What Psychopaths Teach Us about How to Succeed

What Psychopaths Teach Us about How to Succeed [Excerpt]

We can learn a lot from psychopaths. Certain aspects of their personalities and intellect are often hallmarks of success

By Kevin Dutton

Adapted from The Wisdom of Psychopaths, by Kevin Dutton, by arrangement with Scientific American/Farrar, Straus and Giroux, LLC (US), Doubleday Canada (Canada), Heinemann (UK), Record (Brazil), DTV (Germany), De Bezige Bij (Netherlands), NHK (Japan), Miraebook (Korea) and Lua de Papel (Portugal). Copyright © 2012 Kevin Dutton

Traits that are common among psychopathic serial killers—a grandiose sense of self-worth, persuasiveness, superficial charm, ruthlessness, lack of remorse and the manipulation of others—are also shared by politicians and world leaders. Individuals, in other words, running not from the police. But for office. Such a profile allows those who present with these traits to do what they like when they like, completely unfazed by the social, moral or legal consequences of their actions.

If you are born under the right star, for example, and have power over the human mind as the moon over the sea, you might order the genocide of 100,000 Kurds and shuffle to the gallows with such arcane recalcitrance as to elicit, from even your harshest detractors, perverse, unspoken deference.

“Do not be afraid, doctor,” said Saddam Hussein on the scaffold, moments before his execution. “This is for men.”

If you are violent and cunning, like the real-life “Hannibal Lecter” Robert Maudsley, you might take a fellow inmate hostage, smash his skull in and sample his brains with a spoon as nonchalantly as if you were downing a soft-boiled egg. (Maudsley, by the way, has been cooped up in solitary confinement for the past 30 years, in a bulletproof cage in the basement of Wakefield Prison in England.)

Or if you are a brilliant neurosurgeon, ruthlessly cool and focused under pressure, you might, like the man I'll call Dr. Geraghty, try your luck on a completely different playing field: at the remote outposts of 21st-century medicine, where risk blows in on 100-mile-per-hour winds and the oxygen of deliberation is thin. “I have no compassion for those whom I operate on,” he told me. “That is a luxury I simply cannot afford. In the theater I am reborn: as a cold, heartless machine, totally at one with scalpel, drill and saw. When you're cutting loose and cheating death high above the snowline of the brain, feelings aren't fit for purpose. Emotion is entropy—and seriously bad for business. I've hunted it down to extinction over the years.”

Geraghty is one of the U.K.'s top neurosurgeons—and although, on one level, his words send a chill down the spine, on another they make perfect sense. Deep in the ghettoes of some of the brain's most dangerous neighborhoods, the psychopath is glimpsed as a lone and merciless predator, a solitary species of transient, deadly allure. No sooner is the word out than images of serial killers, rapists and mad, reclusive bombers come stalking down the sidewalks of our minds.

But what if I were to paint you a different picture? What if I were to tell you that the arsonist who burns your house down might also, in a parallel universe, be the hero most likely to brave the flaming timbers of a crumbling, blazing building to seek out, and drag out, your loved ones? Or that the kid with a knife in the shadows at the back of the movie theater might well, in years to come, be wielding a rather different kind of knife at the back of a rather different kind of theater?

Claims like these are admittedly hard to believe. But they're true. Psychopaths are fearless, confident, charismatic, ruthless and focused. Yet, contrary to popular belief, they are not necessarily violent. Far from its being an open-and-shut case—you're either a psychopath or you're not—there are, instead, inner and outer zones of the disorder: a bit like the fare zones on a subway map. There is a spectrum of psychopathy along which each of us has our place, with only a small minority of A-listers resident in the “inner city.”

Think of psychopathic traits as the dials on a studio mixing deck. If you turn all of them to max, you'll have a soundtrack that's no use to anyone. But if the soundtrack is graded, and some are up higher than others—such as fearlessness, focus, lack of empathy and mental toughness, for example—you may well have a surgeon who's a cut above the rest.

Of course, surgery is just one instance where psychopathic “talent” may prove advantageous. There are others. In 2009, for instance, I decided to perform my own research to determine whether, if psychopaths were really better at decoding vulnerability (as had been found in some studies), there could be applications. There had to be ways in which, rather than being a drain on society, this ability actually conferred some benefit. And there had to be ways to study it.

Enlightenment dawned when I met a friend at the airport. We all get a bit paranoid going through customs, I mused. Even when we're perfectly innocent. But imagine what it would feel like if we did have something to hide—and if an airport security officer were particularly good at picking up on that feeling?
To find out, I decided to conduct an experiment. Thirty undergraduate students took part: half of them high on the Self-Report Psychopathy Scale, and half of them low. There were also five “associates.” The students' job was easy. They had to sit in a classroom and observe the associates' movements as they entered through one door and exited through another, traversing, en route, a small, elevated stage. But there was a catch. They also had to note who was “guilty”: Which one of the five was concealing a scarlet handkerchief?

To raise the stakes and give the observers something to “go on,” the associate with the handkerchief was handed £100. If the jury decided that they were the guilty party—if, when the votes were counted, they came out on top—then they had to hand it back. If, on the other hand, they got away with it, and the finger of suspicion fell heavier on one of the others, they would, in contrast, stand to be rewarded. They would, instead, get to keep the £100.

Which of the students would make the better “customs officers”? Would the psychopaths' predatory instincts prove reliable? Or would their nose for vulnerability let them down?

More than 70 percent of those who scored high on the Self-Report Psychopathy Scale correctly picked out the handkerchief-smuggling associate, compared with just 30 percent of the low scorers. Zeroing in on weakness may well be part of a serial killer's tool kit. But it may also come in handy at the airport.

Trolleyology

Joshua Greene, a psychologist at Harvard University, has observed how psychopaths unscramble moral dilemmas. As I described in my 2011 book, Split-Second Persuasion, he has stumbled on something interesting. Far from being uniform, empathy is schizophrenic. There are two distinct varieties: hot and cold.

Consider, for example, the following conundrum (Case 1), first proposed by the late philosopher Philippa Foot:

A railway trolley is hurtling down a track. In its path are five people who are trapped on the line and cannot escape. Fortunately, you can flip a switch that will divert the trolley down a fork in the track away from the five people—but at a price. There is another person trapped down that fork, and the trolley will kill him or her instead. Should you hit the switch?

Most of us experience little difficulty when deciding what to do in this situation. Although the prospect of flipping the switch isn't exactly a nice one, the utilitarian option—killing just the one person instead of five—represents the “least worst choice.” Right?


Now consider the following variation (Case 2), proposed by philosopher Judith Jarvis Thomson:

As before, a railway trolley is speeding out of control down a track toward five people. But this time you are standing behind a very large stranger on a footbridge above the tracks. The only way to save the five people is to heave the stranger over. He will fall to a certain death. But his considerable girth will block the trolley, saving five lives. Question: Should you push him?

Here you might say we're faced with a “real” dilemma. Although the score in lives is precisely the same as in the first example (five to one), playing the game makes us a little more circumspect and jittery. But why?

Greene believes he has the answer. It has to do with different climatic regions in the brain.

Case 1, he proposes, is what we might call an impersonal moral dilemma and involves those areas of the brain, the prefrontal cortex and posterior parietal cortex (in particular, the anterior paracingulate cortex, the temporal pole and the superior temporal sulcus), principally implicated in our objective experience of cold empathy: in reasoning and rational thought.

Case 2, on the other hand, is what we might call a personal moral dilemma. It hammers on the door of the brain's emotion center, known as the amygdala—the circuit of hot empathy.

Just like most normal members of the population, psychopaths make pretty short work of the dilemma presented in Case 1. Yet—and this is where the plot thickens—quite unlike normal people, they also make pretty short work of Case 2. Psychopaths, without batting an eye, are perfectly happy to chuck the fat guy over the side.

To compound matters further, this difference in behavior is mirrored, rather distinctly, in the brain. The pattern of neural activation in both psychopaths and normal people is well matched on the presentation of impersonal moral dilemmas—but dramatically diverges when things get a bit more personal.
Imagine that I were to pop you into a functional MRI machine and then present you with the two dilemmas. What would I observe as you went about negotiating their moral minefields? Just around the time that the nature of the dilemma crossed the border from impersonal to personal, I would see your amygdala and related brain circuits—your medial orbitofrontal cortex, for example—light up like a pinball machine. I would witness the moment, in other words, that emotion puts its money in the slot.

But in a psychopath, I would see only darkness. The cavernous neural casino would be boarded up and derelict—the crossing from impersonal to personal would pass without any incident.

The Psychopath Mix

The question of what it takes to succeed in a given profession, to deliver the goods and get the job done, is not all that difficult when it comes down to it. Alongside the dedicated skill set necessary to perform one's specific duties—in law, in business, in whatever field of endeavor you care to mention—exists a selection of traits that code for high achievement.

In 2005 Belinda Board and Katarina Fritzon, then at the University of Surrey in England, conducted a survey to find out precisely what it was that made business leaders tick. What, they wanted to know, were the key facets of personality that separated those who turn left when boarding an airplane from those who turn right?

Board and Fritzon took three groups—business managers, psychiatric patients and hospitalized criminals (those who were psychopathic and those suffering from other psychiatric illnesses)—and compared how they fared on a psychological profiling test.

Their analysis revealed that a number of psychopathic attributes were actually more common in business leaders than in so-called disturbed criminals—attributes such as superficial charm, egocentricity, persuasiveness, lack of empathy, independence, and focus. The main difference between the groups was in the more “antisocial” aspects of the syndrome: the criminals' lawbreaking, physical aggression and impulsivity dials (to return to our analogy of earlier) were cranked up higher.

Other studies seem to confirm the “mixing deck” picture: that the border between functional and dysfunctional psychopathy depends not on the presence of psychopathic attributes per se but rather on their levels and the way they are combined. Mehmet Mahmut and his colleagues at Macquarie University in Sydney have recently shown that patterns of brain dysfunction (specifically, patterns in orbitofrontal cortex functioning—the area of the brain that regulates the input of the emotions in decision making) observed in both criminal and noncriminal psychopaths, exhibit dimensional rather than discrete differences. This, Mahmut suggests, means that the two groups should not be viewed as qualitatively distinct populations but rather as occupying different positions on the same continuum.

In a similar (if less high-tech) vein, I asked a class of first-year undergraduates to imagine they were managers in a job placement company. “Ruthless, fearless, charming, amoral and focused,” I told them. “Suppose you had a client with that kind of profile. To which line of work do you think they might be suited?”
Their answers couldn't have been more insightful. CEO, spy, surgeon, politician, the military … they all popped up in the mix. Amongst serial killer, assassin and bank robber.

“Intellectual ability on its own is just an elegant way of finishing second,” one successful CEO told me. “Remember, they don't call it a greasy pole for nothing. The road to the top is hard. But it's easier to climb if you lever yourself up on others. Easier still if they think something's in it for them.”

Jon Moulton, one of London's most successful venture capitalists, agrees. In a recent interview with the Financial Times, he lists determination, curiosity and insensitivity as his three most valuable character traits.

No prizes for guessing the first two. But insensitivity? The great thing about insensitivity, Moulton explains, is that “it lets you sleep when others can't.”

This article was originally published with the title The Wisdom of Psychopaths.

ABOUT THE AUTHOR(S)

Kevin Dutton is a research psychologist at the Calleva Research Center for Evolution and Human Sciences at Magdalen College, University of Oxford.

