Are psychopaths capable of empathy?

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When I was at university we had to write an essay in our final year that was on the topic of cognitive psychology and we had to find research that used cognitive methods in order to do so. I wanted to write an essay on psychopathy – I have always been interested in mental health, the idea of “good” and “evil” and believed I had a relatively good, but brief, understanding of what psychopaths are. I knew the common theme of a typical psychopath is that they lack empathy – they don’t feel for other people, which is how they are capable of doing what they do, whether that is cold blooded murder, or becoming a successful businessman or politician. They don’t care about other people. I wanted to see if this was entirely true – surely they must feel something for other people, that’s what makes us human, right? So I gave the idea to my lecturer and, despite him having no background knowledge in psychopathy, he let me write it.

It was my most successful essay, completely boosting my overall mark of my degree,  and the most enjoyable one I’ve written throughout my academic career. I’ve decided to post it on my blog for that reason – I enjoyed writing it. I’ve edited it slightly, giving more indepth definitions to those of  you who are not psychologically or scientifically inclined, edited it from an essay structure to a blog post layout, and have taken out the majority of in-essay referencing as it’s not necessarily needed (a full reference list will be posted at the end for those who want to do some further reading).

So read on if you wish to find out the answers I discovered on my research pathway to see if psychopaths can feel empathy at all, or if they really are separate from what makes us human. Any questions? Just leave a comment and I’ll get back to you.

“Psychopathy” is a personality disorder, under the diagnosis of “Antisocial Personality Disorder” in the DSM IV-TR (APA, 2000). Diagnostic criteria include the following: failure to conform, deceitfulness, impulsivity, and disregard for safety. The Psychopathy Checklist Revised (PCL-R; Hare, 1991 – remember this, it’s important!) is used for clinical diagnosis if an individual matches the Antisocial Personality Disorder criteria and qualifies for further examination. The higher the score, the more psychopathic the individual’s personality is. Psychopaths are callous, superficial, shallow, do not fear punishment, lack guilt and have difficulty regarding emotions (Decety et al., 2013).

Psychopaths are also understood to have no empathy (Blair, 2003). This blog post will be looking at whether this is entirely true, and do psychopaths really feel nothing for other people, and if they do, what exactly do they feel?

What is empathy?
Empathy is a “social-emotional response” to another person’s emotional state (Decety et al., 2013). Alternatively, Blair (2005) explains that there are three types of empathy: motor empathy, cognitive empathy and affective empathy.

  • Motor empathy involves automatically synchronising with another person’s physical being (Blair, 2005).
  • Cognitive empathy includes the concept Theory of Mind (TOM) and involves representing the mental states of others (Firth, 1989, Leslie, 1987, Premack & Woodruff, 1978; as cited by Blair, 2005). Theory of mind is the ability to understand that other people have different perspectives, beliefs and knowledge to oneself. Cognitive empathy is considered necessary in order for affective empathy to occur (Blair, 2005). However in psychopathy, it is theorised that cognitive empathy and effective empathy are detached from one another (Domes et al., 2013).
  • Affective empathy is a response to displays of others emotions and emotional stimuli (Blair, 2005).

fMRI Research
Using the three subtypes of empathy- motor, cognitive and emotional empathy- fMRI research will be reviewed to discuss whether psychopaths are capable of empathy, or whether they entirely lack the ability of empathic response. fMRIs are a type of brain scan that look at how the brain functions by looking at blood flow to different areas of the brain whilst the participant is carrying out particular activities.

Decety et al. (2013) looked at perspective taking as an indicator of empathy. Imagining what someone else feels and imagining what oneself feels are the two different forms of perspective taking. The former induces empathy; the latter induces empathy and distress. The “imagine self vs. imagine other perspective” (Batson, 2011) was used to measure whether this outcome was present in diagnosed psychopathic individuals. The participants were assessed using the PCL-R. They were asked to adopt either perspective whilst viewing visual stimuli of feet/hands in painful, familiar situations. The higher the PCL-R scores, then the higher the activity in the anterior insula (aINS) and anterior mid-cingulate cortex (aMCC) during the “imagine self” perspective. The higher the PCL-R scores, the less activity here  during the “imagine other” perspective. These two brain areas are accepted as components of pain empathy in healthy participants. These findings fail to support the view that psychopaths do not respond when viewing pain stimuli due to the high brain activity in psychopaths during the “imagine-self” perspective. Psychopaths have the ability to relate the situation to themselves, rather than another person. Psychopaths may not have the ability to adopt another perspective, which is why they lack the empathy that is evoked by doing so. Alternatively, these results offer evidence for a developmental theory of psychopathy (Kiel, 2006, Glenn & Raine, 2009; as cited by Decety et al., 2013). Those with psychopathy display a failure to form stimulus-response associations connecting harmful actions with the pain of others, which is usually learnt in childhood.
Therefore the conclusion of these results is that they lack empathy for other people.

