Psychopathy, Neurodevelopmental Insult, and the Assessment of Violence Risk

1. 1st time I�ve used this fancy equipment -Spent more time on looks than on content! Admire the looks. This is my best one1st time I�ve used this fancy equipment -Spent more time on looks than on content! Admire the looks. This is my best one

2. Psychopathy, Neurodevelopmental Insult, and the Assessment of Violence Risk Violence prediction before the mid-1980�s A promising sign for improved risk prediction The development and validation of the VRAG and SORAG Ethics of risk assessment The nature of psychopathy Paths to adult violence

3. Prediction of Violence Before Mid-1980�s The challenge and the problem Examples Baxstrom (Steadman, 1973) Quinsey & Ambtman, 1979 Pasewark, Bieber, Bosten, Kiser, & Steadman, 1982 -General consensus was (and studies backed that up) that there was no expertise in the prediction of violence -Baxstrom decision in 1973 was very influential- Showed overprediction of violence- incidence of violence among men all of whom had been kept in because someone thought they were too dangerous to release - yet incidence of future crime and violence was very low-- (But short followup and men were quite old by the time they were released) -Quinsey & Ambtman psychiatrist- teacher study - Pasewark et al.- men who eloped were, if anything, less likely to reoffend than those released (just a trend, not significant)-General consensus was (and studies backed that up) that there was no expertise in the prediction of violence -Baxstrom decision in 1973 was very influential- Showed overprediction of violence- incidence of violence among men all of whom had been kept in because someone thought they were too dangerous to release - yet incidence of future crime and violence was very low-- (But short followup and men were quite old by the time they were released) -Quinsey & Ambtman psychiatrist- teacher study - Pasewark et al.- men who eloped were, if anything, less likely to reoffend than those released (just a trend, not significant)

4. -Monahan�s 1981 monograph, reprinted in 1995? �Predicting Violent Behavior: An Assessment of Clinical Techniques� stated� -very influential - common wisdom was that there was no expertise -When they predicted that someone was going to be violent, they were more likely to be wrong than correct. Why? Problem, experts concluded, was that violent behavior was a low baserate activity. Lots of false positives in prediction- that is, peoplepredicted to be violent who really werent. -Best accuracy in prediction could be attained by predicting that no one would be violent. Because, in early studies, only 3-5% were found to actually go out and commit an act of violence, it was hard to do better in overall accuracy than to predict that no one would be violent-Monahan�s 1981 monograph, reprinted in 1995? �Predicting Violent Behavior: An Assessment of Clinical Techniques� stated� -very influential - common wisdom was that there was no expertise -When they predicted that someone was going to be violent, they were more likely to be wrong than correct. Why? Problem, experts concluded, was that violent behavior was a low baserate activity. Lots of false positives in prediction- that is, peoplepredicted to be violent who really werent. -Best accuracy in prediction could be attained by predicting that no one would be violent. Because, in early studies, only 3-5% were found to actually go out and commit an act of violence, it was hard to do better in overall accuracy than to predict that no one would be violent

5. Rice, Harris, & Cormier, 1992 A Promising Sign A Therapeutic Community Program Evaluation Participants: Psychopaths, Others Program Description Program Evaluation Program Review Outcome

6. Characteristics of Psychopathy Psychopathy Checklist- Revised (Hare, 1981) Glibness/Superficial charm Grandiose sense of self-worth Pathological lying Conning/manipulative Lack of remorse or guilt Shallow affect Callous/Lack of empathy Failure to accept responsibility

7. Characteristics of psychopathy Need for stimulation Parasitic lifestyle Poor behavioural controls Early behaviour problems Lack of realistic longterm goals Impulsivity Irresponsibility Juvenile delinquency Revocation of conditional release Criminal versatility Promiscuous sexual behaviour Many short-term marital relationships

8. Program Review �This is an exciting program which has the hallmark of being right� as the final model of the DNA molecule looked right to Watson and Crick� �We were satisfied that the patients benefited greatly from the Social Therapy Unit experience. We are quite sure that the program itself is of considerable benefit not only to the patients but to the hospital as a whole and the country.� people came from all over the world to look at this program -as best we can tell from records, they were universally impressed -here are quotes from a review panel commissioned by the Ombudsmanpeople came from all over the world to look at this program -as best we can tell from records, they were universally impressed -here are quotes from a review panel commissioned by the Ombudsman