MORE TO EXPLORE

What “Psychopath” Means. Scott O. Lilienfeld and Hal Arkowitz in Scientific American Mind, Vol. 18, No. 6, pages 80–81; December 2007/January 2008.

Inside the Mind of a Psychopath. Kent A. Kiehl and Joshua W. Buckholtz in Scientific American Mind, Vol. 21, No. 4, pages 22–29; September/October 2010.

How to Act Like a Psychopath without Really Trying [Excerpt]. John Whitfield. Published online December 9, 2011, at www.ScientificAmerican.com/article.cfm?id=how-to-act-like-a-psychopath

Psychiatric Times. Vol. 29 No. 7 CLINICAL  Narcissistic Personality Disorder: Rethinking What We Know By Giancarlo Dimaggio, MD | July 18, 2012 Dr Dimaggio is Psychiatrist and Psycotherapist at the Center for Metacognitive Interpersonal Therapy in Rome. Surprisingly, to the eyes of many experts, DSM-5 better captures the essence of narcissistic personality disorder (NPD) than previous versions did. Many clinicians (myself included) were dissatisfied with the descriptions of NPD in earlier versions of DSM. Persons with NPD are aggressive and boastful, overrate their performance, and blame others for their setbacks; current editions of DSM portray them as arrogant, entitled, exploitative, embedded in fantasies of grandeur, self-centered, and charming but emotionally unavailable. This portrayal of persons with NPD conveys only a minimal sense of their self-experience and misses their complexity. (MORE: Psychotherapy Tips: Working With Persons With Narcissistic Personality Disorder) Characteristics of NPD The draft of DSM-5 gives hints of what persons with NPD experience and, most importantly, provides a snapshot of a complex set of their self-experiences and disturbed mental processes. This description, though it may not be complete, is consistent with much of what we know from clinical experience and personality research about both NPD and narcissistic traits in the general population. An inherent problem of NPD is a disturbed internalized representation of self and others. Self-states and self-other schemas Feelings of grandiosity and fantasies of power and success are certainly important but are not the core theme in a narcissistic stream of consciousness. The DSM-5 prototype notes how self-appraisal can swing from hypervalued to self-derogation along with fluctuations in self-esteem. This is consistent with the idea that nuclear narcissistic states are not lim-ited to “being the one who sets people’s standards for the year to come,” as the disdainful protagonist of The Devil Wears Prada loved to say. NPD manifests as anger triggered by feelings of social rejection and tendencies to derogate those who give negative feedback. Persons with NPD often feel hampered in pursuing goals and blame others for being inept, incompetent, or hostile. States in which the self-image is extremely negative are important but are so hard to bear that fighting with others and blaming them for any personal flaws is a more suitable defensive maneuver. When shortcomings are impossible to deny (eg, being fired from work, breaking affective bonds), persons with NPD are likely to become depressed; as they age, the risk of suicide increases. Following the lead of the psychoanalysts Kohut 3 and Modell,4 states of emptiness, emotional numbing, and devitalization are now included in NPD models. Such states are quintessential to the disorder, but they are not included in the current DSM-5 prototype and have been overlooked by researchers. Other prominent narcissistic states include an inability to forgive and feelings of shame, guilt, and envy at others’ successs. In persons with NPD, self-experience patterns coalesce into self-other relational schemas: the dominant motives are concerns with social rank/antagonism, and the need to be admired and recognized by others as being special; the dominant image is of an “other” person unwilling to provide attention. The main schema is the “self” who desires to be recognized or admired and the “other” who is dominant and critical. In one schema, the self reacts with overt antagonism or by resorting to a metaphorical ivory tower.5 Another prominent schema is the self that needs attention while the other rejects and again criticizes the self, which, in turn, steers the self to compulsive self-soothing and denial of attachment needs.5,6 In general, such persons spend much time ruminating about issues of antagonism/social rank and avoid forming or thinking about attachments, thus concealing their vulnerable self. Empirical support has been found for the possibility that patients with NPD or narcissistic traits tend to seek self-enhancement, to overreact when they perceive others are setting limits, and to self-soothe.7 The development of NPD There is no consensus on the causes of NPD, although lack of parental empathy toward a child’s developmental needs may bear some responsibility. In the context of disturbed attachment, parents may fail to appropriately recognize, name, and regulate the child’s emotions, particularly in cases of heightened arousal.8 The developing child is therefore left with intense affects that receive no appropriate recognition or appropriate responses, which leads to affect dysregulation. In children, with their basic needs unmet, attachment becomes an issue; this translates to being attachment-avoidant in adulthood yet, at the same time, constantly striving for attention and admiration. Another trigger for NPD may be that the child is raised in a family where status and success are of utmost importance and only qualities that lead to sustaining a grandiose self-image are valued while other behaviors are disregarded or punished. Another possibility is that overt grandiosity is a reaction to slights and humiliation, a sort of armor used to avoid subjugation. Other factors, such as an externalizing personality and the role of culture (the narcissistic society) in paving the way to narcissism, should also be explored. Although studies on causation are scant, Tracy and colleagues9 summarize some recent findings in which parenting styles, such as mixtures of overt praise and coldness, lack of supervision, corporal punishment, and authoritarian parenting, predicted future narcissism. What is already known about narcissistic personality disorder? ■ Narcissistic personality disorder (NPD) is characterized by complex self-experiences, including grandiosity, anger, self-derogation, and emptiness or apathy. Lack of empathy is a feature of the disorder. Frequently, there are impaired romantic and professional outcomes as well as co-occurring disorders. What new information does this article provide? ■ Impaired ability to recognize inner states is a feature of the disorder. Evidence for affective but not cognitive empathy is presented. An agency deficit is a core characteristic of the disorder, with typical oscillations between diminished agency and hyperagentic behavior. Structured options for psychotherapy are succintly offered. What are the implications for psychiatric practice? ■ Persons with NPD are amenable to treatment. Understanding that underlying feelings of vulnerability, impaired self-reflection, and diminished agency are core features of the disorder may lead to refined psychological treatments, keep these persons in therapy longer, and promote structural personality change. The need for testing the effectiveness of manualized treatments for NPD is called for. Regulatory processes NPD features unrelenting standards for maintaining a sense of self-worth and personal goals valuable enough to be pursued. As a result, narcissism seems to include perfectionism as a trait and, after any accomplishment, the target is usually raised even higher, which results in never-ending dissatisfaction.5 Perfectionist standards are also set for others, which leads the narcissist to easily derogate others for not living up to his expectations. Other strategies for affect and interpersonal regulation are blaming others, withdrawing from relationships, adopting controlling and domineering strategies when facing problems and conflicts, and typically self-enhancing when facing others’ expected feedback. Agency and goal-setting The early observation by Kohut 3 that persons with NPD lack an inner drive to act was counterintuitive, because at least from the overt, blatantly arrogant type, one would expect a tendency to ruthlessly keep singing “I shall overcome.” But, when persistence is needed, strongly narcissistic persons tend, after some initial sparkling moments, to decline. Clinical experience with such patients highlights the fact that when they are not struggling for grandiosity or fighting against a tyrant, they lack access to those innermost wishes that could make them feel alive and vital and instead feel flat and inanimate. They lack a sense of existential agency. Thus, they are other-directed and their striving for admiration is a coping strategy for avoiding a sense of nothingness. DSM-5 observations such as “excessive reference to others for self-definition” or “goal-setting is based on gaining approval from others” capture this agency deficit—a problem that is a primary psychotherapeutic target. Overall, agency in narcissism is 2-sided: when social rank is at stake and narcissists feel competent, they are self-sufficient and feel mastery over the situation, which triggers grandiosity. When there are other motives, such as when success is not in sight, and when narcissists feel vulnerable or in difficulty, agency diminishes. In this latter case, they feel paralyzed, empty, and passive. Impaired empathy and poor understanding of mental states Empathy dysfunction is considered central to narcissism, with cognitive empathy considered less diminished than affective empathy.1,10,11 Persons with narcissism are able to understand how someone else feels but cannot respond appropriately. Only recently has empirical evidence appeared in support of an NPD criterion that to date was only based on clinical observations. This evidence provides insight into how diminished empathy works in the mind of such persons. Narcissism is associated with less emotional empathy in laboratory tasks but not in self-reports, which is to be expected: narcissists think they are empathic, when in reality they are not. Cognitive empathy is unaffected, although lack of motivation may reduce the ability to empathize. A functional MRI study showed that persons high in narcissistic traits displayed decreased activation in the right anterior insula during an empathy task.10 Study participants were unaware of their empathy impairment, which is a typical feature of narcissism and warns against using self-reports for investigating empathy in the NPD population. It is interesting to note that study participants who were high in narcissism and low in empathy were also more unaware of their own emotions. This finding is consistent with claims that reduced empathy is part of a wider impairment in the system of abilities to understand mental states, which includes poor self-awareness.5,12 Indeed, persons with NPD feature an inability to recognize some emotions in the self and, in particular, to understand the triggers for emotional reactions. DSM-5 ascribes dysfunctions in self-awareness to NPD, “often unaware of own motivations” or noting narcissistic tendencies to be “excessively attuned to others’ reactions but only if perceived as relevant to self.” Poor self-awareness is the underlying problem in NPD. Although narcissists are fully aware of being annoyed by persons who hamper their goals and attack their vacillating self-esteem, they have difficulty in accessing wishes and needs and in understanding what triggers some of their reactions. As a consequence, they constantly need others to understand their wishes and provide validation and support. Therefore, empathy is a costly and risky action for persons with NPD. This is likely to be connected to the inadequate parenting they received during their development, with caregivers who were unable to appropriately recognize, name, and regulate their affects. Such poor parenting is thought to leave narcissistic adults constantly looking for someone to help them recognize what they feel and to support their wishes, which leave them deprived of any possibility of focusing on others’ mental states. In short, poor self-awareness yields confusion about wishes and puts the person with NPD at risk for being influenced by others. When others display signs of suffering, the narcissist feels these others are distracting attention that rightly be-longs to him or her and the perception of loss increases. Empathy shuts down. CASE VIGNETTE Fred was a brilliant manager in his late 20s who had NPD. He was a perfectionist who was emotionally constricted, was unable to enjoy life, and reacted to any slights and criticisms with frozen anger or by overcontrolling his behavior to prevent any further criticism. His goal was to reach the highest performance level at work and to be recognized by others for his special qualities. To him, social life made sense only in terms of professional achievements. Any attempts at autonomy or acting spontaneously were inhibited because of fear of criticism and rejection. Self-esteem was regulated either by being successful at work or by physical exercise in order to reach perfect harmony in the functioning of his body. He wanted his girlfriend to be perfect and criticized her when she gained weight. His rigid, overcritical attitude and his inability to fully enjoy sexual life strained their relationship. During therapy, I adopted a validating stance: recognizing and accepting his wishes for autonomy and need to relax instead of striving to be accepted only when he reached the highest standards. I also pointed out that receiving criticism instead of emotional recognition had made him suffer, something I empathized with. He was offered a job in a major firm in the Netherlands that would have required him to move abroad. His girlfriend was supportive but also sad at the idea of separation. Fred interpreted this as a sort of emotional blackmail and became angry because he felt she was constraining his freedom. During sessions, associations were made between his current NPD and events that had taken place when he was younger. He was always an excellent student and at the top of his class, but his father was never satisfied and always expected more. In therapy, Fred understood that for his family, not meeting unrelenting moral and performance standards spelled terror and inability to give life meaning. He realized that he took his girlfriend’s reaction to the job offer as another sign that he could not be free to follow his own plans without evoking negative reactions in others. He realized that she was not being tyrannical, but supportive. Empathy for her increased while at the same time he was able to successfully apply for the new job. To the best of my knowledge, there have been no randomized clinical trials that have looked at treatment for NPD; therefore, the idea that NPD can or cannot be treated relies solely on clinical judgment. Different approaches, both cognitive and psychodynamic, have devised procedures to deal with narcissism, including, among others, relational psychoanalysis, object-relation psychoanalysis, schema-focused therapy, cognitive analytic therapy, and metacognitive interpersonal therapy.3,4,5,6,13,14 Although treatment guidelines have never been formulated, I have distilled tips for treating narcissism using the reported evidence and the DSM-5 prototype as a potentially reliable guide, with no intention, however, of advocating a specific approach (Table). TABLE Psychotherapy tips for working with persons with narcissistic personality disorder Conclusions Research is needed on the hypervigilant NPD subtype, which has been largely understudied in spite of clinicians’ warnings that this is the most frequent presentation in patients. Studies need to focus on the covert/hypervigilant subtype and discover its correlations with symptoms and social functioning. A new and more nuanced description of the narcissistic prototype will generate new case studies, empirical research, and clinical trials. Answering the following questions will help us better understand this problematic personality: • Will the overt and covert types of narcissism, now lumped together, end up being 2 distinct disorders? • Are dysfunctions in self-awareness, such as poor understanding of the triggers of an emotion, a feature of NPD? • Are persons with NPD self-reliant and avoidant of attachment? Do they tend to withdraw when they feel others are accessing their vulnerable self? • Is it possible to measure problems in goal-directed behavior—ie, impaired agency—and see whether this is a narcissistic feature? • Will the empathy deficit appear in future studies and the self-report/objective measures inconsistency stay? • Does the empathy deficit lie at the foundation of narcissism, or is it a consequence of poor self-awareness? • Are anger at being socially (or privately) rejected and states of numbness, anhedonia, and shutting off the prominent features of NPD? Related content Narcissistic Personality Disorder: Rethinking What We Know Psychotherapy Tips: Working With Persons With Narcissistic Personality Disorder References 1. Ronningstam E. Narcissism personality disorder: facing DSM-V. Psychiatr Ann. 2009;39:111-121. 2. Levy KN, Chauhan P, Clarkin JF, et al. Narcissistic pathology: empirical approaches. Psychiatr Ann. 2009;39:203-213. 3. Kohut H. The Analysis of the Self. New York: International Universities Press; 1971. 4. Modell AH. Psychoanalysis in a New Context. New York: International Universities Press; 1984. 5. Dimaggio G, Semerari A, Carcione A, et al. Psychotherapy of Personality Disorders. London: Routledge; 2007. 6. Young JE, Klosko JS, Weishaar ME. Schema Therapy: A Practitioner’s Puide. New York: Guilford Press; 2003. 7. Bamelis LM, Renner R, Heidkamp D, Arntz A. Extended schema mode conceptualizations for specific personality disorders: an empirical study. J Pers Disord. 2011;25:41-58. 8. Fonagy P, Gergely G, Jurist EL, Target M. Affect Regulation, Mentalization, and the Development of the Self. New York: Other Press, 2002. 9. Tracy JL, Cheng JT, Martens JP, Robins RW. The emotional dynamics of narcissism: Inflated by pride, deflated by shame. In: Campbell WK, Miller JD, eds. Handbook of Narcissism and Narcissistic Personality Disorder: Theoretical Approaches, Empirical Findings, and Treatments.Hoboken, NJ: John Wiley & Sons; 2011:330-343. 10. Fan Y, Wonneberger C, Enzi B, et al. The narcissistic self and its psychological and neuralcorrelates: an exploratory fMRI study. Psychol Med. 2011;41:1641-1650. 11. Ritter K, Dziobek I, Preissler S, et al. Lack of empathy in patients with narcissistic personality disorder. Psychiatry Res. 2011;187:241-247. 12. Dimaggio G, Lysaker PH, eds. Metacognition and Severe Adult Mental Disorders: From Basic Research to Treatment. London: Routledge; 2010. 13. Kernberg OF. Borderline Conditions and Pathological Narcissism. New York: Jason Aronson; 1975. 14.< Ryle A, Kerr IB. Introducing Cognitive Analytic Therapy: Principles and Practice. Chichester, England: John Wiley & Sons; 2002.
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Top 10 Survival Tips for the Highly Sensitive Person (HSP)