Meffert, Gazzolar, den Boer, Bartels and Keysers (2013) also used a perspective-taking method and established similar results. Participants were assessed using the PCL-R. Videos were shown of two hands interacting in one of four ways: neutral, loving, painful or excluding. The first trial involved watching the video. Secondly, participants were instructed to imagine “feeling” with either the receiving or the approaching hand. Activity was lowest in the aINS and aCC in the observation trial amongst psychopathic participants compared to healthy participants for both the ‘pain’ and ‘love’ conditions. However, these group differences were reduced from the observation trial to the second trial (instructed to feel). When instructed to feel empathy psychopath’s brain activity was increased in the left aINS and was more parallel with that of the healthy participants. This indicates that empathy may be possible in psychopaths, however it is not an automatic response. However the sample in this study was limited. The healthy participants were non-criminals, whereas the psychopathic participants were incarcerated. Criminal or incarcerated lifestyle may therefore count for several group differences. Despite this, it builds on Decety et al’s., (2013) study by showing that perspective-taking and that empathy evoked may be possible in psychopaths, even if it is not a natural, automatic process as it is in healthy participants.

In the two previous studies, empathy was explored using the idea that empathy is a “social-emotional” response to another person’s state or situation. Motor empathy involves the mirror neuron system (MNS), which is composed of cells that discharge when someone “sees or hears a specific-action” (Fecteau et al., 2008). The MNS is involved in a process called embodied simulation (Fecteau et al., 2008). Here, when mirror neurons are discharged the individual “executes and experiences the same actions, emotions and sensations” as those which the individual observed in another (Gazzola, Aziz-Zadeh & Keysers, 2006). (It’s a bit like if a guy sees another guy getting kicked in the balls, he comments saying he ‘felt that’. He didn’t necessarily feel it, it was just the MNS doing it’s job and inducing motor empathy for the other dude). The MNS has been found to correlate with empathy scores (Gazzola et al., 2006). Fecteau et al., (2008) recruited 18 male college students and assessed their psychopathic personalities using the Psychopathic Personality Inventory (PPI). The participants were randomly presented with four clips; a hand at rest (rest), a needle penetrating the hands skin (needle), a q-tip (cotton bud, here in the UK) touching the skin of the hand (q-tip), and a needle penetrating an apple (control). Motor cortex (an area involved in the MNS) excitability was highest in individuals scoring highest on the cold-heartedness scale of the PPI when viewing the needle condition. This indicates that at the sensorimotor level, those high in psychopathic traits are more responsive to painful stimuli than healthy participants. This builds upon the developmental theory previously mentioned. Psychopaths may neurologically recognise the stimulus, but have never learnt how to respond. On the other hand, this research explains the psychopath’s manipulative behaviour, something about psychopaths that is widely acknowledged (APA, 2000). If psychopaths have an understanding of another’s affective state they will be able to manipulate said person (Rogers et al., 2006; as cited by Fecteau et al., 2008). Therefore they have the ability to behaviourally respond to the pain stimulus, just not in the altruistic way healthy participants do (Batson et al., 1997). The task itself involved showing participants images of hands. No faces were shown; therefore there was no confusion between the pain stimuli-response and facial recognition abilities of the participants. This study opted to use the cold-heartedness scale of the PPI rather than the PCL-R, however the two do correlate. PPI is designed to look at psychopathic traits in non-incarcerated and non-psychiatric populations, therefore is relevant for this sample. Furthermore, only males were used in this study. Despite psychopathy being more prevalent in males, future research should look at including females in the sample. Nonetheless, this research supports the possibility of empathy in psychopaths. It offers the idea that empathy may have two levels – understanding another’s state and responding to another’s state. It may be this ability to respond that is maladaptive in psychopathic individuals.