9. Program Review �We were satisfied that the program [has]�.a very low recidivism rate� �.developed the techniques that�are the most fruitful anywhere in the universe at the present time� based on these glowing reviews, we thought it would be worthwhile to do a proper outcome evaluation -by that time, the program had died for reasons having nothing to do with its efficacybased on these glowing reviews, we thought it would be worthwhile to do a proper outcome evaluation -by that time, the program had died for reasons having nothing to do with its efficacy

10. Outcome Study Treated Untreated n=146 n=146 Therapeutic Prison Community - not random assignment because study was retrospective - took all men who had been in program >= 2yrs - yoked each exptl. S to a man who didn�t come for treatment, but who, after having been assessed here prior to trial, went to prison after trial -Matched on: -146 men in each group -Psychopathy in brackets because� - Men followed for a mean of 10 yrs at risk- not random assignment because study was retrospective - took all men who had been in program >= 2yrs - yoked each exptl. S to a man who didn�t come for treatment, but who, after having been assessed here prior to trial, went to prison after trial -Matched on: -146 men in each group -Psychopathy in brackets because� - Men followed for a mean of 10 yrs at risk

11. What got us interested in the concept of psychopathy and got us thinking there was something fundamentally different between psychopathic and nonpsychopathic offenders -Interaction between psychopathy and treatmentWhat got us interested in the concept of psychopathy and got us thinking there was something fundamentally different between psychopathic and nonpsychopathic offenders -Interaction between psychopathy and treatment

12. Implications Importance of Psychopathy Importance of true followup Promise of renewed prediction optimism

13. Predictors of Violent Recidivism Among MDOs Bonta, Law & Hanson, 1998 meta-analysis Big predictors objective risk assessment, antisocial personality, violent history, juvenile delinquency, age* Medium predictors nonviolent criminal history, adult criminal history, substance abuse, not married Small predictors clinical judgement, psychosis*, offense severity

14. Predictors of Violence Among Psychiatric Patients (MacArthur Risk Study) Big predictors: Psychopathy (PCL:SV); Adult arrests, Antisocial personality disorder, Major mental disorder without substance abuse*, drug or alcohol abuse, anger (Novaco) Moderate predictors: Violent arrests, schizophrenia*, child abuse, threat-control overrride symptoms* delusions at the time of admission* Big= Bivariate correlation >= .16 Moderate= Bivariate correlation > .09 < .16 Small = Bivariate correlation <.09 and significant Nonpredictor= nonsignificant (approx. < .06) Note: I�ve listed highest correlation for measures that had many versions (e.g. Novaco Anger Inventory- Behavior, Cognitive, Arousal) There were many other correlations, I�ve just listed ones most relevant for this talkBig= Bivariate correlation >= .16 Moderate= Bivariate correlation > .09 < .16 Small = Bivariate correlation <.09 and significant Nonpredictor= nonsignificant (approx. < .06) Note: I�ve listed highest correlation for measures that had many versions (e.g. Novaco Anger Inventory- Behavior, Cognitive, Arousal) There were many other correlations, I�ve just listed ones most relevant for this talk

15. MacArthur Data (cont) Small predictors persecutory delusions*, male, BPRS hostility, BPRS thought disturbance, medication nonadherence on admission* Nonpredictors mania, depression, any delusions, hallucinations, command hallucinations, grandiose delusions, GAF, BPRS Total

16. Combining Predictors Clinical vs..... Actuarial Prediction Grove & Meehl (1996) �We know of no social science controversy for which the empirical studies are so numerous, varied, and consistent as this one.� (p.318) Mossman (1994)

17. Development of the VRAG: 618 MDOs Variables Predictor Selection Definition of Violent Recidivism Multivariate Methods Subgroups Weighting System� Actuarial Risk Assessment:The Violence Risk Appraisal Guide

18. The Violence Risk Appraisal Guide (VRAG) Psychopathy Checklist Score Elementary school maladjustment Age at index offense* DSM III personality disorder Separation from parents before age 16 Failure on prior conditional release History of nonviolent offenses

19. The Violence Risk Appraisal Guide (VRAG) Never married DSM III schizophrenia* Victim injury in index offense* History of alcohol abuse Male victim in index offense

20. Performance of the VRAG

22. Receiver Operator Characteristic

23. How good is the instrument? What if we change the average followup period? 3.5 years Baserate = 15% 7 years Baserate = 31% 10 years Baserate = 43% What if we predict time until violent failure?