Prescriptions for Life

How to attain your goals, great and small, and create a life you love.

by Susan Biali, M.D.

Top 10 Survival Tips for the Highly Sensitive Person (HSP)

Secrets to surviving a highly sensitive (HSP) life

Published on May 21, 2011 by Dr. Susan Biali, M.D. in Prescriptions for Life

 

 

I've written about being a Highly Sensitive Person on this blog several times now, and each time I'm amazed by the intensity with which people respond to this topic. There are always a few critics who belittle or question the HSP concept, yet based on the huge number of page reads and overwhelmingly positive (and often grateful) responses, there really does seem to be something to this HSP phenomenon.

 

I first learned of this relatively common but misunderstood trait - and recognized myself in it - via the work of psychologist Dr. Elaine Aron (for detailed info on her work in this area, as well as an HSP self-test, see www.hsperson.com ). According to Aron's stats, HSPs make up 15-20 percent of the population yet often don't have a name for what has made them feel or seem "strange" or "overly sensitive" their entire life.

HSPs are easily overwhelmed by stimuli, get stressed by loud noises and strong smells, are extremely perceptive, have rich and often intense internal lives, and need plenty of quiet and down time to maintain their equilibrium (and sanity, I would personally add).

It was a great relief to me to finally understand what was "wrong" with me. I now even had an explanation for why I find any kind of violence, even the fake Hollywood kind, so abhorrent. It's not easy to go to a epic action movie with friends and to be the only one sobbing after war scenes (despite having covered my eyes the whole time - having only two hands I'm not able to cover my ears and the battle sounds alone are usually enough to push me over the edge).

Knowing what I am has helped so much, especially when it comes to supporting myself through experiences that otherwise might overload my hypersensitive senses. Here, for you, are my top ten survival strategies:

1) Get enough sleep

Lack of sleep (less than 7 hours, for most people) is well known to produce irritability, moodiness, and decreased concentration and productivity in the average person. Given our already ramped-up senses, I'm convinced that lack of sleep can make a highly sensitive life almost unbearable. Getting enough sleep soothes your senses and will help you cope with an already overwhelming world.

2) Eat healthy foods regularly throughout the day

Aron points out that extreme hunger can be disruptive to an HSP's mood or concentration. Keep your edgy nerves happy by maintaining a steady blood sugar level through regular healthy well-balanced meals and snacks. I also take fish oil (omega-3) supplements daily as the brain loves these, lots of studies support their beneficial cognitive and emotional effects.

3) Wear noise-reducing headphones

A boyfriend introduced Peltor ear protecting headphones (usually used by construction workers, not pre-med students) to me when I was 19 and studying for exams. No matter where I am in the world I have had a pair with me ever since. HSPs are highly sensitive to noise, especially the kind we can't control, and my beloved headphones give me control over my personal peace in what's all too often a noisy intrusive world.

 

4) Plan in decompression time

HSPs don't do well with an overly packed schedule or too much time in noisy, crowded or high pressure environments. If you know you're going to spend a few hours in a challenging environment - such as a concert, a parade, or a crowded mall at Christmas time - know that you're likely to be frazzled after and will need to decompress somewhere quiet and relaxing, on your own if possible.
5) Have at least one quiet room or space to retreat to in your home
If you live with others, create a quiet safe place you can retreat to when you need to get away from people and noise. This could be a bedroom, a study, or even just a candlelit bath (or shower if that's all you have!). I've found it often helps to listen to quiet relaxing music as well, this can even drown out more jarring external noise when you need it to.

6) Give yourself time and space to get things done

I mentioned above that HSPs don't do well with a packed schedule. I've managed to structure my work life so that I work afternoon/evening shifts the days I'm at the medical clinic. This way I'm able to get out of bed without an alarm, eat a calm unrushed breakfast and putter around before getting down to business. The calm this gives me carries through my whole day. Another strategy for those who work in the morning might be getting up extra early (after 8 hours sleep, of course) to enjoy the quiet before the rest of the household wakes up.

7) Limit caffeine

HSPs are sensitive to caffeine - I usually can't even handle the traces of caffeine found in decaf coffee. If you're a coffee drinker (or dark chocolate junkie) and identify with the HSP trait description, giving up the joe might be a big step towards feeling more collected and calm.

 

8) Keep the lights down low

I've never liked bright lights and learning about HSP helped me understand why. Minimizing light stimulation goes a long way: I only put on low lights in the evening, and prefer to shop in certain local grocery stores which have gentle mood lighting, avoiding the garishly lit, crowded "big box" stores whenever I can.

9) Get things done in off hours

To avoid crowds and the associated noise and stimulation, I've learned to live my life outside of the average person's schedule. I grocery shop late in the evenings, run errands during the week whenever I can, go to movies on weeknights, and go out for my walks before the rest of the world hits the jogging path. An added bonus: by avoiding the crowds I usually get things done faster , and almost always get a parking spot!

10) Surround yourself with beauty and nature

Since we HSPs are so sensitive and deeply affected by our surroundings, envelop yourself with beauty and calm whenever possible. I've decorated my home simply in a way that's very pleasing to my eye, with minimal clutter and chaos. I also spend as much time as I can walking in nature, enjoying the quiet and its naturally healing and calming beauty.

Dr. Susan Biali is a practicing medical doctor, wellness expert, international speaker, life coach and professional flamenco dancer.  She is also the author of Live a Life You Love: 7 Steps to a Healthier, Happier, More Passionate You.

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Relationship Secrets for Highly Empathic People

Judith Orloff MD

Author, 'Emotional Freedom: Liberate Yourself from Negative Emotions and Transform Your Life'

Relationship Secrets for Highly Empathic People

 

Loneliness gets to some more than others. But why it hangs on isn't always apparent when read by traditional medical eyes. In my psychiatric practice in Los Angeles and in my workshops I've been struck by how many sensitive, empathic people who I call "emotional empaths" come to me, lonely, wanting a romantic partner, yet remaining single for years. Or else they're in relationships but feel constantly fatigued and overwhelmed. The reason isn't simply that "there aren't enough emotionally available people 'out there,'" nor is their burnout "neurotic." Personally and professionally, I've discovered that something more is going on.

In "Emotional Freedom" I describe emotional empaths as a species unto themselves. Whereas others may thrive on the togetherness of being a couple, for empaths like me, too much togetherness can be difficult, may cause us to bolt. Why? We tend to intuit and absorb our partner's energy, and become overloaded, anxious, or exhausted when we don't have time to decompress in our own space. We're super-responders; our sensory experience of relationship is the equivalent of feeling objects with 50 fingers instead of five.
Energetically sensitive people unknowingly avoid romantic partnership because deep down they're afraid of getting engulfed. Or else, they feel engulfed when coupled, a nerve-wracking, constrictive way to live. If this isn't understood, empaths can stay perpetually lonely. We want companionship, but, paradoxically, it doesn't feel safe. One empath patient told me, "It helps explain why at 32 I've only had two serious relationships, each lasting less than a year." Once we empaths learn to set boundaries and negotiate our energetic preferences, intimacy becomes possible.