Mier et al., (2014) looked at these two levels of empathy by looking at affective and cognitive Theory of mind (TOM). It was the first study to apply a TOM task specifically to psychopaths. The participants were presented with a statement and then a photograph of a face, and the aim of the task was to evaluate the matching of these. Affective TOM and PCL-R score were negatively correlated, as were emotion recognition and PCL-R score. This indicates that those with psychopathic personalities were poorer than healthy participants at recognising the emotions displayed using the statement and the face photograph, and whether they were consistent with one another. Furthermore, healthy controls displayed increasing activation in areas such as the STS, amygdala and prefrontal gyrus when the task increased in difficulty (e.g. when there was an increasing need to recognise emotions). This increasing activation only occurred in the right amygdala for psychopathic individuals, suggesting altered social-cognitive processing in psychopaths compared to healthy participants. There was also a hypo-activation (not a lot of activity) of the MNS detected in psychopaths, indicating emotional detachment. This suggests different conclusions to Fecteau et al’s., (2008) results, which indicated higher activation in areas associated with the MNS. The present study concludes that due to the hypo-activation of the MNS, psychopaths cannot feel emotions for themselves and therefore it is impossible for them to feel emotions for others. However due to the activation in the amygdala, it is implied that they are able to understand emotions, just not feel them. Due to this inability, they are also unable to interpret and respond to them. However, the brain areas studied here in relation to the MNS (e.g. amygdala) also have other functions, including those involved in affective and cognitive empathy, therefore it is difficult to distinguish precision of hypo-activity. Despite this, the results here can lead to therapies for psychopaths by teaching them how to feel emotions in relation to what they understand, and also how to respond to them. This can increase both levels of empathy – understanding and responding.

Blair (2005) explained that cognitive empathy is necessary for emotional empathy to occur and stated that research should focus on brain damage that leads to impaired affective TOM in comparison to psychopaths. Shamay-Tsoory, Harari, Aharon-Peretz and Levkovitz (2010) looked at performance on TOM tasks in psychopaths and non-psychopathic individuals with orbitofrontal cortex (OFC) lesions. They argued that as psychopaths are good manipulators, they must have an ability to infer others mental states (e.g. Fecteau et al., 2008), therefore TOM must be intact. The task involved two conditions: cognitive TOM, involved in inferring intentions and beliefs (Poletti, Enrici, & Adenzato, 2012), and affective TOM, understanding emotions (Poletti et al., 2012). Participants were shown a cartoon face and either four pictures of objects belonging to a category, or faces in each corner of the screen. The participants had to answer questions by inference of a sentence at the top of the screen or the characters facial expression. Affective TOM impairments were observed in both the OFC and psychopath patients across all conditions, indicating that the OFC underlies TOM abilities in psychopaths. However cognitive TOM showed no correlations with psychopathy scores. Furthermore, there were several limitations with the samples and methods of the study. The task was initially designed for developmental psychopathy, giving the task a child-like theme reducing the validity of the task and therefore the results. Furthermore, OFC lesions in each patient were unique, meaning as a group of participants they were unstandardised; however it is clinically impossible to have a group of patients with identical lesions in any area of the brain. Similar to Meffert et al’s., (2013) study, the psychopaths used were criminal psychopaths. Therefore, as previously discussed, criminal and incarcerated lifestyles may account for some of the group differences. Despite these, the results support the theory that psychopaths have an intact cognitive TOM, and deficits in their affective TOM may be due to underlying OFC problems. Therefore it can be determined that psychopaths have an ability to infer individual’s mental states, but they do not understand emotion.

Sommer et al., (2010) also obtained results showing that psychopaths do not lack TOM. Also, in opposition to previously discussed studies samples, Sommer at al., (2010) used criminal psychopaths and non-psychopaths. This would reduce the likelihood of any group differences being due to criminal or incarcerated lifestyles. However the task used was again designed for children, limiting the validity of the results. The task required participants to decide on cartoon character’s mental state in relation to his/her intention and outcome of their action (whether the intention was fulfilled or unfulfilled). Psychopath’s accuracy was similar to non-psychopaths; both groups indicated unpleasant emotions when the intention was unfulfilled, and pleasant emotions when the intention was fulfilled. This indicates that psychopaths showed no difficulties in understanding the mental states of the characters, implying intact TOM. Yet, psychopaths showed more activation in the OFC than non-psychopaths, and the researchers concluded that this reflected their concentration on the outcome values. This supports Mier et al., (2014) study that discussed that psychopaths have altered social-cognitive processing, compared to healthy participants. This altered processing may be because psychopaths require more rational strategies to infer mental states compared to non-psychopaths. However it must be noted that because all participants were criminals, it limits the ability of the results to be generalised to non-criminal populations. Furthermore, the psychopathic participants had, on average, spent a longer time incarcerated than the non-psychopathic participants. Therefore this may be a factor affecting the differences. Additionally, similar to other studies, only males were used in the study. As a consequence, results cannot be generalised to females. However, these results do show promise of the recognition of psychopaths having an intact TOM. Therefore, having the ability to have empathic reactions, even if that empathic reaction is limited to cognitive empathy, not emotional.

