Tag Archives: antisocial

Anosognosia, Psychopathy, and the Conscience

How people see and understand themselves is likely to have an impact on how they interpret interactions with others. Here, I briefly explore the brain areas implicated in anosognosia, how these areas are also relevant in psychopathy, and why anosognosia is important when considering the crime and the conscience.

ANOSOGNOSIA AND SELF BELIEF

Anosognosia is defined as the impaired ability of patients with neurological disorders to recognize the presence or adequately appreciate the severity of their deficits [1]. Torrey (2012) cites three examples of anosognosic patients; a stroke victim with a paralyzed arm claimed he couldn’t lift it because he had a shirt on; a woman with paralysis in her left arm was asked to raise it, and instead raised her left leg. When this was pointed out to her she responded that some people call it an arm, others a leg, and jokingly inquired as to the difference; the Supreme Court Justice, William Douglas, was paralyzed on his left side. He claimed this was a myth, and was still inviting people to go hiking [2].

NEUROLOGICAL FINDINGS IN ANOSOGNOSIC PATIENTS

Recent research on this phenomenon has identified deficits in the brain of the patients who in all honesty do not recognize that they are in some way impaired. By using fluorodeoxyglucose positron emission tomography (FDG-PET) and single photon emission computed Tomography (SPECT) Perrotin et al. (2015) found that anosognosic Alzheimer’s patients had a disruption in connectivity between the posterior cingulate cortex (PCC) and the orbitofrontal cortex (OFC) [1]. Ries et al. (2007) also implicated a compromised precuneus in anosognosic patients. These midline structures are susceptible to damage in those with Alzheimer’s Disease (AD) and stroke victims. Anosognosia is also experienced by schizophrenic patients; according to Gerretsen et al. (2015), 60% of schizophrenic patients experience moderate to severe illness awareness, and this can lead to medication non-adherence and poor treatment outcomes [4]; they found left hemispheric dominance in the left prefrontal cortex in anosognosic schizophrenic patients and cortical thinning in the temporoparietalocciptal junction (TPO).

There is still much work to be done to determine the mechanistic and functional basis of anosognosia, and to determine the subtleties between illnesses and disorders, but research is starting to identify suspect brain regions. This is useful if anosognosia is questioned in other disorders, because neurological studies exploring the disorder can be explored and legitimate avenues of scientific inquiry explored.

RESEARCH PARALLELS WITH PSYCHOPATHY

A failure to recognize a disorder is also present in those with psychopathy. While anosognosia is yet to be explored thoroughly in those with psychopathy, there are behavioral items on the Psychopathy Checklist (PCL-R) [5] that suggest anosognosia is present; grandiose sense of self-worth, lack of remorse, and failure to accept responsibility. The sense of self-worth and narcissistic traits of the psychopath clearly means that they think very highly of themselves. This negates the idea that the psychopath believes they suffer from a defect or a disorder; at the most they might recognize that most others are different, and perhaps inferior to themselves. If a lack of remorse is experienced, this is an explicit demonstration that they do recognize, at least on an emotional level, the consequences of their bad behavior as being wrong; if they do not believe their behavior is inappropriate, it stands to reason that they believe they behaved appropriately, and thus experience nothing ‘wrong’ about themselves. This aspect of self-belief and self-reflection is also seen in the psychopath’s failure to accept responsibility; if they are always good and right, there is little motivation to make amends.

Based upon this cursory examination of psychopathic behavior, it would seem reasonable to explore the neurological studies of psychopathy and see if there could be some overlap with previous studies on anosognosia, and in fact some of the same compromised brain areas are implicated. Many studies have demonstrated developmental differences in the PFC of the psychopath (for a review, see Umbach et al. (2015) [6]), and the white matter pathways, such as the uncinate fasciculus (UF) connecting to the PFC from the limbic regions [7]. Perrotin et al. [1] hypothesized that Anosognosia can result from a disruption in connectivity in the UF. When exploring connectivity in the frontoparietal network (FPN), Philippi et al. (2015) found reduced connectivity in those with higher scores on the PCL-R, which included the right precuneus. And to further the overlap, Glenn et al. (2009) [8] found that those with who scored high on the interpersonal factors of the PCL-R (manipulative, conning, deceitful), showed reduced activity in the PCC during an fMRI scan when having to make judgments during moral dilemma scenarios.

Anosognosia and psychopathy both demonstrate complex neurological constructs, and it is premature to conclude that the neurological basis for Anosognosia (itself still understood) would tuck neatly into the already known neurological research on the psychopath. However, given the neat juxtaposition of behavioral traits and neurological dysfunction, it is worth bringing psychopathy into discussions of Anosognosia for the following reason. The research on psychopathy is currently deeper and richer than the research on anosognosia, and behavior of the psychopath has been widely observed and studied. If we can reasonably conclude that psychopaths, particularly criminal psychopaths, are also anosognosics, their behavior can be assessed in light of what it means to recognize no disorder or defect within oneself. The parallel is further relevant with psychopathy when considering that a number of those with schizophrenia, and a minority of those with AD, have been known for antisocial, and sometimes criminal, behavior [9, 10].