For emotional empaths to be at ease in a relationship, the traditional paradigm for coupling must be redefined. Most of all, this means asserting your personal space needs -- the physical and time limits you set with someone so you don't feel they're on top of you. Empaths can't fully experience emotional freedom with another until they do this. Your space needs can vary with your situation, upbringing, and culture. My ideal distance to keep in public is at least an arm's length. In doctors' waiting rooms I'll pile my purse and folders on the seats beside me to keep others away.

With friends it's about half that. With a mate it's variable. Sometimes it's rapture being wrapped in his arms; later I may need to be in a room of my own, shut away. One boyfriend who truly grasped the concept got me a "Keep Out" sign for my study door! For me, this was a sign of true love. All of us have an invisible energetic border that sets a comfort level. Identifying and communicating yours will prevent you from being bled dry by others. Then intimacy can flourish, even if you've felt suffocated before. Prospective mates or family members may seem like emotional vampires when you don't know how to broach the issue of personal space. You may need to educate others -- make clear that this isn't about not loving them -- but get the discussion going. Once you can, you're able to build progressive relationships.

If you're an empath or if the ordinary expectations of coupledom don't jibe with you practice the following tips.

Define your personal space needs 

Tip 1. What to say to a potential mate

As you're getting to know someone, share that you're a sensitive person, that you periodically need quiet time. The right partner will be understanding; the wrong person will put you down for being "overly sensitive," and won't respect your need.

Tip 2. Clarify your preferred sleep style

Traditionally, partners sleep in the same bed. However, some empaths never get used to this, no matter how caring a mate. Nothing personal; they just like their own sleep space. Speak up about your preferences. Feeling trapped in bed with someone, not getting a good night's rest, is torture. Energy fields blend during sleep, which can overstimulate empaths. So, discuss options with your mate. Separate beds. Separate rooms. Sleeping together a few nights a week. Because non-empaths may feel lonely sleeping alone, make compromises when possible.

Tip 3. Negotiate your square footage needs

You may be thrilled about your beloved until you live together. Experiment with creative living conditions so your home isn't a prison. Breathing room is mandatory. Ask yourself, "What space arrangements are optimal?" Having an area to retreat to, even if it's a closet? A room divider? Separate bathrooms? Separate houses? I prefer having my own bedroom/office to retreat to. I also can see the beauty of separate wings or adjacent houses if affordable. Here's why: conversations, scents, coughing, movement can feel intrusive. Even if my partner's vibes are sublime, sometimes I'd rather not sense them even if they're only hovering near me. I'm not just being finicky; it's about maintaining well-being if I live with someone.

Tip 4. Travel wisely

Traveling with someone, you may want to have separate space too. Whether my companion is romantic or not, I'll always have adjoining rooms with my own bathroom. If sharing a room is the only option, hanging a sheet as a room divider will help. "Out of sight" may make the heart grow fonder.

Tip 5. Take regular mini-breaks

Empaths require private downtime to regroup. Even a brief escape prevents emotional overload. Retreat for five minutes into the bathroom with the door shut. Take a stroll around the block. Read in a separate room. One patient told her boyfriend, "I need to disappear into a quiet room for ten minutes at a party, even if I'm having fun," a form of self-care that he supports.

In my medical practice, I've seen this creative approach to relationships save marriages and make ongoing intimacies feel safe, even for emotional empaths (of all ages) who've been lonely and haven't had a long-term partner before. Once you're able to articulate your needs, emotional freedom in your relationships is possible.

Why Happy Pills Don't Make Us Happy

AlterNet.org

PERSONAL HEALTH  

Psychotherapy Networker / By Andrew Weil

We Have Happy Pills, Anxiety Drugs, and Therapists Galore: So Why Are We More Stressed and Depressed Than Ever?

More of us than ever are discontented and not experiencing optimum emotional well-being. Why is the vast enterprise of professional mental health unable to help us feel better?

July 3, 2012  |  

 

 

An alternative to the old talking cure is expanding the knowledge base of psychotherapy as we recognize the role that exercise, nutrition, spirituality, mind-body approaches, and lifestyle can play in enhancing our clinical effectiveness. Epidemic depression is occurring at a time when the field of mental health appears very robust. There are more mental health professionals treating more people than ever before in history: psychiatrists, clinical psychologists, licensed social workers, counselors, and therapists of all kinds.

We have a powerful “therapeutic arsenal” of drugs to make us happier, calmer, and saner. When I leaf through the pharmaceutical ads that take up so much space in psychiatric journals, I get the feeling that we should all be in great emotional health. Depression and anxiety should be as fully conquered as smallpox and polio. But more of us than ever are discontented and not experiencing optimum emotional well-being. What is wrong with this picture? Why is the vast enterprise of professional mental health unable to help us feel better?

I want you to consider the possibility that the basic assumptions of mainstream psychiatric medicine are obsolete and no longer serve us well. Those assumptions constitute the biomedical model of mental health and dominate the whole field.

In 1977, the journal Science published a provocative article titled “The Need for a New Medical Model: A Challenge for Biomedicine.” I consider it a landmark in medical philosophy and the intellectual foundation of today’s integrative medicine. The author, George L. Engel, M.D., was a professor of psychiatry at the University of Rochester (New York) School of Medicine. Determined to overcome the limiting influence of Cartesian dualism, which assigns mind and body to separate realms, Engel envisioned medical students of the future learning that health and illness result from an interaction of biological, psychological, social, and behavioral factors, not from biological factors alone. He fathered the field of psychosomatic medicine and devoted much of his career to broadening our understanding of disease. He was particularly interested in mental health.

George Engel died in 1999 with his vision largely unrealized. In fact, the field of psychosomatic medicine ran out of steam sometime before his death and was never able to challenge the ascendancy of biological medicine.

“Biology Explains All” was in full swing when I was a student at Harvard Medical School in the late 1960s. At that time, I was taught that just four diseases were psychosomatic: peptic ulcer, rheumatoid arthritis, bronchial asthma, and ulcerative colitis. Four out of the entire catalog of diseases is not a lot, but at least for those four, doctors conceded that mental/emotional factors played a role. Peptic ulcer was knocked off the list in the early 1980s when a bacterial infection (Helicobacter pylori) was identified as the “real” cause of ulcers, now treatable with antibiotics. Investigation of biological factors associated with the three remaining conditions has led to more powerful drug treatments for them and greatly lessened interest in attending to any psychological, social, or behavioral factors that might be involved.

Rheumatologists today, for example, are most enthusiastic about a new class of immunosuppressive drugs called TNF-α blockers, which often appear to put rheumatoid arthritis and ulcerative colitis into full remission. Never mind that these drugs can be highly toxic and are very expensive; once doctors prescribe them for these conditions, they no longer see the point of addressing emotional or lifestyle factors of the patients who have them.

Although George Engel’s efforts in psychosomatic medicine were ahead of their time, their relevance today is great, and I advise all health professionals, especially mental health professionals, to read his 1977 paper in Science. I will summarize his “challenge for biomedicine” here, because it exposes the great limitations of the conceptual model that now dominates medicine in general and psychiatric medicine in particular. That model often fails to help doctors maintain and heal our physical bodies, and it has greatly hindered our understanding of and ability to manage the epidemic of depression and other mood disorders that plague our society. It does not point the way to contentment, comfort, serenity, and resilience, nor does it show us how to attain optimum emotional well-being.

Models are belief systems—sets of assumptions and explanations we construct to make sense of our experience. In Engel’s words, “The more socially disruptive or individually upsetting the phenomenon, the more pressing the need of humans to devise explanatory systems.” Disease is a very upsetting phenomenon, and humans throughout history have come up with a variety of belief systems to explain it, from the wrath of the gods to possession by spirits to disharmony with the forces of nature. The dominant model of disease in our time is biomedical, built on a foundation of molecular biology. As Engel explains, “It assumes disease to be fully accounted for by deviations from the norm of measurable biological (somatic) variables. It leaves no room within its framework for the social, psychological, and behavioral dimensions of illness. The biomedical model not only requires that disease be dealt with as an entity independent of social behavior, it also demands that behavioral aberrations be explained on the basis of disordered somatic (biochemical or neurophysiological) processes. Thus the biomedical model embraces both reductionism, the philosophic view that complex phenomena are ultimately derived from a single primary principle, and mind-body dualism.”

Engel goes on to say, “The biomedical model has . . . become a cultural imperative, its limitations easily overlooked. In brief, it has now acquired the status of a dogma. . . . Biological dogma requires that all disease, including ‘mental’ disease, be conceptualized in terms of derangement of underlying physical mechanisms.” He proposed an alternative: a biopsychosocial model of health and illness.

There is no question that over the past century, biomedicine has advanced our knowledge of human biology, but the real test of a scientific model—the measure of its superiority to an alternative belief system—is whether or not it increases our ability to describe, predict, and control natural phenomena. In my books about health and healing, I have written a great deal about how strict application of the biomedical model has actually made it harder for us to understand and manage common diseases. For instance, I have pointed out that it fails to account for the fact that many people infected with H. pylori never develop peptic ulcers or have any symptoms at all. They coexist with it in a balanced way. Clearly, factors other than the simple presence of that germ play a role in peptic ulcer disease, including the strength or weakness of host defenses, of an individual’s resistance. One of those defenses is stomach acid, whose production is influenced by the autonomic (involuntary) nervous system and through it by emotions. In the fight-or-flight response, the sympathetic division of the autonomic nervous system shuts down gastrointestinal function, which is unnecessary in an emergency, in order to divert energy and blood flow to muscles. That includes turning off the production of acid in the stomach. In chronic anxiety and stress, the sympathetic nerves are constantly overactive, and therefore there is constantly less acid in the stomach to keep potentially invasive germs from causing tissue damage. To say that H. pylori infection is strongly correlated with peptic ulcer disease is accurate. To say that it is the sole cause of ulcers ignores the complexity of causation and the possible influence of emotions.

In 1980, the American Psychiatric Association radically revised the Diagnostic and Statistical Manual–III (DSM-III) to be in accord with the biomedical model. As a consequence, the role of psychiatrists went from being facilitators of insight in patients to being dispensers of drugs to modify brain chemistry. Although some psychiatrists still rely on talk therapy, of all medical specialties, the profession as a whole is the most dominated and, to my mind, hobbled by blind faith in biomedicine. Psychiatrists were easily seduced because of a collective inferiority complex with regard to their place in the medical hierarchy. Still referred to as witch doctors and shrinks (from headshrinkers), they themselves have a history of questioning whether they are real doctors and whether they need the same basic medical training as cardiologists and surgeons. With the spectacular rise of biomedicine, their discomfort increased, and, not wanting to be left behind, they looked for ways to be even more biologically correct than their colleagues in other specialties. They saw their ticket to acceptance in the new and rapidly developing field of psychopharmacology—the study of the effect of drugs on mental and emotional disorders.

In 1921, Otto Loewi (1873–1961), a German pharmacologist, demonstrated that nerve cells (neurons) communicate by releasing chemicals. Prior to that time, neuroscientists thought nervous communication was electrical. Among the many important breakthroughs that followed from Loewi’s work were the identification of neurotransmitters and the discovery of receptors on cell surfaces that bind them. Neurotransmitters are chemicals made within the body, stored in tiny sacs clustered within a neuron and released into the synapse, the gap between the neuron and a target cell, which might be another neuron (the postsynaptic neuron) or a muscle or glandular cell. The released molecules then bind to receptors—specialized proteins on the surface membrane of the target cell—causing changes in that cell, making it more or less likely to produce an electrical signal (in the case of a neuron), to contract (in the case of a muscle), or to secrete a hormone (in the case of a glandular cell). Later, the neurotransmitters can separate from their receptors and be taken up by presynaptic cells for reuse or be broken down by enzymes into inactive metabolites. Neuroscientists have now compiled long lists of neurotransmitters, described their actions, and identified many types and subtypes of receptors.

