Anxiety and Attachment
Laboratory evidence has supported the clinical view that psychopathic criminals do not experience anxiety and worry to the degree that nonpsychopathic criminals do. Self-report measures of anxiety also show a robust negative correlation with one factor of psychopathy, aggressive narcissism . Rorschach measures of anxiety have further validated this finding. In comparison with male outpatients with borderline personality disorder and narcissistic personality disorder, psychopathic males are significantly less anxious.

Anxiety is a necessary correlate of any successful mental health treatment that depends on interpersonal methods, because it marks a capacity for internalized object relations and concern over the actions of oneself and others. As the severity of psychopathy increases in patients with antisocial personality disorder, anxiety lessens, and with it the personal discomfort that can motivate a patient to change.

Attachment, or the capacity to form an emotional bond, also has been shown to be significantly less in psychopathic criminals than in nonpsychopathic criminals. This finding is empirically consistent with the clinical literature, which has described the psychopathic individual as chronically emotionally detached. Psychopathic patients are significantly more detached than are outpatients with borderline and narcissistic personality disorder. It appears that chronic emotional detachment varies in severity among patients with antisocial personality disorder, is a measurable trait of the psychopathic patient with antisocial personality disorder, and is a stable characteristic that is already seen in solitary-aggressive children with conduct disorder.

The ability to form an alliance with the therapist, a behavior related to attachment, has been shown to be a positive prognostic marker in the psychotherapeutic treatment of males with antisocial personality disorder. This ability was especially associated with decreased drug use and increased employment. Without an attachment capacity, any treatment that depends on the emotional relationship with the psychotherapist will fail and may pose an explicit danger to the professional because an empathic capacity to inhibit aggression is nonexistent. The more severe the psychopathy, the more the patient will relate to others on the basis of power rather than affection. The psychobiological basis for this absence of anxiety and attachment is probably rooted in chronic cortical underarousal or, more specifically, a peripheral autonomic hyporeactivity to aversive stimuli that is apparent in severely psychopathic individuals.

Narcissism and Hysteria
Psychopathic patients can be conceptualized as aggressive narcissists, with the attendant intrapsychic object relations, structure, and defenses that have been described in the psychoanalytic literature. In a clinical and treatment setting, the more severe the psychopathic disturbance in the patient with antisocial personality disorder, the greater the likelihood that aggressive devaluation will be used to shore up feelings of grandiosity and repair emotional wounds. In some patients, this is defensive, whereas in others, a core, injured sense of self is not apparent. This behavioral denigration of others can run the clinical spectrum from subtle, verbal insults to the rape and homicide of a female staff member. It also distinguishes the psychopathic patient from the narcissistic patient, who can devalue in fantasy without resorting to the infliction of emotional or physical pain on others. Although male outpatients with narcissistic personality disorder are as self-absorbed and grandiose as are psychopathic patients, their capacity for anxiety and attachment makes them much better treatment candidates.

In addition to the devaluation of others, which in some clinical cases may appear compulsive, the severity of psychopathy will determine the degree to which the patient must control other patients and staff. This “omnipotent control” in the actual clinical setting, often felt by staff as being “under the patient’s thumb” or “walking on eggshells,” usually serves the purpose of stimulating the patient’s grandiose fantasies and also warding off the patient’s fears of being controlled by malevolent forces outside him- or herself. Psychopathic criminals, moreover, appeared to be less fearful than nonpsychopathic criminals in laboratory studies in which startle probe analyses were used. When the grandiosity of the nonpsychopathic patient with antisocial personality disorder is challenged by failure, there will be clinical manifestations of anxiety or depression, both of which are positive prognostic indicators.

Hysteria has been linked to psychopathy in the scientific literature for a century. In the PCL-R (

Table 82-2), several criteria are identified that are consistent with hysterical character: glibness/superficial charm, need for stimulation/proneness to boredom, shallow affect, and promiscuous sexual behavior. Other intrapsychic characteristics of antisocial personality disorder that are consistent with hysterical traits include unmodulated affect, sexual preoccupation, self-absorption, and aggressive expectations of others. Shapiro termed the hysterical cognitive style impressionistic: “global, relatively diffuse, and lacking in sharpness, particularly in sharp detail”.

Cognition in patients with antisocial personality disorder is characterized by moderate and pervasive formal thought disorder that appears to be psychodynamically linked to narcissism; for example, the need to self-aggrandize leads to circumstantial or tangential comments about the self that are only remotely related to the clinical task. The hysterical aspect of psychopathy is apparent in clinical settings when the patient shows evasive and impressionistic thought, minimizes and denies his or her behavior, and shows sudden, dramatic, and shallow emotional outbursts. The latter affective style is normally used by the patient with antisocial personality disorder to seek attention and control others.

Psychological Defenses
Antisocial personality disorder patients with severe psychopathy most predictably use the following psychological defenses: projection, rationalization, devaluation, denial, projective identification, omnipotence, and splitting. The psychopathic patient is usually organized at a pre-oedipal level and is unlikely to show any higher-level defenses. For instance, projective identification is most apparent in treatment when the psychopathic patient attributes certain negative characteristics to the clinician and then attempts to control the clinician, perhaps through overt or covert intimidation. An aspect of the psychopathic patient’s personality is then perceived in the clinician and viewed as a threat that must be diminished. One patient with antisocial personality disorder who also had severe psychopathy reported to his psychotherapist several homicides that he had ostensibly committed. He then sat back, smiled, and said, “You know a lot about me, doc, and sometimes when people know too much they get killed.” The speechless psychotherapist felt frightened and controlled.