24. Replications of VRAG/SORAG (n=26)

25. Illustrative ROCs

26. Other Actuarial Instruments MacArthur Iterative Classification Tree For civilly committed psychiatric patients (Monahan et al., 2001) Static-99, RRASOR For sex offenders (Hanson & Thornton, 2000, Hanson, 1999)

27. Ethics of Violence Risk Assessment Best instruments contain only static variables Psychopathy is important part of risk prediction Is it ethical to use VRAG or SORAG or PCL-R For release decisions for insanity acquittees? For sexual predator determinations? For capital sentencing decisions?

28. The nature of psychopathy Psychopathy as a disorder Psychopaths as a discrete class Disorder vs. adaptation Psychopathy reconsidered A first empirical test Other evidence Traditional ways of looking at psychopathy -Is psychopathy discrete or continuous? Look at differences between a disorder and an adaptation -Reconsider differences between psychopaths and nonpsychopaths How could we study this empirically? -Other things we�re studyingTraditional ways of looking at psychopathy -Is psychopathy discrete or continuous? Look at differences between a disorder and an adaptation -Reconsider differences between psychopaths and nonpsychopaths How could we study this empirically? -Other things we�re studying

29. Raine & Sanmartin Violence & Psychopathy, 2002 Psychopathy as a Disorder DSM-IV Cleckley : Semantic dementia Hare: Socially devastating disorder Patrick: Defective processing of emotional stimuli Newman: Defective integration of BAS & BIS Raine: Damage to frontal lobes Most past and current conceptualizations of psychopathy have considered it to be a disorder -DSM-IV considers psychopathy as synonymous with APD- ie. a serious PD -Cleckley - Considered psychopaths closer to psychosis than normality.--lifestyle characterized by aimlessness, impulsivity, untruthfulness, lack of remorse or empathy, lack of insight. He hypothesized that the problems stemmed from a failure to process the emotional meanings of language-- �semantic dementia�. In normals, stimuli that have been associated with aversive consequences in the past evoke unpleasant emotional images that in turn inhibit new antisocial behavior. But not in psychopaths. They know the words of emotion, but not the music. Support for this-- Hare et al.-- normals and psychopaths judge pleasantness & unpleasantness of emotional words equally, but psychopaths show much less differentiation between emotional and neutral words in reaction time and electrodermal activity than normals -Hare- Calls psychopathy a ��� defined by many of same characteristics named by Cleckley with some refinements and additions-- egocentricity or selfishness, pathological lying, sexual promiscuity, parasitic lifestyle, glib, superficially charming and persistent antisocial and criminal behavior-- says now that behavioral, electrocortical and neuroimaging research adds weight to the clinical belief that psychopaths fail to appreciate the emotional significance of events. They are �without conscience� -Patrick-- calls it a disorder characterized by defective processing of emotional stimuli. His work on the �startle reflex� and fear imagery supports his view. -Newman- Psychopathology characterized by deficient integration of the Behavioral Activation System and the Behavioral Inhibition System. Once BAS is activated, BIS doesn�t work as it should. -Raine- Most past and current conceptualizations of psychopathy have considered it to be a disorder -DSM-IV considers psychopathy as synonymous with APD- ie. a serious PD -Cleckley - Considered psychopaths closer to psychosis than normality.--lifestyle characterized by aimlessness, impulsivity, untruthfulness, lack of remorse or empathy, lack of insight. He hypothesized that the problems stemmed from a failure to process the emotional meanings of language-- �semantic dementia�. In normals, stimuli that have been associated with aversive consequences in the past evoke unpleasant emotional images that in turn inhibit new antisocial behavior. But not in psychopaths. They know the words of emotion, but not the music. Support for this-- Hare et al.-- normals and psychopaths judge pleasantness & unpleasantness of emotional words equally, but psychopaths show much less differentiation between emotional and neutral words in reaction time and electrodermal activity than normals -Hare- Calls psychopathy a ��� defined by many of same characteristics named by Cleckley with some refinements and additions-- egocentricity or selfishness, pathological lying, sexual promiscuity, parasitic lifestyle, glib, superficially charming and persistent antisocial and criminal behavior-- says now that behavioral, electrocortical and neuroimaging research adds weight to the clinical belief that psychopaths fail to appreciate the emotional significance of events. They are �without conscience� -Patrick-- calls it a disorder characterized by defective processing of emotional stimuli. His work on the �startle reflex� and fear imagery supports his view. -Newman- Psychopathology characterized by deficient integration of the Behavioral Activation System and the Behavioral Inhibition System. Once BAS is activated, BIS doesn�t work as it should. -Raine-