Three of the most studied neurotransmitters are norepinephrine, dopamine, and serotonin, all very relevant to the subject at hand because they influence our moods and emotions. For example, dopamine is involved in what is known as the reward system of the brain; drugs that affect it can alter our experience of pleasure. Cocaine is such a drug. It blocks reuptake of dopamine back into the presynaptic neuron, effectively increasing its action at the synapse to produce an intense pleasurable response. With prolonged use of cocaine, postsynaptic neurons become less responsive to dopamine, leading to depression and dependence on the drug to relieve it. The dopamine hypothesis of schizophrenia attributes psychosis to overactivity of this neurotransmitter. Norepinephrine regulates both reward and arousal. Disturbances in that neurotransmitter system are associated with anxiety disorders. And serotonin affects our moods and sleep.

The most widely used psychiatric drugs today influence the production and effects of these major neurotransmitters. Psychopharmacologists made their first big breakthrough in the 1950s from work with antihistamines, used to quell allergic symptoms. Although antihistamines are best known for blocking the effects of the compound responsible for certain immune responses, they also affect the brain, often making people groggy, sleepy, and depressed. By tinkering with these molecules, chemists produced a new class of psychoactive drugs—the phenothiazines—that blocked dopamine transmission. Thorazine and other phenothiazines were successfully marketed as major tranquilizers and antipsychotics and quickly revolutionized the treatment of schizophrenia. Psychiatrists hailed them as magical compounds that cured psychosis, while critics argued that they simply made psychotic people groggy, sedated, and easier to manage, even as outpatients. Energized by this achievement, psychopharmacologists then turned their attention to depression. Over the past sixty years, they have come up with a number of drugs to treat it.

The efforts of psychopharmacologists give us an opportunity to evaluate the usefulness of the biomedical model in psychiatry. In practice, psychiatric medicine today is synonymous with psychopharmacology. The credo of that field is “There is no twisted thought without a twisted molecule.” (The words of the American neurophysiologist Ralph Gerard, 1900–1974). The biomedical model explains depression as the result of a chemical imbalance in the brain, specifically of neurotransmitters affecting our moods. How well does that explanation enable us to describe, predict, and control depressive illness? In other words, just how effective are the antidepressant drugs that psychopharmacologists have developed, that the big pharmaceutical companies sell such quantities of, and that so many people today take? The answer, I’m afraid, is not very.

The first antidepressant drug was discovered serendipitously in 1952. Iproniazid, an antimicrobial agent being studied as a possible treatment for tuberculosis, was found to affect mood, making even terminally ill patients cheerful and optimistic. Investigation of a possible mechanism for this unexpected psychoactivity revealed that the drug blocked enzymatic breakdown of all three major neurotransmitters: norepinephrine, dopamine, and serotonin.

Pharmaceutical chemists then looked for other drugs with this action and soon after produced a different class of antidepressant drugs by modifying the phenothiazine tranquilizers. These became known as tricyclic antidepressants, of which amitriptyline was the prototype; Merck pharmaceutical company gave it the brand name Elavil. In 1961, the FDA approved Elavil for the treatment of major depression, and it quickly became a bestselling drug. The tricyclics appeared to work by blocking presynaptic reuptake of norepinephrine and serotonin without affecting dopamine.

Because all of the early antidepressants had unpleasant side effects and serious potential interactions with other drugs and medications, pharmaceutical chemists continued their search for better ones with more specific action. But what specific action should it be? Some thought deficiency of norepinephrine was the biochemical cause of depression. Others argued for a serotonin hypothesis of depression and looked for compounds to prevent its breakdown or reuptake. The proponents of the serotonin hypothesis would win the day; their big discovery came in the 1970s, again, interestingly enough, as a result of work with an antihistamine.

Very likely you have taken Benadryl (diphenhydramine) at some point in your life. It is one of the oldest and most widely used antihistamines, the first such drug to be approved by the FDA for prescription use, in 1946. Benadryl is so sedating that it is now sold over the counter as a sleep aid. In the 1960s, this tried-and-true drug was found to have an action independent of its effect on histamine: it selectively inhibited the reuptake of serotonin. By modifying this molecule, scientists at Eli Lilly and Company in the 1970s came up with the first safe and effective selective serotonin reuptake inhibitor, fluoxetine, much better known by its brand name Prozac. The rest is history. Today the accepted biomedical explanation of depression is that it results from a deficiency of serotonin at synapses in key areas of the brain; therefore, boosting the activity of this neurotransmitter with drugs that block its reuptake will treat or cure the problem.

It’s a good bet that thirty years ago, not one American in a thousand had heard of this neurotransmitter—or any neurotransmitters, for that matter. Today, when you Google serotonin, about 11 million results appear, and Amazon sells nearly three thousand books with the word in the title (including The Serotonin Solution: The Potent Brain Chemical That Can Help You Stop Bingeing, Lose Weight, and Feel Great). “Serotonin” is the name of a professional wrestling team and an album by the British rockers The Mystery Jets. You can even proclaim your autumn blues to friends by way of a greeting card that reads, “The leaves and my serotonin levels are falling.” A once-obscure neurochemical has become pop-culture currency, and increasing levels of this feel-good compound has turned into a public obsession.

None of this just happened on its own. In order to sell antidepressant medications, drug manufacturers launched a relentless worldwide marketing and public-relations campaign promoting serotonin as the distilled biochemical essence of happiness. The message was that selective serotonin reuptake inhibitors—SSRIs—increase synaptic levels of serotonin in the brain by slowing its rate of reabsorption by presynaptic neurons, ending depression. Psychiatrists and other physicians got the technical version of this message, while consumers got a simplified one, often reduced to the rallying cry “Boost serotonin!”
The only problem is that it probably isn’t true.

Like the dopamine hypothesis of schizophrenia and other attempts to attribute complex mental phenomena to simplistic biochemical causes, the serotonin hypothesis of depression is shaky at best. Several studies have established that lowering serotonin levels does not negatively impact mood. In fact, a new pharmaceutical known as tianeptine—sold in France and other European countries under the trade name Coaxil—has been shown to be as effective as Prozac. Tianeptine works by lowering synaptic serotonin. As psychology professor Irving Kirsch of the University of Hull in England told Newsweek, “If depression can be equally affected by drugs that increase serotonin and by drugs that decrease it, it’s hard to imagine how the benefits can be due to their chemical activity.”

It is, indeed, especially as evidence accumulates that, in most cases, SSRIs work no better than placebos to boost mood. The first such analysis, published in 1998, looked at thirty-eight manufacturer-sponsored studies that included more than three thousand depressed patients. It found negligible differences in improvement between those on the drugs and those on dummy pills. At least 75 percent of the benefit from this class of antidepressants seemed to be a placebo effect. This finding has since been confirmed by other research.

To say that biomedically minded physicians have been reluctant to accept this finding or modify their prescribing habits as a result would be a great understatement. Both professional and popular media have tried to play down the significance of this new research and in some cases have misreported the findings. In April 2002, the Journal of the American Medical Association (JAMA) published the results of a large randomized controlled study sponsored by the National Institutes of Health to evaluate a popular herbal treatment for depression, St. John’s wort (Hypericum perforatum). Its effect was compared with that of the widely prescribed SSRI Zoloft (sertraline) and a placebo in 340 patients with major depressive disorder. The conclusion that made front-page news around the world was that St. John’s wort worked no better than the placebo at relieving depression. Television news shows featured reporters in health-food stores pointing to St. John’s wort products and advising consumers not to waste their money on natural remedies whose supposed benefits were nothing more than old wives’ tales.

Never mind that St. John’s wort is not indicated for the treatment of major depression, making the point of the study questionable. The finding from this well-designed trial that should have made front-page news was that Zoloft also worked no better than the placebo. In fact, the placebo treatment was acually more effective in these very depressed patients than either Zoloft or St. John’s wort!

Irving Kirsch summarized the growing body of evidence against SSRIs in his 2010 book, The Emperor’s New Drugs: Exploding the Antidepressant Myth, which I recommend. In response, proponents of the drugs and the serotonin hypothesis retreated to a more defensible position: SSRIs may owe much of their apparent benefit to patients’ belief in them, they admit, but they still have a real biochemical effect that makes them useful in the treatment of severe depression. Unfortunately for those proponents, the most recent analysis, published in the January 6, 2010, issue of JAMA, rates the real biochemical effect of SSRIs as nonexistent to negligible even in most cases of severe depression. Only in patients with very severe symptoms can researchers detect a statistically significant drug benefit compared with that of a placebo. About 13 percent of people with depression have very severe symptoms. One of the authors of the JAMA paper, Steven D. Hollon, Ph.D., of Vanderbilt University, has said, “Most people [with depression] don’t need an active drug. For a lot of folks, you’re going to do as well on a sugar pill or on conversations with your physicians as you will on medication. It doesn’t matter what you do; it’s just that you’re doing something.”

I would argue that the dismal performance of Prozac, Zoloft, Paxil, and other antidepressant drugs relative to placebos not only leaves the serotonin hypothesis of depression without a leg to stand on but also exposes the failure of the biomedical model to further our understanding of and ability to manage emotional disorders. I firmly believe that the nature of depression will never be revealed solely in studies of brain biochemistry that are isolated from the rest of human experience. Like coronary heart disease, depression is a multifactorial health problem, rooted in complex interactions of biological, psychological, and social variables, best understood and managed through a broader biopsychosocial model of the sort proposed by George Engel.

Loneliness, for example, is a powerful predictor of depression. Numerous studies show that people with few intimate social contacts are more likely to be depressed than those who enjoy a rich network of friends and family.
Reductionists might argue that being part of a social group boosts serotonin, but I am confident that there is something in a successful social life that transcends any effect on brain biochemistry, at least insofar as we currently understand that biochemistry. In other words, a happy family life probably raises serotonin in some people, lowers it in others, and leaves it unaffected in still others. Yet it makes them all more comfortable, serene, and relatively immune to mood disorders through a body-mind-social interaction that can’t be reduced to its constituent parts.

The New Model

I have written about possible causes of epidemic depression in our society, among them such lifestyle factors as diets high in processed foods, lack of physical activity, social isolation resulting from affluence, and altered brain activity from information overload. In its narrow focus on molecular biology, the biomedical model fails to capture any of this, and practitioners under its spell cannot give depressed patients the advice they need to address the complex causes of their problems. All they can do is dispense drugs that for the majority of patients might as well be sugar pills.

In an effort to give mental health professionals more and better options, I convened the first national conference on integrative mental health in March 2010. Together with Victoria Maizes, M.D., executive director of the Arizona Center for Integrative Medicine, I invited psychiatrists, psychologists, social workers, and other health professionals to attend a three-day event in Phoenix to “learn how to treat their patients within a new paradigm of integrative mental health care that utilizes scientifically proven alternative methods in combination with drugs and traditional therapy to address patients’ physical, psychological, and spiritual needs.” The use of the word spiritual here is significant; it expands George Engel’s concept to include yet another dimension of human life, one often overlooked in medicine. Adding it creates a biopsychosocialspiritual model. For convenience, I prefer the term integrative to describe this new way of thinking about health and illness in general and mental health in particular.