Higher-level or neurotic defenses, such as idealization, intellectualization, isolation, and repression, appear to be virtually absent in the patient with antisocial personality disorder and severe psychopathy. Idealization of other people is inconsistent with psychopathy. It represents a positive treatment indicator because it signals hope and the anticipation of meaning in the future. Psychopathic patients are prone to feelings of envy toward the goodness in others and will aggress against this perceived goodness to ward off such unpleasant feelings. If neurotic defenses are present in the patient with antisocial personality disorder, they suggest amenability to treatment. Internal experience will more likely be expressed with thought rather than just through feeling and impulse.

Object Relations
Some empirical evidence indicates that patients with antisocial personality disorder, both severely psychopathic and nonpsychopathic, are organized at a borderline level of personality, consistent with the clinical and theoretical literature. Psychopathic patients produced more total primitive object relations than did nonpsychopathic individuals in several empirical Rorschach studies. They appeared to have narcissistic wishes to both symbiotically merge with the object and be mirrored by the object, which may partially explain why they continually aggress against other people when they are also chronically emotionally detached. They appear to experience their aggressive impulses and identifications as ego-syntonic, or in league with their self-image.

The treatment implications of these object relations surround the risk of violence by the patient with antisocial personality disorder. The more psychopathic he or she is, the more pleasurable, less conflicted, and more sadistic aggressive acts will be. Unlike the patient with borderline personality disorder, in whom impulses to aggress against the self or others may be frightening, the psychopathic patient may wholly identify with the aggressor and have no inhibitions. A history of violence, coupled with the predatory nature of their violence, makes antisocial personality disorder patients with severe psychopathy very dangerous in a hospital milieu without appropriate security.

Affects
The emotions of the patient with antisocial personality disorder lack the subtlety, depth, and modulation of “normal” individuals. The antisocial personality disorder patient with severe psychopathy appears to live in a “presocialized” emotional world, where feelings are experienced in relation to the self but not to others. Such a patient is unlikely to have a capacity to experience emotions, such as reciprocal pleasure, gratitude, empathy, joy, sympathy, mutual eroticism, affection, guilt, or remorse, that depend on whole, real, and meaningful other persons. The patient’s emotional life is dominated by feelings of anger, sensitivities to shame or humiliation, envy, boredom, contempt, exhilaration, and pleasure through dominance. The more psychopathic the patient with antisocial personality disorder, the more apparent his or her limited emotional repertoire will be to the clinician.

Chronic cortical underarousal may be one biological substrate for this paucity of development of socialized emotions. Affective dysfunction in the psychopathic patient is also apparent in his or her inability to understand the emotional or connotative meaning of words and in less of a startle blink reflex in response to both pleasant and unpleasant stimuli. Both male and female adults with antisocial personality disorder appear to modulate affect about as well as a 5- to 7-year-old child. Research also indicates that patients with antisocial personality disorder are often confused by the nature and quality of their emotions, feel damaged or injured, and hold a chronic anger toward others. They also experience emotion less often than do males without antisocial personality disorder and avoid emotionality in others.

These findings pose difficult treatment problems, but their absence in any one patient should support a more positive prognosis. Such findings in the patient with antisocial personality disorder and severe psychopathy predict a nonresponsiveness to treatment modalities that depend on cognitive or emotional access to the patient, such as cognitive-behavioral relapse prevention or psychodynamic approaches that require a capacity to feel emotion in relation to the psychotherapist and talk about it. In these cases, treatment should not be attempted. Most troublesome and difficult to detect is the psychopathic patient who imitates certain emotional states for secondary gain or to manipulate the psychotherapist. This rewarding of the clinician, often by appealing to the clinician’s narcissistic belief that he or she can heal the most difficult patient, has been called “malignant pseudoidentification” and may be used to describe other ways in which the psychopathic patient deceptively represents himself or herself as having feelings, thoughts, and behaviors wished for by the treating clinician.

Superego Pathology
The touchstone of psychopathy and antisocial personality disorder has been the absence of conscience, or serious deficits in moral judgment. Although few controlled studies of moral development in psychopathy have been done, clinicians agree that this characteristic is a marker for the character pathology. Minimal anxiety, attachment failure (whether biogenic or sociogenic), and cortical underarousal may be contributory substrates for the absence of internalized value in the antisocial personality disorder patient with severe psychopathy, typically a PCL-R score of 30 or higher.

The presence of any superego development, whether a prosocial ego ideal (a realistic, long-term goal) or clinical evidence of a socially desirable need to rationalize antisocial acts, is a positive prognostic sign. Certain nonpsychopathic patients with antisocial personality disorder may show evidence of harsh and punitive attitudes toward the self and assume a masochistic attitude toward the clinician. This signifies some internalized value and attachment capacity. Antisocial personality disorder patients with severe psychopathy are likely to behave cruelly toward others and show no need to justify or rationalize their behaviors. Such individuals should not be considered for a treatment setting because they place both staff and genuinely mentally ill patients at risk.

When such patients are ordered into forensic hospitals by the courts, strict behavioral controls should be used to manage behavior, and any clinical improvement should be viewed with great skepticism. Meloy identified the following five clinical features that contraindicate treatment of any kind:

1. History of sadistic and violent behavior
2. Total absence of remorse
3. Intelligence two standard deviations from the mean
4. No history of attachments
5. Fear of predation on the part of experienced clinicians without any overtly threatening behavior by the patient

These are clinical guidelines and are not the result of controlled empirical research. The presence of a treatable Axis I condition, such as schizophrenia, in such a patient poses an ethical dilemma for the psychiatrist. Successful remission of the Axis I mental disorder may contribute to better organization of the psychopathy.