30. Harris, Rice & Quinsey, 1994 Psychopathy as a Taxon Difference in degree or difference in kind? Continuum or discrete class? Carving nature at its joints Schizotypy Psychopathy Etiology? - - - Finding out whether something is a taxon is like what Plato called � - Paul Meehl & colleagues have developed a set of mathematical methods for determining if something we can only measure indirectly is really a continuum or whether it is a dichotomy. Strong evidence exists for schizotypy as a taxon. Meehl proposes that schizotypy is a major gene locus and that while not everyone with the locus develops schizophrenia, everyone with schizophrenia is in the schizotypy taxon. Meehl hypothesized that psychopathy might also be a taxon. -We have tested this hypothesis using every set of methods that has yet been developed and found very strong evidence that psychopaths differ in kind and not just in degree from other offenders - Meehl says that evidence for a taxon is evidence for a major gene locus. Proof of this for psychopathy is a long way off, but there is evidence of a strong inherited component for antisocial and criminal behavior.- - - Finding out whether something is a taxon is like what Plato called � - Paul Meehl & colleagues have developed a set of mathematical methods for determining if something we can only measure indirectly is really a continuum or whether it is a dichotomy. Strong evidence exists for schizotypy as a taxon. Meehl proposes that schizotypy is a major gene locus and that while not everyone with the locus develops schizophrenia, everyone with schizophrenia is in the schizotypy taxon. Meehl hypothesized that psychopathy might also be a taxon. -We have tested this hypothesis using every set of methods that has yet been developed and found very strong evidence that psychopaths differ in kind and not just in degree from other offenders - Meehl says that evidence for a taxon is evidence for a major gene locus. Proof of this for psychopathy is a long way off, but there is evidence of a strong inherited component for antisocial and criminal behavior.

31. What�s inherited? A Disorder? A harmful dysfunction Dysfunction: A failure of a mechanism to perform a function for which it was designed by natural selection Harm : to self (Wakefield, 1993) An Adaptation? A mechanism that contributed to an individual�s ability to reproduce in the ancestral environment (after Williams, 1966) - Define disorder... Psychopaths don�t seem to suffer form their �disorder�. Other people do. -Maybe it�s not a disorder, but rather an adaptation - Define disorder... Psychopaths don�t seem to suffer form their �disorder�. Other people do. -Maybe it�s not a disorder, but rather an adaptation

32. Evolutionary Stable Strategies Prisoner�s dilemma Robustness of tit-for-tat in iterative games (or generations) When cheaters can prosper Psychopaths as cheaters in the �game� of life -.. -a game in which there are 2 players and 2 possible moves on each turn: Cooperate or Defect. Each must select without knowing what the other does. If both cooperate, both get a small reward. If both defect, both lose a little. But if 1 cooperates, and 1 defects, defector wins big, and cooperator loses big. Best joint strategy is for both to cooperate and both end up ahead. But best individual strategy under almost all conditions is to defect-- a defector always beats a cooperating opponent. - a tit-for-tat strategy has been shown to do well against virtually all others under virtually all conditions when games are played over several generations where the winning strategies from one round of games �a generation� are allowed to play in the next generation according to their number of wins in the previous round. - However, �cheaters� i.e. �defectors� can almost always find a niche- so long as there aren�t too many of them, their numbers can remain stable from generation to generation- i.e. cheating is an evolutionary stable strategy - Cheaters prosper under certain conditions- e.g.When the games will be short, & when cheaters don�t have to play the same player more than once. -We and others have proposed that psychopaths are ...-.. -a game in which there are 2 players and 2 possible moves on each turn: Cooperate or Defect. Each must select without knowing what the other does. If both cooperate, both get a small reward. If both defect, both lose a little. But if 1 cooperates, and 1 defects, defector wins big, and cooperator loses big. Best joint strategy is for both to cooperate and both end up ahead. But best individual strategy under almost all conditions is to defect-- a defector always beats a cooperating opponent. - a tit-for-tat strategy has been shown to do well against virtually all others under virtually all conditions when games are played over several generations where the winning strategies from one round of games �a generation� are allowed to play in the next generation according to their number of wins in the previous round. - However, �cheaters� i.e. �defectors� can almost always find a niche- so long as there aren�t too many of them, their numbers can remain stable from generation to generation- i.e. cheating is an evolutionary stable strategy - Cheaters prosper under certain conditions- e.g.When the games will be short, & when cheaters don�t have to play the same player more than once. -We and others have proposed that psychopaths are ...