Dr. Maizes and I invited leading practitioners and researchers to share their experience and findings with attendees. We planned for an audience of three hundred, but, in a time of great economic recession, the conference sold out six weeks in advance with a total of seven hundred registrants. If we had had a larger venue, we could have doubled that number, so great was the interest in the topic—evidence, I think, that professionals are even more fed up than patients with the dead end that the drug-only approach represents.
On the closing day of the conference, I spoke about the failure of the biomedical model and the great advantages of the new integrative model of mental health. I quoted Albert Einstein on the subject of conceptual models:

“Creating a new theory is not like destroying an old barn and erecting a skyscraper in its place. It is rather like climbing a mountain, gaining new and wider views, discovering unexpected connections between our starting point and its rich environment. But the point from which we started still exists and can be seen, although it appears smaller and forms a tiny part of our broad view gained by the mastery of the obstacles on our adventurous way up.”

The new integrative model of mental health does not ignore brain biochemistry. It takes into account correlations between imbalances in neurotransmitters and mood disorders. Nor does it reject psychopharmacology. Integrative treatment plans for depression, particularly for severe depression, may well include medication, but my colleagues and I prefer to try other methods first and to use antidepressant drugs for short-term management of crises rather than rely on them as long-term solutions. One of the invited speakers, a noted expert on psychopharmacology, gave an optimistic presentation on psychiatric drugs of the future, drugs that will have more specific, better-targeted actions. People listened to his lecture with interest but showed much greater enthusiasm for talks on the critical importance of dietary omega-3 fatty acids to optimum emotional health and the latest neuroscientific evidence for the benefits of meditation, among others.

To say that the psychiatrists, psychologists, and other mental health professionals in attendance appreciated this larger perspective fails to convey their excitement. One told me that she had been waiting years for such a conference. Another said he would take the information he received and use it to change standards of practice in a large group of mental health care facilities in his state. Many expressed interest in seeking formal training in integrative mental health, training that I and my colleagues at the University of Arizona hope to provide.

Presentations that particularly interested me concerned neuroplasticity, the potential of the brain and nervous system to change and adapt. The speakers were neuroscientists influenced by Buddhist psychology and the teachings of the Dalai Lama. Using such new techniques as PET scans and functional MRIs, which make it possible to visualize living brains, they have been able to show that individuals trained in meditation have different brain activity from those without such training, and they respond differently to situations that would cause most of us to lose our emotional equilibrium. The broader implication of this research is that changes in the mind can cause changes in both the function and structure of the brain, a fact that cannot be explained by the biomedical model and that suggests many more options for taking charge of our emotional well-being.

In retrospect, seeing human beings as nothing more than the sum of biochemical interactions was probably a necessary stage of medical evolution. Medical systems of the past lacked the technology to study the biological underpinnings of human health with rigor and precision. Now we have that technology, and we’ve used it well to gain invaluable insights about our physical bodies. But it is impossible to restore or promote human health unless we begin with a complete definition of a human being. An incomplete definition will always result in incomplete diagnoses and less-than-optimal treatments.

So now is the time to ascend the mountain and see the biomedical model as one part of our broadening view. Our health or lack of it is the result of biochemical interactions and genetics, dietary choices, exercise patterns, sleep habits, hopes, fears, families, friends, jobs, hobbies, cultures, ecosystems, and more. Chemical imbalances in the brain may well correlate with depression, anxiety, and other emotional states but the arrows of cause and effect can point in both directions. Optimizing emotional wellness, by improving attention, changing destructive patterns of thinking, and finding contentment within, can also optimize brain chemistry, correcting any deficiencies in neurotransmitters.

George Engel showed us the path upward more than thirty years ago. Now, I am happy to say, we are starting to follow it.

Andrew Weil, M.D., is a world-renowned leader and pioneer in the field of integrative medicine, a healing oriented approach to health care which encompasses body, mind, and spirit.

Oxford Journals

Social Cognitive and Affective Neuroscience

Psychopaths know right from wrong but don’t care

1. Maaike Cima¹,²,
2. Franca Tonnaer²,³ and
3. Marc D. Hauser⁴,⁵

+ Author Affiliations

1. ¹Department of Developmental, Clinical and Crosscultural Psychology, Tilburg University, P.O. Box 90153, 5000 LE Tilburg, ²Forensic Psychiatric Centre, De Rooyse Wissel, Oostrum, ³Department of Clinical Psychological Science, Maastricht University, The Netherlands, ⁴Department of Psychology, Harvard University and ⁵Department of Human Evolutionary Biology, Harvard University, Cambridge, MA, 02138, USA

1. Correspondence should be addressed to Maaike Cima, Department of Developmental, Clinical and Crosscultural Psychology, Tilburg University, P.O.Box 90153, 5000 LE Tilburg, The Netherlands. Email: M.J.Cima@uvt.nl

• Received July 31, 2009.
• Accepted October 19, 2009. 

Abstract

Adult psychopaths have deficits in emotional processing and inhibitory control, engage in morally inappropriate behavior, and generally fail to distinguish moral from conventional violations. These observations, together with a dominant tradition in the discipline which sees emotional processes as causally necessary for moral judgment, have led to the conclusion that psychopaths lack an understanding of moral rights and wrongs. We test an alternative explanation: psychopaths have normal understanding of right and wrong, but abnormal regulation of morally appropriate behavior. We presented psychopaths with moral dilemmas, contrasting their judgments with age- and sex-matched (i) healthy subjects and (ii) non-psychopathic, delinquents. Subjects in each group judged cases of personal harms (i.e. requiring physical contact) as less permissible than impersonal harms, even though both types of harms led to utilitarian gains. Importantly, however, psychopaths’ pattern of judgments on different dilemmas was the same as those of the other subjects. These results force a rejection of the strong hypothesis that emotional processes are causally necessary for judgments of moral dilemmas, suggesting instead that psychopaths understand the distinction between right and wrong, but do not care about such knowledge, or the consequences that ensue from their morally inappropriate behavior.

Key words

• psychopaths
• moral intuitions
• emotions
• permissible harms
• immoral behavior

INTRODUCTION

The behavior of psychopaths is, without doubt, morally inappropriate, including murder, sexual molestation, fraud, and arson. Further, clinical analyses show that they present abnormal emotional profiles, as well as problems with inhibitory control, often leading to both reactive and instrumental aggression (Blair, 1995, 1997, 2008; Blair and Cipolotti, 2000; Blair et al., 1995; Glenn and Raine, 2008; Kiehl, 2006; Kiehl et al., 2001; Raine and Yang, 2006). What is unclear is the extent to which psychopaths suffer from damage to morally-specific knowledge that, in healthy individuals, guides intuitive judgments of right and wrong independently of their moral actions. On the one hand, studies indicate that psychopaths, both adults and juveniles, show a diminished capacity to distinguish between conventional and moral transgressions (Blair, 1995, 1997, 2008; Smetana, 2005; Turiel, 1998, 2005). For example, unlike healthy adults, adult psychopaths will typically judge as equally forbidden transgressions in which a person wears pyjamas to a restaurant (conventional) and a person who gratuitously hits a waiter in the restaurant (moral). Psychopaths also show diminished inhibitory control, a deficit that may contribute to their impulsive behavior, especially in the context of violence (Blair, 2008; Blair and Cipolotti, 2000; Kiehl, 2006). This research has led to the view that because of their emotional deficits, psychopaths have corresponding deficits in moral knowledge which, coupled with poor inhibitory control, leads to morally inappropriate behavior (Blair, Mitchell, and Blair, 2005; Nichols, 2002; Prinz, 2008).

Further support for the idea that the deficit in moral psychology seen among psychopaths is due to the deficit in emotional processing, comes from the wealth of research showing a significant relationship between emotional experience and moral judgment. For example, dozens of studies now show that you can prime people’s emotional state, and as a result, change their judgment of particular moral scenarios. For instance, putting people in a happy state is associated with a greater tendency to allow someone to be used as a means to some greater good (Valdesolo and DeSteno, 2006); associating a neutral word with disgust under hypnosis is associated with more severe moral condemnation (Wheatley and Haidt, 2006); inducing disgust is associated with more severe moral judgments (Schnall et al., 2008).

In addition to these behavioral studies, neuroscientific experiments also support the critical role of emotion in moral judgment. In particular, several imaging experiments reveal clear patterns of activation in emotionally-relevant areas when subjects read about moral dilemmas (Greene, 2003; Greene et al., 2003, 2004; Moll et al., 2002, 2005, 2007). And further, recent studies of patients with severe deficits in emotional processing [i.e. fronto-temporal dementia (FTD) and individuals with bilateral damage to the ventral medial prefrontal cortex (VMPC)], show a highly selective, but significant deficit in moral judgment (Ciaramelli et al., 2007; Koenigs et al., 2007). For example, whereas VMPC patients, like controls, judged actions involving impersonal harms (e.g., flipping the switch on the trolley to kill one person, but save five) as more permissible than actions involving personal harms (e.g., pushing the fat man off the footbridge to stop the trolley, killing the man, but saving the 5), VMPC patients were more likely to endorse these personal cases, including situations where aversive acts lead to significant benefits to others. Thus, for a broad range of moral dilemmas, emotions appear to play little to no role in guiding judgment; for dilemmas that pit highly aversive actions against significant utilitarian gains, these patients favour the outcome, providing evidence for the causal role of emotion for a specific class of moral problems.

The neuropsychological data are of particular interest because they provide a more causal account of the relationship between emotional processes and moral judgment. Further, and of special interest to the present paper, several authors have alluded to the similarity in profile between VMPC patients and psychopaths, especially their flat socio-emotional responses and their lack of inhibitory control (Anderson et al., 1999; Barrash et al., 2000). On this view, psychopaths and VMPC patients should show the same pattern of moral judgments.

Summarizing, a dominant perspective in the current literature sees intact emotional processes as essential to our moral psychology. Here, we consider an alternative framework, one that motivates the present studies of psychopaths. In particular, though we do not deny that emotions play some role in our moral psychology, it is possible that our emotional experiences follow from our moral judgments as opposed to preceding and guiding them (Huebner et al., 2008). If this view is correct, then psychopaths may well show normal patterns of moral judgments relative to control populations. Where psychopaths deviate is in both not caring about their judgments (i.e. what they know about morally forbidden and permissible cases) and in not engaging with the kinds of motivational systems that inspire morally appropriate behavior and inhibit morally inappropriate behavior.

The following study targets three issues at the core of current work in moral psychology: (i) To what extent is normal emotional regulation necessary for making normal moral judgments, especially in the context of moral dilemmas where there are no clear, societally-mandated or typical responses? (ii) To what extent are the systems that guide moral judgments dissociable from those that guide moral behavior? More specifically, do psychopaths show deficits in both moral knowledge and behavior, in knowledge, or in the link between knowledge and behavior? (iii) Given the parallels between psychopaths and VMPC patients with respect to their deficits in socio-emotional processing and self-control, do they show parallel patterns of moral judgments?

