Resources for Clinicians
Q: Why should I assess patients for psychopathy if it’s not even in the DSM 5? Why can’t I just stick with Conduct Disorder and Antisocial Personality Disorder?
The reason psychopathy is not in the DSM is not related to the empirical or clinical data. Psychopathy is a widely accepted and well validated scientific and clinical term, reflects specific patterns of cognitive and neural dysfunction, and requires targeted treatment approaches. Psychopathy’s exclusion from the DSM 5 and its predecessors has more to do with myths, stigmas, and lack of information surrounding the disorder. These are also the reasons many parents and clinicians prefer to avoid the term. But psychopathy has critical implications for treatment decisions.
More general terms like Conduct Disorder (CD) or Oppositional Defiant Disorder (ODD) are often used when assessing children. And many children with psychopathy do qualify for these disorders. However, decades of research show that children with psychopathy plus CD or ODD show opposite patterns of brain functioning as children who have CD or ODD without psychopathy. Whereas many children with CD or ODD are highly reactive or anxious, children with psychopathy may present as unusually cold or fearless. Because of this, the Limited Prosocial Emotions specifier was included in DSM-5 to distinguish children at risk for psychopathy (those who have Limited Prosocial Emotions) from other children.
According to DSM 5, children whose symptoms meet criteria for the “Limited Prosocial Emotions” specifier for conduct disorder (CD) also show at least 2 of the following traits over at least 12 months and in multiple relationships or settings:
- Lack of remorse or guilt
- Callousness or lack of empathy
- Lack of concern about performance in activities like school or work
- Shallow or deficient affect, especially a fearless disposition
This specifier should always be considered when a child is diagnosed with CD or ODD. Limited Prosocial Emotions can be assessed using new semi-structured screening tools.
More general terms like Antisocial Personality Disorder (ASPD) are often used when assessing adults. But only a subset of adults with ASPD have psychopathy. And many adults with psychopathy do not qualify for ASPD, which focuses overwhelmingly on externally observable behaviors rather than the emotional and interpersonal features that are the core of psychopathy. As is the case for children, adult psychopathy is associated with specific patterns of cognitive and neural dysfunction that are not observed in other adults with disorders of antisociality.
The fact that psychopathy in both children and adults is associated with different genetic and environmental causes, and different patterns of cognitive and neural dysfunction, makes clear that children and adults with psychopathy require tailored treatment approaches.
If there is uncertainty about whether a child or adult has psychopathy, our online screening tools, which were developed by leaders in the field of psychopathy research, may provide valuable information.
Q: But how can assessing patients for psychopathy make a difference? I thought psychopathy is untreatable.
It is a common myth that psychopathy is untreatable. Like many disorders of personality, psychopathy can be difficult to treat. This is in part because it is a developmental disorder which typically emerges early in childhood. But young children are rarely screened for psychopathy. This means treatment often begins too late in development to be maximally effective, after critical windows of neuroplasticity have passed. One of the missions of our organization is to promote the development and use of better screening tools for use in early childhood so that at-risk children can be identified and treated earlier. (A similar approach has been used to successfully treat children with autism.)
A number of treatments have been demonstrated to reduce symptoms in psychopathy. We provide detailed information on our site about the various treatment strategies that have been demonstrated to be effective in reducing symptoms of psychopathy.
Clinicians who are concerned about their safety when working with psychopathic clients should consider recommendations for working with clients who are potentially violent.
The first line approach that should always be used is psychotherapy. In children, the most effective treatments include both individually-focused and family-based therapy approaches. We provide information and links for forms of psychotherapy with demonstrated efficacy in treating psychopathy, including:
- Cognitive Behavioral Therapy (CBT)
- Risk-Need-Responsivity (RNR)
- Schema-Focused Therapy (SFT)
- Transference Focused Psychotherapy (TFP)
- Parent Management Training (PMT)
- Multi-systemic therapy (MST)
- Family Check-UP (FCU)
- Integrated Family Intervention (TFP)
In some cases, medication should be used as an adjuvant to psychotherapy. No medications have been developed specifically to treat psychopathy. Although medications developed to treat other disorders are often used off-label to treat children with psychopathy, almost no clinical trials have been conducted to assess their long-term efficacy. However, because many children with psychopathy have symptoms of comorbid mood, anxiety, or attention-related disorders, we provide information about medications that randomized controlled-trials suggest may be effective for some children, including:
- Mood stabilizers
Research has shown that it is preferable to treat children and youths in their homes and communities when this is possible. However, because of the complex issues involved in treating youths with psychopathy (including safety concerns, lack of community support, and low access to effective treatment options) residential treatment is a necessary option for many families. We provide information about options for residential treatment.
Finally, we provide information about treatments that should absolutely be avoided when treating children with psychopathy, as no empirical evidence supports their efficacy, and they may cause harm.
Q: What about insurance coverage?
It is common for clinicians to report that insurers will not reimburse clinicians for treating children whose primary diagnosis is a disruptive behavior disorder. Often this is because they view disruptive behavior disorders as problems that result from “bad parenting” rather than being medical problems. This is an unfortunate myth and absolutely not true. Research on the causes of psychopathy show that it is a strongly heritable disorder. It results in early, persistent patterns of brain dysfunction that disrupt emotion and social behavior.
This difficulty is one of many persistent systemic problems in the treatment of psychopathy that our organization is seeking to change.
In the meantime, organizations like NAMI offer resources and suggestions for dealing with denials of coverage.
Q: Where can I go for more information about psychopathy?
The most comprehensive and up-to-date source of information about psychopathy can be found in the Handbook of Psychopathy (2nd Edition, 2018). See a review of the scientific evidence about treating psychopathy.