ANOSOGNOSIA, ANTISOCIAL BEHAVIOR, AND THE CONSCIENCE

Those with schizophrenia and AD also suffer from abuse, but when they have been known to act violently, their behavior and motivations need to be understood. Torrey (2012) has documented extensively the violent acts of those with schizophrenia [2]. There is usually a history of progressively worse episodes of psychosis that can convince the patient that they are receiving supernatural or alien instructions to kill or harm individuals, and more often than not family members. Whether or not the auditory hallucinations slowly convince the patient over time of the necessity for deadly action, or whether the act is impulsive, after the event the patient often remains remorseless and attributes their behavior to necessary and mandated (often divine) reasons. This state of mind is similar to the violent psychopath, who also viewed his violent actions as necessary and fully justified. The problem is never attributed to the self; a disorder or defect is not recognized. While psychopaths are widely regarded as not having a conscience and experience only limited affect, more research is needed on the experience of conscience by schizophrenics, especially understanding the role that psychosis played in circumventing the conscience and providing them with permission to act. It is also crucial to discover how those events are remembered and felt post psychosis, perhaps when the patient has reconvened their medication.

In illnesses and disorders that can be associated with antisocial behavior or aggression, anosognosia could be a partial reason for the event of the behavior. Not recognizing any problems or defects, and thinking that one acted rightly or righteously, will affect personal judgments on the self-evaluation of behavior. This does not provide a fertile ground for remorse or responsibility, and if the behavior was aggressive, the patient could continue to remain dangerous, inflexible to a reasoned and peaceful behavioral change. This makes the search for the neural representation of anosognosia all the more crucial, treatment all the more pressing, and methods of identification all the more necessary.

© Jack Pemment, 2016

 

REFERENCES

  1. Perrotin, A. et al. (2015). Anosognosia in Alzheimer disease: Disconnection between memory and self‐related brain networks. Annals of neurology, 78(3), 477-486
  2. Torrey, E. F. (2012) The Insanity Offense, New York, W. W. Norton and Company
  3. Ries, M. L. et al. (2007). Anosognosia in mild cognitive impairment: relationship to activation of cortical midline structures involved in self-appraisal. Journal of the International Neuropsychological Society, 13(03), 450-461
  4. Gerretsen, P. et al. (2015). Illness denial in schizophrenia spectrum disorders. Human brain mapping, 36(1), 213-225
  5. Hare, R. D. et al. (1990). The revised Psychopathy Checklist: Reliability and factor structure. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 2(3), 338-341
  6. Umbach, R. et al. (2015). Brain imaging research on psychopathy: Implications for punishment, prediction, and treatment in youth and adults. Journal of criminal justice, 43(4), 295-306
  7. Motzkin, J. C. et al. (2011). Reduced prefrontal connectivity in psychopathy. The Journal of Neuroscience, 31(48), 17348-17357
  8. Glenn, A. L. et al. (2009) The Neural Correlates of Moral Decision-Making in Psychopathy. Retrieved from http://repository.upenn.edu/neuroethics_pubs/55
  9. Fazel, S. et al. (2009). Schizophrenia and violence: systematic review and meta-analysis. PLoS Med, 6(8), e1000120
  10. Lopez, O. L. et al. (2003). Psychiatric symptoms vary with the severity of dementia in probable Alzheimer’s disease. The Journal of neuropsychiatry and clinical neurosciences, 15, 346–353

Evolution and the Psychopath

http://www.rudecactus.com/archives/001430.html

Since I began studying psychopathy, I have often wondered about an evolutionary basis for this dangerous disorder. Psychopathy is considered to be a developmental disorder (Blair, 2006), which means that through its normal course of development the brain experiences stresses or biochemical changes that are not conducive to proper neurological development. This idea is supported by suppositions from both behavioral psychology and neuroscience; firstly, in behavioral psychology, it is suspected that serious child abuse could be an underlying factor behind psychopathy (Kunitz et al., 1998), and secondly, in neuroscience, it has been noted that many with psychopathy show a significant underdevelopment of a number of regions in their brain (for a review see Pemment, 2012).

Read more at Psychology Today…

Copyright Jack Pemment, 2012

Revisions to Antisocial Personality Disorder (APD) for the DSM V

The DSM-V development website lists a number of proposed revisions for personality disorders from how they initially appeared in the DSM IV. Part of the problem with the DSM IV was that people with a personality disorder were frequently diagnosed with two or more, and as individuals only have one personality the need to recognize a singular personality as dynamic has been recognized.

For more information on how the classification of personality disorders will be different in the DSM V, click here.

The proposed revision of APD does not include recognizing Conduct Disorder (CD) before the age of 15, even though many studies have shown that CD in the pre-pubescent years is a good indicator of APD in adulthood. Although, the revision still includes the need to be 18 or over to have a diagnosis of APD.