The above studies have either looked at the effects of facial expressions or the effect of visual scenarios. Decety et al., (2013) looked at the effect of both on eliciting empathic reactions in incarcerated psychopaths. The PCL-R was used to assess 80 incarcerated males. Those with a score above or equal to 30 were classified as psychopathic; scores below 30 formed a control group. This method is problematic, as those with an extremely low score were classed as quantitatively equal to those with a score marginally close to the cut off point. There were two tasks, one assessing neural responses to scenarios depicting physical harm, and another assessing the neural responses to facial expressions of pain. When viewing physical harm scenarios, control participants had greater activation in the OFC, whereas psychopaths exhibited higher activation in the anterior insular cortex (AIC). This activation in the AIC amongst psychopathic participants was also evident when they were viewing facial expressions of pain. The AIC is seen as necessary for empathic responses in relation for pain to occur (Gu et al., 2012). Therefore, the high level of activation in the AIC in psychopaths here is surprising. However, it is possible that the AIC is used for a cognitive assessment of the situation, rather than an affective assessment (Decety et al., 2013). Williamson et al., (1991) explained that psychopaths employ cognitive strategies to process affective material. This is similar to previously mentioned research (Sommer at al., 2010, Mier et al., 2014) where it was concluded that psychopaths have altered social-cognitive processing. This also supports the idea that psychopaths have an intact TOM. There is an alternative theory that psychopaths up-regulate and increase their emotional processing, resulting in higher activation compared to non-psychopaths, due to them compensating for their emotional deficits (Decety et al., 2013). Finally, the role of the OFC in psychopathy is once again supported here (Shamay-Tsoory et al., 2010) with higher activation being seen in non-psychopaths in response to viewing physical harm scenarios, compared to psychopaths. The sample consisted of all incarcerated males, limiting the ability to generalise the results to other psychopathic populations.

Conclusions

To conclude, the aforementioned studies have featured tasks examining a range of empathic responses in psychopathic individuals compared to healthy controls. It is clear that TOM is intact in psychopathic individuals, with cognitive empathy being both behaviourally displayed (Shamay-Tsoory et al., 2010, Sommer et al., 2010) and an altered social-cognitive processing being neurologically observed (Decety et al., 2013, Sommer at al., 2010, Mier et al., 2014). There is evidence that motor empathy and the MNS is also evident in psychopaths, with high sensorimotor response in those high in psychopathic traits compared to healthy controls (Fecteua et al., 2008). Cognitive empathy is necessary for affective empathy to occur (Blair, 2005) however the latter is absent in many psychopaths. Therefore, psychopaths may be capable of empathy at the neural level, but are unable to affectively respond to the stimuli presented to them (e.g. Shamay-Tsoory et al., 2010, Mier et al., 2014), at least not automatically (e.g. Meffert et al., 2013). However, it can be argued that the manipulative personality of a psychopath is a response to the emotionally charged stimuli they are presented with. Yet, this was not looked at here. In order to carry out further research in this area, tasks that are higher in ecological validity need to be employed. This would be rather than the tasks used in studies explored, e.g. cartoon vignettes (e.g. Shamay-Tsoory et al., 2010, Sommer et al., 2010), videos of only particular body parts (e.g. Meffert et al., 2013, Fecteau et al., 2008) and photographic facial expressions (e.g. Mier et al., 2014). Despite the low prevalence of psychopathy within females (APA, 2000), this population also needs to be examined alongside samples including a balance of criminal and non-criminal psychopaths and non-psychopaths. This will increase the ability for the results to be generalised. Finally, research in this area is important for diagnostic criteria and assumptions surrounding psychopathy. It is a popular belief that psychopaths have extreme emotional deficits and lack complete empathy, yet are also extremely manipulative, which is conflicting. It can also lead to intervention programs with psychopaths; cognitive-behavioural therapy can focus on their cognitive abilities to empathise, translating this into affective responses (Decety et al., 2013).

Overall, the research above suggests that psychopaths do lack empathy, but only in their affective response to stimuli due to their alternative social-cognitive processing of information. However, their MNS and TOM are intact, giving them the capability to have motor and also cognitive empathy, which is necessary for affective empathy.

