactivity and subjective distress. And you don't really find that in psychopathy, but it is co morbid with all the externalising behaviours. So various sorts of substance use alcohol problems, I mean all, all that sort of what gets called externalising stuff, psychopathy sits right in the middle of that.

Dr. Chase Thompson:
So is it kind of protective against the internalising depressive depressive anxiety disorders?

Dr. Lynam:
It is, especially if you allow that boldness component in. I mean, in fact, if you allow boldness in psychopaths, psychologically speaking, you really want to be psychopathic because you are relatively immune to those sorts of those sorts of problems. If you don't have that in there, then you can get some of the kind of depressive sorts of stuff going on. But but if you allow boldness as a piece of psychopathy, it definitely protects against against kind of internalising disorders because frankly, it's it's virtually the opposite of internalising disorders.

Dr. Chase Thompson:
Right, Right. So I think we're getting closer to the end of our time together. One maybe question I have is sort of more theoretical, broader question, but sometimes thinking about personality, I wonder why is psychopathy a something that's developed in people as opposed to any other disorder? And does it we've talked about it being sort of on the spectrum.

Dr. Lynam:
I see.

Dr. Chase Thompson:
Is there some sort of benefit that antagonism maybe has a in a more milder sense or what is is there any sort of function of psychopathic orientation?

Dr. Lynam:
Sure. So I'd say a couple of things. One, one thing I would say I think is that I'm not sure psychopathy is a natural category in the sense that sort of I think what it is, is it's a it's a presentation that is really kind of bothersome and people notice it. Right. And so you can't help but see it. These folks are like this. But but I'm not sure that it coheres like a syndrome does. So I'm not sure it's a natural category. But but the question is interesting, like, why does high antagonism exist at all? But why are we not all just kind of flat, bare and all nice to each other and stuff? And, and I do think there's some advantage to being a bit of a jerk. I mean, quite quite frankly, I think I think this is a way of pushing and getting what you want. It's a way of stepping ahead of others while stepping on others, which can be to kind of your individual advantage. I mean, these are sometimes I think of these if you think of these in evolutionary terms, different reproductive strategies, these are the cheaters. These are the folks who aren't following kind of our rules as long as there are too many of them.

Dr. Lynam:
It's a very successful strategy. And so I think that sort of these folks are probably I mean, if you want to talk purely evolutionarily, these folks are having more babies, right? At least at least the men are right. If you're if you're sort of can't have committed relationships, then any relation you have is sort of uncommitted. And so you have lots of them. And and just that'll propagate your genes just quite simply. And I do think just from a subjective feeling, I mean, some of these folks are decently successful because they're the first in line and they will find their way up front if they're not there already. And so this is a manipulative they don't care what they do to you. They don't think you're particularly important. And this this this allows them to get some of what they need at the expense of others. And so so that's why I think probably, you know, there is high antagonism out in the world. But not everybody could be like that. Right. Because living in community becomes really very difficult, is my thought on it. I mean, I'm not an evolutionary psychologist, but that's me pretending to be one.

Dr. Chase Thompson:
Fair enough. I know you spoke a little bit about treatment, just in the sense that there's not a lot a ton of intersubjective distress that drives someone towards treatment. But say you did have someone who is, for some reason, very motivated to get treatment. Is there any sort of modality that's been shown to help at all? Or.

Dr. Lynam:
Not really

Dr. Lynam:
I mean, I don't think I mean, I don't think people have studied treatment for psychopathy in the same way they have, say, for for borderline or for depression. I mean, not what works best. I mean, so you certainly don't have these sort of cross treatments and people trying to figure out what will work. I think people have thought for a while that these folks are probably relatively untreatable. So and frankly, they don't come in a lot. I mean, you know, in your clinical practice, let's say, how many grandiose narcissists do you see rolling in of their own accord? I think the answer is very few. They get there because the spouse brings them in or court orders them there. I mean, this is what kind of brings them in. So there's not a huge population to work with. And I think a lot of a lot of clinicians find that group a difficult group to work with. And I think individuals with psychopathy are much the same because they've got that same core of I don't know why I'm here, I don't have a problem. You guys have a problem. This kind of shifting of blame. And again, what do you do? I mean, I think Reed Molloy was probably right. If I find a lover in there, that's a selfish leaver. Look, you don't like coming in to see me. You don't like being in trouble with everybody? What's something we could maybe figure out that you could do differently that would keep you from ending up in jail or would allow you to resume a decent marriage with with your spouse. Right. I mean, that's kind of the only thing I can think of. I mean, I do think I mean, I'd love to see somebody develop. There's a unified protocol for negative affects in the world today. I mean, boy, if you could come up with something like that for antagonism, that'd be great. You know, maybe it starts with this kind of motivational interviewing approach about sort of just getting them to think about change because the way they're doing stuff now is is less than optimal for them.

Dr. Chase Thompson:
Hmm. Mm hmm.

Dr. Lynam:
But but I mean, appeals to look at. Look at how you hurt this person are probably not going to work very well. Wow. Yeah.

Dr. Chase Thompson:
Hmm. Well, is there anything that you think that we haven't touched on in terms of psychopathy that you think is important to say at this point?

Dr. Lynam:
No, I think I think I've got to say pretty much everything I wanted to say. I appreciate your questions and I hope I was somewhat clear, at least.

Dr. Chase Thompson:
Yeah, I think you're. Yeah, absolutely. Well, thank you very much for being on our podcast. We really appreciate it.

Dr. Lynam:
Thanks for the invitation.

Dr. Chase Thompson:
Okay.

Dr. Chase Thompson:
PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by myself, Chase Thompson. Theme song is Working Solutions by all Live music, especially thanks to our incredible guest, Dr. Donald Lynam, for serving as our expert for this episode. If you want to get in touch with us, you can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.Org. Thank you for listening bye.

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