For more information on the proposed classification of APD in the DSM V, which should be published in May of 2013, please click here.

An interview with Bundy, the day before his execution

Bundy is surprisingly forthcoming in his attempts to explain and understand how he came to be a monster. There are a number of responses that seem decidedly un-psychopathic. He has no problem taking full responsibility for the murders and he realizes that he is very different from other people.

Bundy claims that he was from a good home and was never abused, and that it was his exposure from soft to violent pornography that made his fantasies become more and more violent; one could raise the argument that it was simply stumbling across violent pornography as a child that constituted the abuse necessary to traumatize and stymie the development of his brain.

He speaks of the need to murder (which included necrophilia) as an addiction. Keppel, one of the detectives who helped to apprehend Bundy explained that Bundy experienced the desire for necrophilia as a chemical tidal wave, like an addiction to a narcotic. It certainly seems like his frontal lobe, and the connections between it and the limbic system, failed to control and inhibit his desires.

The interview does not strike me as a manipulation or an attempt to spread lies, but of course that can’t be ruled out. He does, however, appear to respect his interviewer.

This is a good interview with Bundy, which anyone interested in the development of extreme human behaviors should watch.

The faceless victims of John Wayne Gacy

I recently stumbled across an article on NPR entitled 30 Years Later, Serial Killer’s Victims Exhumed. Gacy is thought to have killed about 33 young men, many of whom were buried in the crawlspace of his house. A fair number of the victims were identified upon his capture, mostly using dental records and information provided by family members who had suffered the disappearance of sons and brothers in the Chicago area throughout the 1970s.

There were, however, numerous unidentified bodies and the upper and lower jaws (including teeth) were preserved so that future technologies may I.D. the victims. Over the last few years DNA from about half of the bones of the unidentified victims has been accurately obtained, meaning that a relative could provide their own DNA to confirm a familial relationship.

One of the shocking things with regards to this story, is that numerous families failed to report relatives as missing because Gacy was a homosexual serial killer, which was taboo enough in the 1970s (and maybe even today?) and this prevented families from reporting missing offspring; apparently, it was better to believe the missing offspring had never come into contact with this homosexual killer than to identify the victims, which would allow closure, grieving, and justice.

A number of the victims were also said to be wards of the state and so were from broken homes; nobody was going to miss them, regardless.

It’s just sad to note that some of the unidentified victims will remain faceless not just because of a lack of DNA evidence, but from the fact they may have been gay and/or started out life with no real family.

Jon Ronson discussing psychopathy and mental illness at TED

This is not a bad TED talk by Jon Ronson. In a fairly humorous 20 minute discussion he points out the follies of the DSM and the Psychopathy Check List. He concludes that our obsession to categorize people within narrow mental illness parameters ends up dehumanizing the patient and can lead to fatal outcomes.

 

How biological and psychological perspectives on psychopathy shape public opinion

It is commonly known that when a psychopath is on the stand, the prosecution is going to push for a jail term based upon the idea that the defendant is sane. The defense, on the other hand, will no doubt argue that their client is insane, and so should therefore be sent to a psychiatric institution.

In order to determine if the defendant is a psychopath, very often a test called the psychopathy checklist – revised (PCL-R) will be administered. This test has to be conducted by a trained psychologist who has the time to get familiar with the defendant and their history. However, it has been shown that psychologists hired by the prosecution and the defense can come up with different verdicts that tend to favor their own arguments. If the test determines that the defendant is a psychopath then they have essentially just been tarred and feathered and will meet the full wrath of the law with no sympathy. If the test shows otherwise, that label of psychopath will not be applied, and the defendant is likely to meet some leniency.

Numerous points can be made here, but the point I would like to make is  that the use of the psychological test (the PCL-R), if it determines that the defendant is a psychopath, seems to convince the jury of the worst, and they are likely to reflect this in their judgment. However, a recent article on NPR pointed out that judges tends to be lenient when the biological basis for psychopathy is pointed out. It is indeed true that the neurobiology of the psychopath is different; this has been indicated on the tissue level and the genetic level.

This seems to suggest that a judge can be told that a psychological test has determined the defendant is a psychopath and so causes the worst possible outcome, yet if an explanation is given on the tissue, cellular, or genetic level, they can be swayed back towards leniency. It’s as if biological explanations destroy the facade of an individual and look to the minute building blocks of life (which we have no/limited control over), but the minute psychology appears, the individual is back and suddenly accountable for their actions.

This is one problem with juries when it comes to trying psychopaths. If the level of scientific analysis focuses on the individual, the jury will see the individual, whereas if the level of analysis on the molecular biological level, the jury will see cells and genes (which have a life of their own). I, personally, think it is irresponsible to allow a jury to have to reconcile these differences during the trial, especially if they have no scientific understanding.

**I would like to point out that not all psychologists work at the level of the organism, of course, and even if they do they are likely to be aware of cellular/genetic implications of their work.

Copyright Jack Pemment, 2012

Author, Seeing Red