Tag Archives: pcl-r

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 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].


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.


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].


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



  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

Diversity within psychopathy

diversityMuch of medical science today is about further understanding disease, disorder, and treatment. By manipulating context, we hope to tease the unknowns out of the chaotic vacuum of human ignorance into the controlled environment of categorization and understanding. There is nothing more satisfying in research to draw a statistically probable connection between concept x and concept y. The mind revels in these successes and after years of research, shedding blood, sweat, and tears, it can feel like the beast has been tamed.

However, as is the nature of scientific knowledge, there are never absolutes, only probabilities. And so once we have our category, it soon becomes apparent that sub-categories are needed. In the world of psychology, humans are forever providing exceptions  to what we thought we knew (who would’ve thought that with billions of neurons and trillions of synapses, humans would ever throw continual curve balls?).

In psychopathy research, there have been some tremendous strides in identifying those with the disorder. The PCL-R and the CAPP are both powerful tools, but it is also important to remember that just as all people are different, the list of behaviors that make up these tests can be exhibited very differently, depending on the individual. This is partly why it takes a trained mental health expert, with a thorough understanding of the subject’s history, to determine whether or not the criteria is met.

Psychopathy, for many years now, is still being explored within different sub categories; along gender lines, within prison populations, in children and adolescents, and in those whose behavior never resulted in incarceration. The latter of this group have previously been termed ‘successful’ psychopaths, and researchers have pushed to see if there are any brain differences that could explain this phenomenon; for example, do psychopaths who have never been incarcerated have better impulse control? Does the way they express their ‘psychopathic’ behavior never quite fall foul of the law? Are they simply more intelligent and better at covering their criminal tracks?

Cleckley seems to recognize the problem of varying degrees of psychopathy in a variety of different individuals. In The Mask of Sanity, he lists six types of individual and attempts to explain how psychopathy manifests in all of them: These are psychopaths as business man, man of the world, gentleman, scientist, physician, and psychiatrist.* This list is clearly indicative of his time, and one has to wonder what the few pages on psychopath as customer service representative, rap star, or cable guy would look like. However, it is an interesting debate to see if there is anything remotely formulaic about how a psychopath’s career could influence and be influenced by all of the behaviors they are known to exhibit (in varying frequency), that is if they are a psychopath that can maintain a career for any length of time.

Psychopathy remains a very dynamic disorder, and there is clearly a profound amount of difference between those afflicted. There are many areas in the brain that have been implicated in the disorder, and it is when these areas have failed to develop that the disorder could start to make an appearance. One has to wonder that in the symphony of brain development, how much of x has to fail to develop, in light of the failures of y and z to reach maturation? What are the ratios in terms of tissue development and cellular activity that will increase the probability of psychopathic behavior to the point where the disorder is there to stay?

How much can psychopathy be parceled up, before it splits into independent diagnostic components?


*Despite having listed two female case studies, when theorizing Cleckley tends to default to psychopaths as male.


The reappearing psychopath: Psychopathy’s stain on future generations

Aggression and Violent BehaviorI have finally gotten my third review paper published in Aggression and Violent Behavior. At a Science Direct near you!

(Click link) The reappearing psychopath: Psychopathy’s stain on future generations


The genesis of the psychopath has long been debated, typically within the framework of the long-held nature versus nature argument. Are psychopaths born psychopathic or are they molded by society? Like all personality disorders, the development of the psychopathic brain is dynamic, and as the psychopath remains a consistent, albeit small, part of the population, one has to wonder why psychopathy continues to reappear in generation after generation.

I explore the characteristics of psychopathic behavior, current theories on the adaptive qualities of this behavior, and psychopathy as it manifests in women. I argue that psychopathic behavior is not itself selecting for psychopathy. Psychopathy is a mental disorder that increases the likelihood of a set of behaviors, but these behaviors are not unique to the psychopath, and so will not favor the continued presence of psychopaths in the population. I also discuss the biological characteristics of the male brain that may make it more susceptible to psychopathy than the female brain.

Psychopathy: Choosing Victims

BundyI just stumbled across a very interesting study by Angela Book, Kimberly Costello, and Joseph A. Camilleri, who managed to explore how violent inmates choose their victims. The motivation for the study was built upon previous research that had explored the idea that a person’s gait (the way they walk and how they hold themselves) is likely to factor in when they are targeted by violent criminals, as it perhaps betrays a person’s vulnerability.

The authors include a statement from Bundy where he explains that he could tell a victim by the way she walked down the street, the manner in which carried herself, etc.

The study found that psychopathic criminals did tend to indicate gait as important for selecting a victim, but only if they scored highly on the Factor 1 part to the psychopathy checklist (PCL-R). There are a number of variations of this test, but one of the simplest is divided into two factors: Factor 1 measures personal characteristics, such as manipulating behavior, charm and charisma, and factor 2 measures aspects of an unstable lifestyle, such as impulsivity and antisocial behavior. So those scoring highly on the personal characteristics, the characteristics that trick us into liking and trusting them, were more likely to mention gait as an indicator of vulnerability.

The authors point out that a previous study exploring similar things found no such correlation, but the participants in that study were college students who exhibited some psychopathic traits, not seasoned criminals serving time in jail.

I found this study interesting for two reasons. Firstly, observing gait is most likely done while their is no personal interaction going on, i.e. you’re being studied and watched, probably without knowing it. And so then, secondly, psychopaths who score/would score highly on Factor 1 characteristics have probably already assessed you for weaknesses as they talk to, charm, and manipulate you throughout the course of the day.

The inmates in the study had to consciously express characteristics about victim-choosing, and so gait had to be realized. This is to distinguish it from the idea that these people are looking for certain weaknesses without really knowing what they’re doing. Obviously, with practice and success, checking a person’s gait would become second nature, but it appears to be a learned behavior.

Anyway, food for thought.

Copyright Jack Pemment, 2013


Book, A.B.; Costello, K.; Camilleri, J.A. (2013) Psychopathy and victim selection: The use of gait as a cue to vulnerability, Journal of Interpersonal Violence, In press

A rebuttal to Ronson’s book – The Psychopath Test

I was so happy to come across this response today from the Society for the Scientific Study of Psychopathy (SSSP) to Ronson’s book, ‘The Psychopath Test’. I have never been overly impressed with Ronson, and it always seemed to me that from what I had found out about Hare’s PCL-R, didn’t quite match up with Ronson’s take on it.

“In short, we think that Ronson’s book trivializes a serious personality disorder and its measurement, which is not helpful to those who have the disorder or to their unfortunate victims.”

To read the full commentary from the SSSP, click here.

Jack Pemment, 2013

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