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METHODS

Subjects

Participants (all male adults) provided informed consent in accord with the policies of the Ethical Commission of the Faculty of Psychology and Neuroscience, Maastricht University, The Netherlands. Healthy controls (n = 35; mean age = 30.29 years, SD = 9.99) were recruited from the south of the Netherlands. The psychopath (n = 14; mean age = 36.66 years; SD = 6.55) and non-psychopath (n = 23; mean age = 40.95 years; SD = 9.77) offenders were sampled from the Forensic Psychiatric Centre de Rooyse Wissel (FPCdRW) in Venray, the Netherlands. Of the 37 delinquents, IQ scores were available for a subgroup of 20 (7 psychopaths and 13 non-psychopathic offenders) participants. Though mean IQ scores for the psychopaths (M = 81.6, SD = 8.66) was slightly lower than for the non-psychopathic offenders (M = 92.5; SD = 19.37), there was no group difference [t(18) = 1.41; P = 0.18; d = 0.66].

Clinical diagnosis

Psychopathy was assessed by a clinician presenting the Psychopathic Checklist-Revised [PCL-R (Hare, 1991)] test. The PCL-R is a reliable and valid instrument, designed to measure psychopathic traits such as antisocial behaviour, shallowness, impulsivity, callousness, criminal history, and lack of moral emotions, based on evidence obtained from medical and juridical records and documents, as well as extensive interviews with the forensic patients. Based on a study of Grann et al. (1998), a PCL-R cutoff score of 26 was used to divide the current sample into psychopaths (PCL-R ≥ 26) and non-psychopaths (PCL-R < 26). Total PCL-R scores were available for all 37 offenders. However, of the 14 psychopaths, 2 were described in the crime record as having high PCL-R scores, without mentioning the exact scores. Therefore, the relationship within the psychopathic group between PCL-R scores and type of crime (Figures 3 and 4) were only available for 12 psychopaths. Finally, regarding PCL-R factor scores, Factor 1 and Factor 2 scores were only available for 15 subjects.

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Fig. 1

The left column presents the results for subjects’ judgments of all 21 dilemmas. There were no differences between healthy controls (white bar, n = 35), non-psychopathic delinquents (gray bar, n = 23), and psychopaths (hashed bar, n = 14) for the mean proportion (+s.d.) of Yes judgments. The right column presents the results for subjects’ judgments on impersonal (top) and personal dilemmas. Again, there were no differences between groups. However, all three groups judged impersonal dilemmas as more permissible (i.e. a higher proportion of Yes judgments) than personal dilemmas.

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Fig. 2

Scatterplot of subjects’ judgments (mean proportion of Yes responses) for all personal moral dilemmas, divided into self-serving (far left, first three cases) and other-serving (right, 11 cases) vignettes. Healthy controls are indicated by white circles, non-psychopathic delinquents by gray circles, and psychopaths by hashed squares.

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Fig. 3

(A) Scatterplot of psychopathy factor 1 scores for offenders [psychopaths and non-psychopathic delinquents[ [N = 15*] grouped by the proportion of yes judgments for all personal moral dilemmas. (B) Scatterplot of psychopathy factor 2 scores for offenders [N = 15*] grouped by the proportion of yes judgments for the personal moral dilemmas. *: For 20 individuals, crime files documented the administration of a PCL-R interview. However, these juridical file records only described PCL-R total score without mentioning both factor scores.

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Fig. 4

(A) Scatterplot of psychopathy scores (PCL-R; N = 12*) grouped by type of crime, against the proportion of yes judgments for all personal moral dilemmas. (B) Scatterplot of psychopathy scores (PCL-R; N = 12*) grouped by type of crime, against the proportion of yes judgments for the high conflict, other-serving personal moral dilemmas. *: For two individuals, crime files documented the administration of a PCL-R interview. However, these juridical file records only described these subjects as being a psychopath without mentioning the exact PCL-R score.

The PCL-R has two main factors. The first factor comprises interpersonal and affective characteristics of psychopathy, including shallow affect, lack of remorse or guilt and glibness/superficial charm (Cooke and Michie, 2001; Hare, 2003). The second impulsive, antisocial and unstable lifestyle factor comprises the social deviance characteristics, and includes impulsivity, early behavioural problems, and parasitic lifestyle (Cooke and Michie, 2001; Hare, 2003).

All psychopathic offenders had a personality diagnosis (Table 1). Most of them (57.1%) had a diagnosis of cluster B (narcissistic personality disorder or antisocial personality disorder), while the minority had a personality disorder not otherwise specified. Of the non-psychopathic offenders, the majority suffered a personality disorder not otherwise specified, 21.7% had a cluster B personality disorder, and 4.3% had a cluster C personality disorder.

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Table 1

Biographical descriptions in percentages and mean (s.d.’s) of the background information of the psychopaths (n = 14), non-psychopathic delinquents (n = 23), and healthy controls (n = 35)

To strengthen the link to emotion all subjects in our test groups also participated in a well-established, physiological test of stress reactivity involving measures of cortisol [i.e., Trier Social Stress Test; (Kirschbaum et al., 1993; Kirschbaum et al., 1995)]. Results showed that psychopathic offenders, unlike the two comparison groups, showed no significant increase in cortisol in response to the stressor. Within both the non-psychopathic group and healthy controls, cortisol levels significantly increased at T1 (before administering the stressor) to T3 (after administering the stressor) as demonstrated by pairwise comparison (all t’s > 2.81; all P’s < 0.01 and all t’s > 3.07; all P’s < 0.01, respectively). In contrast, within the psychopathic group there was no significant increase of cortisol levels between T1 and T3 (all t’s < 1.00; all P’s > 0.34); see Cima, Popma, and Nicolson (in preparation) for a more detailed overview of these data. Thus, based on both their PCL-R scores and stress reactivity profiles, this psychopathic population showed relatively flat emotional responses, consistent with many other studies.

Participants had no history of psychosis or depression, and no current alcohol or drug dependence. In the delinquent sample these criteria were considered by the psychologist, psychiatrist and file records. In the healthy control sample, these criteria were inquired. We tested all offenders on the moral dilemmas after they had been interviewed with the PCL-R.

Summarizing, both psychopaths and non-psychopathic delinquents differed from healthy controls in that they had been convicted of crimes; and as in numerous other studies (Herpertz et al., 2001; Kirschbaum et al., 1995; Williamson et al., 1991), psychopaths differed fundamentally from non-psychopath delinquents in that they showed diminished emotional reactivity based on both the standard clinical diagnostic test [i.e. the PCL-R (Hare, 1991)] and physiological measures (Cima et al., in preparation).

Stimuli

We used the moral dilemmas of Greene et al. (2001, 2004), previously tested with the VMPC patients (Koenigs et al., 2007). Each dilemma was first translated into Dutch by FT, back-translated into English by a second bilingual Dutch-English speaker, and then checked by MH for accuracy. We presented seven impersonal and 14 personal moral dilemmas (see Supplementary Information). Subjects then answered “yes” or “no” to the question “Would you X?”. A population of native Dutch speakers (adults, 324 females, 348 males) judged these cases on a Dutch version of the Moral Sense Test (http://www.serve.com/∼harvardpcnl/MST/Dutch/), whereas the three test groups responded to these dilemmas with paper and pencil. Though we recognize that studies of moral judgment and responses to artificial dilemmas in particular, represent only one of several valid approaches to understanding our moral psychology, we used this approach to provide the most direct comparison with VMPC patients, as well as other recent studies of intuitive moral judgments.

To control the possibility that psychopaths simply lie about their responses to our moral dilemmas, we also administered a questionnaire [Socio-Moral Reflection; SRM-SF (Gibbs et al., 1992)], asking straightforward and explicitly whether certain familiar transgressions would be morally permissible. For instance, “How important is it to keep a promise to your friend?”; “How important is it not to steal?”. Answers could be given on a 5-point scale, ranging from very unimportant to very important. Scores on the SRM-SF questionnaire result in a total score and a score of moral standing, indicating the level of moral development.

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RESULTS

The Dutch sample responding on the web-based version of this task replicated the overall pattern obtained in prior research: subjects provided fewer endorsements of personal dilemmas (M = 0.37, SD = 0.28) than of impersonal dilemmas (M = 0.75; SD = 0.26; U = 22; z = 2.01; P = 0.04; r = 0.08).

As in our larger Dutch sample, all three test groups judged impersonal cases as more permissible than personal cases (Figure 1): healthy controls (U = 13.0; z = 2.69; P = 0.007; r = 0.46); non-psychopathic delinquents (U = 18.0; z = 2.32; P = 0.02; r = 0.48); psychopaths (U = 23.5; z = 1.92; P = 0.05; r = 0.52). Thus, for all four test populations, individuals are more likely to perceive up close and personal harms as less permissible than harms that come about by impersonal means, such as flipping a switch in the classic trolley problem.

To examine whether the groups differed on the percentage of cases in which they endorsed the action – supporting the utilitarian outcome – and more generally, test the hypothesis that psychopaths (like VMPC patients) are more utilitarian on personal scenarios, we performed a 3 (test populations) × 2 (impersonal vs personal dilemmas) ANOVA (see also, Supplementary Information for Bayesian analyses of the same data set, designed to test the null hypothesis of no group differences). There was, as noted above, a highly significant dilemma type effect [F(1,69) = 20.02; P = 0.0001; d = 2.03], but no significant group effect [F(2, 69) = 0.21; P = 0.81], and a non-significant interaction [F(2,69) = 0.22; P = 0.80; Figure 1]. Bonferroni corrected post-hoc tests revealed no statistically significant group effect for either impersonal (P’s > 0.18) or personal moral dilemma (P’s > 0.41).

Evaluation of educational level demonstrated a significant difference between the groups, with offenders having lower levels of education than non-offenders, but no difference between the two groups of offenders (χ²[2] = 12.90; P < 0.05). More importantly, an ANCOVA demonstrated that there was no significant effect of education on judgments of either personal or impersonal dilemmas (all P’s > 0.05).

Healthy controls were generally younger than both delinquent groups. Since there was a significant age difference [F(2,69) = 9.29; P < 0.000], due to healthy controls being younger than non-psychopathic delinquents, we conducted a correlation analysis to examine whether age was related to moral responses. For both personal as well as impersonal dilemmas, there was no effect of age (r = 0.04 and −0.21 respectively with all P’s > 0.05).

Given that prior work on VMPC and FTD patients revealed a highly selective deficit within the personal dilemmas, with greater endorsements of the utilitarian outcome for other-serving (i.e. harming one for the benefit of others) than self-serving (harming one for self-benefit) personal dilemmas, we explored in greater detail the variance in responses to personal dilemmas by both delinquent groups and our controls (Figure 2). An overall 2 (Self vs Other-serving) × 3 (Psychopaths, Delinquents, Controls) ANOVA revealed a statistically significant main effect for dilemma type, with subjects judging other serving cases as more permissible than self-serving [F (1, 36) = 48.52; P < 0.0001]. There was, however, no main effect for the three test populations [F (2, 36) = 0.81; P = 0.45] and nor was there a statistically significant interaction between dilemma type and test population [F (2, 36) = 1.01; P = 0.37]. Thus, psychopaths were not more likely to endorse the utilitarian outcome for other-serving, personal dilemmas.

On a scenario level, there were several dilemmas that elicited virtually complete support of the utilitarian outcome by subjects in all groups (80–100% Yes judgments) or virtually complete prohibition of this outcome (0–20% Yes judgments; Figure 2). For example, each of our test populations agreed that the actions to be taken in dilemmas 2, 3, 4 and 6 were largely impermissible, whereas those in dilemmas 13 and 14 were largely permissible; furthermore, although subjects in all three test populations were less clear about the permissibility of the action for several cases (e.g. 7, 8, and 11 in Figure 2), all clustered around the same proportion of Yes responses. Lastly, although the mean permissibility ratings for psychopaths were higher than the control populations for 8 out of 11 other-serving dilemmas, the variance in all three groups was sufficiently high to make this apparent difference non-significant. More specifically, for 3 of the 11 other-serving dilemmas, the delinquents provided a greater proportion of Yes judgments; for four of these dilemmas, the psychopaths differed from the other groups by less than 15%, leaving only four cases where the psychopaths judged the case more permissible by 20–40%. Thus, even on a case by case basis, there is no consistent pattern of judgments that is mediated by the characteristics of our study populations.

