Can psychopathy be successfully treated?

1. Are there any known medications or other interventions useful for treating psychopathy?

(Answer provided by a psychopathy expert and Aftermath volunteer and endorsed by the Executive Committee)

Although psychopathy is not currently listed as a personality disorder in the official psychiatric taxonomy (the DSM-IV), it is comprised of enduring affective, behavioral, and interpersonal components and may be conceptualized as a personality disorder. (In fact, some preliminary criteria for psychopathy are likely to be listed as a personality disorder in the DSM-V.) Although there are no medications specifically designed to treat psychopathy, there are medications that can treat some of the associated symptoms. For example, it is possible antidepressants, antipsychotics, and mood stabilizers may help address the irritability, aggression, and impulsivity associated with the disorder. As more is learned about the neural substrates underlying psychopathy, the prospects for effective pharmacotherapy of the disorder are likely to improve.

Aside from medication, there is some evidence for the effectiveness of treatment in those with psychopathic traits, although findings have been conflicting. A study by Caldwell and colleagues (2007) showed that adolescents rated high in psychopathic features showed improvement following a forensic inpatient treatment which emphasized the development of appropriate interpersonal skills and relationships. Although youth who scored higher in psychopathic traits exhibited poorer behavior during the baseline period and at the time of release than youth low on psychopathy, all of the youth exhibited improved behavior during treatment, regardless of their level of psychopathy. Furthermore, psychopathy scores did not have a significant effect on treatment response, and youth who spent substantial time in treatment were less likely to commit additional violent offenses following release (assessed over a period of four years).

Another study (Skeem, Monahan, & Mulvey, 2002) examined the relationship between psychopathy, community treatment, and subsequent violence among adults. They found that psychopathic patients showed similar benefits to nonpsychopathic patients in terms of violence reduction following treatment, consisting largely of psychotherapy or psychotherapy and medication, providing they attended a sufficient number of treatment sessions. However, other studies have reported that youth with psychopathic traits do not benefit from treatment, (consisting largely of individual/group therapy and classroom schooling); they exhibited more behavioral problems during treatment, less improvement upon discharge from the treatment setting, poorer participation and attendance in treatment, and higher rates of re-commission of crimes after release (O’Neill, Lidz, & Heilbrun, 2003).

One way to interpret these discrepancies in findings is that some treatments may work better than other treatments. Another possible interpretation is that treatments may be more effective for some youth with psychopathic traits than for others. Finally, it is possible that a treatment can be effective even if some participants are less compliant with the treatment than other participants. We do not know enough to be able to decide which of these interpretations makes the most sense.

The chapter “Treatment of psychopathy: A review of empirical findings” in C.J. Patrick’s Handbook of Psychopathy (2006), and the chapter “Treatment of Child and Adolescent Psychopathy: Focusing on Change,” in Salekin and Lynam’s Handbook of Childhood and Adolescent Psychopathy (2010) provide good overviews of recent studies examining treatment outcomes. Another good resource regarding treatment is F. Rotgers and M. Maniacci’s Antisocial Personality Disorder: A Practitioner’s Guide to Comparative Treatments (2005).

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