 

Glossary

AIC                 Anterior Insula Cortex

aINS                Anterior Insula

aMCC             Anterior Midcingulate Cortex

MNS               Motor Neuron System

OFC                Orbitofrontal Cortex

PCL-R             Psychopathy Checklist Revised (Hare, 1991)

TOM              Theory of Mind


 

References

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). Washington, DC: Author.

Batson, C. D., Early, S., & Salvarani, G. (1997). Perspective taking: Imagining How Another Feels Versus Imaging How You Would Feel. Personality and social psychology bulletin, 23(7), 751-758.

Batson, C. D. (2011). Altruism in Humans. New York, NY: Oxford University Press.

Blair, R.J.R. (2003). Neurobiological Basis of Psychopathy. British Journal of Psychiatry. 182(1), 5-7.

 

Blair, R.J.J. (2005). Responding to the Emotions of Others: Dissociating Forms of Empathy Through the Study of Typical and Psychiatric Populations. Consciousness and Cognition, 14(4), 698-718.

 

Decety, J., Chen, C., Harenski, C., & Kiehl, K.A. (2013). An fMRI Study of Affective Perspective Taking in Individuals With Psychopathy: Imagining Another in Pain Does Not Evoke Empathy. Frontiers in Human Neuroscience, 7, doi: 10.3389/fnhum.2013.00489.

 

Decety, J., Skelly, L.R., & Kiehl, K.A. (2013). Brain Response to Empathy-Eliciting Scenarios Involving Pain in Incarcerated Individuals With Psychopathy. JAMA Psychiatry, 70(6), 638-645.

 

Decety, J., Skelly, L., Yoder, K.J., & Kiehl, K.A. (2013). Neural Processing of Dynamic Emotional Facial Expressions in Psychopaths. Social Neuroscience, 9(1), 36-49.

 

Domes, G., Hollerbach, P., Vohns, K., Mokros, A., & Habermeyer, E. (2013). Emotional Empathy and Psychopathy in Offenders: An Experimental Study. Journal of Personality Disorders, 27(1), 67-84.

 

Fecteau S., Pascual-Leone, A., & Théoet, H. (2008). Psychopathy and the Mirror Neuron System: Preliminary Findings From a Non-Psychiatric Sample. Psychiatry Research, 160(2), 137-144.

 

Gazzola, V., Aziz-Zadeh, L., & Keysers, C. (2006). Empathy and the Somatotopic Auditory Mirror System in Humans. Current biology, 16(18), 1824-1829.

 

Gu, X., Gao, Z., Wang, X., Liu, C., Knight, R.T., Patrick, R.H., & Fan, J. (2012). Anterior Insular Cortex is Necessary for Empathetic Pain Perception. Brain, 135(9), 2726-2735.

 

Hare, R. D. (1991). The Hare Psychopathy Checklist – Revised. Toronto, Ontario: Multi-Health Systems.

 

Kiehl, K.A., Smith, A.M., Hare, R.D., Mendrek, A., Forster, B.B., Brink, J., & Liddle, P.F. (2001). Limbic Abnormalities in Affective Processing by Criminal Psychopaths as Revealed by Functional Magnetic Resonance Imaging. Biological Psychiatry, 50(9), 677-684.

 

Meffert, H., Gazzola, V., den Boer, J.A., Bartels, A.A.J., & Keysers, C. (2013). Reduced Spontaneous but Relatively Normal Deliberate Vicarious Representations in Psychopathy. Brain, 136(8), 2550-2562.

 

Mier, D., Haddad, L, Diers, K., Dressing, H., Meyer-Lindenberg, A., & Kirsch, P. (2014). Reduced Embodied Stimulation in Psychopathy. The World Journal of Biological Psychiatry, 15(6), 479-487.

 

Poletti, M., Enrici, I., & Adenzato, M. (2012). Cognitive and affective Theory of Mind in neurodegenerative diseases: neuropsychological, neuroanatomical and neurochemical levels. Neuroscience & Biobehavioral Reviews, 36(9), 2147-2164.

 

Shamay-Tsoory, S.G., Harari, H., Aharon-Peretz, J., & Levkovitz, Y. (2010). The Role of the Orbitofrontal Cortex in Affective Theory of Mind Deficits in Criminal Offenders with Psychopathic Tendencies. Cortex, 46(5), 668-677.

 

Sommer, M., Sodian, B., Döhnel, K., Schwerdtner, J., Meinhardt, J., & Hajak, G. (2010). In Psychopathic Patients Emotion Attribution Modulates Activity in Outcome Related Brain Areas. Psychiatry Research: Neuroimaging, 182(2), 88-95.

 

 

 

 

 

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