We also explored the difference in judgments within the class of other-serving cases in which sometimes, harming one to benefit many others makes the one worse off (e.g., the footbridge trolley case where pushing the man off the bridge kills him but saves five) whereas in others, harm to the one is inevitable, does not make the individual worse off, and yet benefits many others (e.g., every person in a war bunker will be killed by enemy soldiers if anyone makes noise, so if a baby starts crying, killing the crying baby doesn’t make her worse off, but saves the others); these latter cases are often described as Pareto dilemmas, and in previous work, are typically judged more permissible than non-Pareto cases where the one is made worse off (Huebner, Pettit, and Hauser, in review; Moore et al., 2008). Group contrasts for the Pareto cases failed to reveal a significant difference (P’s > 0.22).

Of the 37 delinquents, PCL-R factor scores were available for 15 subjects. There was no statistically significant correlation between subjects’ moral judgments on personal dilemmas and their factor 1 (r = −0.02, P = 0.95) or 2 scores (r = −0.02; P = 0.93; Figure 3A and B).

Though there is a generally agreed upon cut-off on the PCL-R diagnostic for classifying individuals as psychopaths (i.e., scores of 26 or higher), there was, as in all previous work, variation among our subjects in such scores, as well as in the nature of their criminal conviction. To assess whether such variation was related to their moral judgments, we plotted (Figure 4A) each psychopath’s PCL-R score against the proportion of personal dilemmas that they endorsed, and further grouped the subjects by their type of crime. Though the sample size is too small to evaluate statistically, neither the scatter in the data shows relationship between PCL-R score and proportion of personal dilemmas endorsed, nor a clear pattern for type of crime. Similarly, there was no effect of PCL-R score or type of conviction on the proportion of utilitarian outcomes endorsed for the other-serving cases (Figure 4B).

Results on the SRM-SF showed that overall there was no statistically significant difference among the groups, with psychopaths showing slightly lower SRM-SF scores (M = 276.14; SD = 33.43) than healthy controls (M = 286.03; SD = 45.15), whereas non-psychopathic offenders had slightly higher SRM-SF scores (M = 290.01; SD = 46.59) than healthy controls [F(2,69) = 0.45; P = 0.64]. None of the post-hoc tests were statistically significant (all t′s < 0.98; P > 0.34).

DISCUSSION

Philosophers, legal scholars, and scientists agree that our moral judgments are influenced by processes of reasoning, intuition and emotion (Damasio, 1994; Dwyer, 2004; Greene, 2003; Haidt, 2001; Hauser, 2006; Mikhail, 2007, 2009; Posner, 1999), where controversy emerges in deciding which of these processes alone or in combination provide the source of our moral judgments. For example, though we often reflect upon moral problems, weighing the pros and cons of particular actions and outcomes, using our knowledge of similar cases to deliberate, several recent studies indicate that such rational and reasoned contemplation often arises after an intuitive system has fired off a judgment of moral permissibility. Commonly, this intuitive process has been aligned with the emotions, and more specifically, the source of our moral judgments lie in our feelings about particular actions and outcomes (Blair et al., 2005; Haidt, 2001; Moll et al. 2007; Nichols, 2004; Prinz, 2008). Support for this position comes from three lines of evidence: (i) subjects are dumb-founded by their judgments, unable to provide a coherent explanation for why a particular action is morally forbidden (Haidt, 1993, 2001); (ii) emotional priming influences moral judgment (Schnall et al., 2008; Valdesolo and DeSteno, 2006; Wheatley and Haidt, 2006); (iii) when healthy subjects process moral scenarios, classic emotional areas activate (Greene et al., 2001, 2004; Moll et al., 2002a, b, 2005); in contrast, patients with diminished emotional processing (i.e., FTD, VMPC, and psychopaths) show different patterns of moral judgments than healthy subjects, at least for a particular set of moral problems (Anderson et al., 1999; Blair, 1995, 1997; Koenigs et al., 2007; Mendez et al., 2005).

The present work was aimed at both the general thesis that proper emotional processing is necessary for moral understanding, and the more specific thesis that the compromised emotional processes of psychopaths accounts for their abnormal moral psychology, including most specifically, their heinous violence and disregard for others. Our results license two conclusions. First, like healthy subjects and non-psychopath delinquents, psychopaths judged impersonal moral actions as more permissible than personal moral actions. As previously noted (Greene et al., 2001, 2004), this distinction is anchored on an emotional gradient, with impersonal cases considered less emotionally intense than personal cases. Thus, even though psychopaths show diminished emotional processing, either a sufficient level or type of emotion is preserved or non-emotional processes can carry out the relevant computation required to evaluate these particular moral scenarios. Second, though psychopaths showed diminished emotional processing relative to both control groups, and even though both delinquent groups differed from healthy subjects in their morally inappropriate behaviors (e.g., paedophilia, murder), there were no group differences in moral judgments for either impersonal or personal scenarios. Furthermore, though there was variation among our psychopathic participants in terms of their PCL-R scores, as well as the nature of their criminal convictions, there was no relationship between these factors and their moral judgments.

At one level, these results could be perceived as conflicting with both previous studies of psychopaths as well as those with VMPC patients. In particular, adult psychopaths generally make less distinction between conventional and moral transgressions, whereas VMPC patients tend to provide a higher proportion of utilitarian judgments for a subclass of personal moral dilemmas. These data have been used to argue among the critical and causal role of emotion in generating normal moral judgments. However, it is difficult to provide firm evidence for a causal link between emotion and moral judgments, since both the theoretical arguments and empirical evidence to date are unclear about how specific types of emotion, impact upon moral judgment with moral concerns. Consider, for example, the Koenigs et al. (2007) paper, though it is generally agreed that patients with damage to VMPC have emotional deficits, and in particular, show difficulty with social emotions such as empathy, embarrassment, and guilt, it is not clear how the absence of these emotions, or the reduction in their manifestation would cause subjects to provide more utilitarian judgments for the narrow range of other-serving dilemmas. That is, why would the aversiveness of harming one person be diminished because one feels less embarrassment, empathy, or guilt? And even if one could provide a coherent account, including the possibility in the absence of guilt, one is simply less affected by harming one person, then why would not the same argument go through for other cases of harm that were present but that showed no group differences? Furthermore, even if there is a coherent account for this aspect of process, it doesn’t necessarily show that emotions dictate how we decide whether an action is morally right or wrong. For example, it could be some other set of processes that makes this decision, but emotions titrate the severity of judgment. Thus, for example, when the social emotions are diminished with respect to their impact on decision making, we see harming one as less bad when there is a greater good, i.e. both VMPC patients and normals see harming one for some greater good as bad, but VMPC patients simply see the harm as less bad. On this view, emotions are like a gain function, moving our judgments up and down a scale from very bad or forbidden to obligatory or required (see Huebner et al. 2008, for further development of this argument).

There are at least two reasons why the psychopathy data on the moral-conventional distinction leave many questions unanswered, especially in terms of the specific role of emotions: 1) since both adults and juveniles received scenarios that were designed for children, it is unclear how adult psychopaths would fare on adult versions; 2) the adult and juvenile psychopaths appear to have opposite judgment biases, with adults judging most cases to be forbidden whereas juveniles consider most to be permissible; why differences in emotion would lead to this developmental flip-flop is unclear.

Though VMPC patients show some of the same kinds of emotional deficits as do psychopaths, no one has yet established how specific kinds of emotion are causally linked to specific kinds of moral problems. For example, though VMPC patients generate normal judgments for most moral dilemmas tested so far, it is not clear why diminished capacity to experience empathy, embarrassment and loyalty should lead to a selective deficit for other-serving moral dilemmas in which a highly aversive action is pitted against a significant utilitarian outcome. Given these uncertainties, it is perhaps less surprising, and at odds with the existing data, psychopaths show normal patterns of moral judgments for moral dilemmas. More specifically, though psychopaths show some of the same emotional deficits as patients with damage to VMPC, other aspects of their emotions may be relatively preserved, and these may be the most important with respect to moral understanding. At present, however, this literature is unclear, with some studies reporting normal recognition and judgments by psychopaths of basic emotions such as anger, fear, sadness and disgust, whereas other studies show differences, including evidence of abnormalities in brain activation during imaging studies of emotional processing (Blair et al., 2002; Fullam and Dolan, 2006; Muller et al., 2003; Pham et al., 2000). Furthermore, though psychopaths may show deficits in distinguishing conventional from moral cases, whatever cognitive function is necessary for this distinction is apparently unnecessary with respect to judging moral dilemmas, and especially, for perceiving the difference between personal and impersonal cases. This conclusion is reinforced by a recent imaging study of psychopaths in which individuals evaluated the same set of dilemmas presented here, showed reduced activation in the amygdala relative to controls (Glenn et al., 2009), but no difference in judgments (Glenn, Raine, Schrug, Young, and Hauser, in press). Moreover, Glenn et al. (in press) show that non-prison convicted psychopaths (classified based on the PCL-R) evidence significantly lower amygdala activation relative to controls, and significantly higher DLPC activation. Amygdala is associated with processing predominant negative emotions, and especially fear. In contrast, the DLPC plays a critical role in conscious reasoning and decision making. Despite these neural differences, population of non-prison convicted psychopaths showed no differences in moral judgment from a control group.

Lastly, it is possible that the emotional deficits of psychopaths only show up, or show up most intensely, under pressure to respond quickly, or feel compelled to do so, thereby triggering their more impulsive character (Kiehl, 2007). Here, there was no such pressure, perhaps resulting in normal patterns of judgment.

We conclude that psychopaths make the same kind of moral distinctions as healthy individuals when it comes to evaluating the permissibility of an action embedded in a moral dilemma. Consequently, these results support the hypothesis that normal social emotional processing does not appear necessary for making these kinds of moral judgments. Normal emotional processing is likely to be most important in generating an appreciation of these distinctions and in guiding actions (Huebner et al., 2008). Psychopaths know what is right or wrong, but simply don’t care. Given that legal distinctions often turn on whether crimes are committed knowingly (e.g., Model Penal Code), these results could have bearing on court decisions concerning the nature of moral knowledge – i.e. instead of strictly focusing on criminal actions carried out knowingly, we should also focus on whether such knowingly immoral and illegal actions are carried out caringly. Equally important, these results may shed light on treatment, pushing clinicians to distinguish between the sources of deficit regarding morally relevant decisions and actions.

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SUPPLEMENTARY DATA

Supplementary data are available at SCAN online.

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Acknowledgments

This study was supported by a grant to MC from the Netherlands Organization for Scientific Research (NWO) grant number: 451-05-020, and to MH from the National Science Foundation-Human Social Dynamics. We would like to thank the patients of the Rooyse Wissel for participating in this study. For comments on the data and earlier drafts of the manuscript, we thank James Blair, Joshua Greene, Kent Kiehl, Walter Sinnott-Armstrong, Liane Young, and two authors of SCAN. The authors declare they have no competing interests.

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