33. Psychopathy Reconsidered Psychopathic Characteristics Language Startle Reflex BAS and BIS Type of Violence -Consider the characteristics of psychopaths and see if they sound like they �d equip psychopaths to be cheaters-- glib, superficially charming, pathological lying, parasitic lifestyle, conning and manipulative, lacking in remorse and empathy, lack of remorse and empathy, �without conscience�, AND sexual promiscuity -Language-- Maybe the �semantic dementia� is actually adaptive. To thrive by cheating, it�s probably a good thing not to be as affected by stimuli that could represent other people�s emotions -Startle reflex- Maybe psychopaths show less of a startle reaction than other people because they truly feel less emotion to outside stimuli (not necessarily to their own internal stimuli) -Maybe its easier to get in, get what you want and get out if your BIS doesn�t work very well once the BAS is pursuing a goal -Theory fits also with the finding that the violence perpetrated by psychopaths is different from that committed by nonpsychopaths- victims are more likely to be strangers, violence more likely to be instrumental -Consider the characteristics of psychopaths and see if they sound like they �d equip psychopaths to be cheaters-- glib, superficially charming, pathological lying, parasitic lifestyle, conning and manipulative, lacking in remorse and empathy, lack of remorse and empathy, �without conscience�, AND sexual promiscuity -Language-- Maybe the �semantic dementia� is actually adaptive. To thrive by cheating, it�s probably a good thing not to be as affected by stimuli that could represent other people�s emotions -Startle reflex- Maybe psychopaths show less of a startle reaction than other people because they truly feel less emotion to outside stimuli (not necessarily to their own internal stimuli) -Maybe its easier to get in, get what you want and get out if your BIS doesn�t work very well once the BAS is pursuing a goal -Theory fits also with the finding that the violence perpetrated by psychopaths is different from that committed by nonpsychopaths- victims are more likely to be strangers, violence more likely to be instrumental

34.  868 violent male offenders Clinical records: Neurodevelopmental problems Psychopathy Antisocial parenting Violent crime Measurement

43. Summary Two independent paths to violence Neurodevelopmental insults Psychopathy Psychopathy is the stronger path

44. Psychopathy among Sex Offenders Do psychopaths� victim �choices� reflect what appears to be a strategy (compared with nonpsychopaths)? 288 Child molesters, rapists and both Assessed at a maximum security institution mean PCL-R score = 17 (8.5) Total victims::PCL-R r = .17, p <.01

45. Victim Characteristics and Correlations with PCL-R Score - Psychopaths have more victims, which is not surprising, BUT their victims are not randomly distributed, but rather tend to be in specific categories: - More likely to be female -More likely to be adults - Much more likely to be PUBESCENT FEMALES (i.e. 13-17)- Psychopaths have more victims, which is not surprising, BUT their victims are not randomly distributed, but rather tend to be in specific categories: - More likely to be female -More likely to be adults - Much more likely to be PUBESCENT FEMALES (i.e. 13-17)

46. A Multi-site Sex Offender Follow-up Study Subjects: Maximum Security Institution n = 118 Community/ psych. ward: n = 125 Federal penitentiary n = 191 Rapists (52%) and Child Molesters (59%) Phallometric assessment of sexual interests

47. Psychopathy and Victim Characteristics PCL-R and Number of: Female Victims -- r = .13* Male Victims -- r = -.03 Adult Victims -- r = .13* Child Victims -- r = -.11*

48. PCL-R and Sexual Interests PCL-R and Phallometric Response to: Females > 13 -- r = .15* Females < 13 -- r = -.12* Males any age -- r = -.06

49. Conclusions and Implications Evidence in favor of actuarial instruments for violence risk assessment is increasing VRAG and SORAG do well for long and short-term prediction, very serious and less serious violence Best place for clinical judgement is inside an actuarial instrument There is increasing evidence that psychopathy is an adaptation, and not a disorder