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Psychopathy and Externalizing
Syndromes: Conceptualization,
Mechanisms, and Perspectives on
Treatment
Chris Patrick
Department of Psychology
University of Minnesota
Outline:
1. Background: Dual Process Model of Psychopathy
- fearlessness, externalizing vulnerability
2. The Externalizing Spectrum
a.
b.
c.
d.
Etiologic basis
Hierarchical model
Brain mechanisms
Links to other problem domains
3. Clinical Implications
Outline:
1. Background: Dual Process Model of Psychopathy
- fearlessness, externalizing vulnerability
2. The Externalizing Spectrum
a.
b.
c.
d.
Etiologic basis
Hierarchical model
Brain mechanisms
Links to other problem domains
3. Clinical Implications
Cleckley (1976)
• described psychopathy as a paradoxical condition
in which severe behavioral pathology and positive
adjustment seemed to go hand in hand:
I find it necessary…to postulate that the psychopath has
a genuine and very serious disability, disorder, defect, or
deviation…[but] a different kind of abnormality from all
those now recognized as seriously impairing
competency…The first and most striking difference is
this: In all the orthodox psychoses…,there is a more or
less obvious alteration of reasoning processes or of
some other demonstrable personality feature. In the
psychopath, this is not seen. The observer is confronted
with a convincing mask of sanity. (p. 368)
Cleckley (cont’d)
The surface of the psychopath…shows up as equal to or
better than normal and gives no hint at all of a disorder
within. Nothing about him suggests oddness, inadequacy,
or moral frailty. His mask is that of robust mental health.
Yet he has a disorder that often manifests itself in conduct
far more seriously abnormal than that of the schizophrenic.
(p. 383)
The psychopath, however perfectly he mimics man
theoretically, that is to say, when he speaks for himself in
words, fails altogether when he is put into the practice of
actual living. His failure is so complete and so dramatic
that it is difficult to see how such a failure could be
achieved by anyone less defective than a downright
madman... (p. 370)
Clinical features of psychopathy
identified by Cleckley:
• overt adjustment: social charm & good
intelligence; absence of delusions or
irrationality; absence of anxiety or depressive
symptoms; non-suicidal
• chronic behavioral deviance: impulsive
antisocial action; failure to learn from
experience; irresponsibility; promiscuity;
absence of any life plan
• emotional-interpersonal deficits: lack of
remorse; poverty of affect; incapacity for
love; absence of loyalty; untruthfulness
What accounts for this paradoxical
syndrome?
Traditional perspective: Behavioral deviance and
emotional-interpersonal features arise from a
common underlying impairment in emotion
and/or cognition. [“Unitary process model”]
Alternative perspective: Psychopathy as
Cleckley described it reflects the confluence of
two distinct processes, one related in part to
adjustment, and the other related more purely to
pathology. [“Dual process model”]
Empirical evidence…
The Psychopathy Checklist - Revised
(PCL-R; Hare, 1991, 2003)
Factor 1
Emotional-Interpersonal
• charm, grandiosity
• lying, manipulation
Factor 2
Behavioral Deviance
• child behavior
problems
•
remorse
• juvenile delinquency
•
emotional depth
• boredom, impulsivity
•
empathy
• irresponsibility
• violent behavior
PCL-R
Psychopathy
Factor 1:
Emotional
Interpersonal
Factor 2:
Behavioral
Deviance
r = .5
Note: Alternative 3- and 4-factor
models have recently been proposed.
PCL-R Factors: Differential Correlates
Emot-Interpersonal Behavioral Deviance
Factor
Factor
Emotion: low fear
reactivity
Emotion: normal fear
reactivity
Personality: hi dom- Personality: hi impulinance, low neg affect sivity, hi aggression
Behavior: instrumental aggression
Behavior:
- reactive agg, suicide
- DSM APD, alcohol &
drug abuse
Dual Process Model of Psychopathy:
The “classic” psychopath reflects the cooccurrence of 2 distinct etiologic processes:
1) Trait fearlessness
- reduced sensitivity to aversive cues.
- associated with narcissism, thrill-seeking; but
confers immunity to Internalizing problems.
2) Externalizing vulnerability
- broad, underlying propensity toward impulse
control problems (“disinhibitory psychopathology”).
The Structure of Common Mental Disorders (Krueger, 1999)
Major Depressive Disorder
.82
Dysthymia
.81
.81
N = 8,098
o &o
+
(community)
Anxious-Misery
.93
Generalized Anxiety DO
Social Phobia
.72
Simple Phobia
.77
.76
.74
Agoraphobia
INTERNALIZING
.78
Fear
Panic Disorder
.51
Alcohol Dependence
.79
Drug Dependence
.84
.74
Antisocial Personality DO
EXTERNALIZING
Parallel in the developmental literature:
Internalizing and externalizing dimensions of
child psychopathology (Achenbach &
Edelbroch, 1984)
Cortical Reactivity
Dual Process Model
of Psychopathy:
Psychopathy
Trait Fear
Blink Startle
Parallel in the developmental literature:
Fearful temperament and effortful control as
independent constructs relevant to
conscience formation in childhood
(Kochanska, 1997, 2002; see also
Rothbart & Ahadi, 1994)
Individuals extreme in only one or the other
of these dispositions (externalizing,
fearlessness) will show psychopathic
tendencies, but would not be “true”
psychopaths according to Cleckley’s
definition…
Outline:
1. Background: Dual Process Model of Psychopathy
- fearlessness, externalizing vulnerability
2. The Externalizing Spectrum
a.
b.
c.
d.
Etiologic basis
Hierarchical model
Brain mechanisms
Links to other problem domains
3. Clinical Implications
Externalizing Spectrum Model: Key Ideas
A broad vulnerability factor or dimension
(“Externalizing”) underlies the spectrum of
disorders that involve deficient impulse control.
 General proneness to developing disorders within this
spectrum reflects one’s position along this vulnerability
continuum, which is determined mainly by genetic
influences.
 The specific expression of this underlying vulnerability
(e.g., as APD vs. drug dependence) is determined
substantially by environmental influences.
The Externalizing Dimension:
[single or less severe disorders]
[normative traits]
Low
[multiple or more
severe disorders]
High
…single continuum encompassing disinhibitory
personality & impulse disorder symptoms.
Outline:
1. Background: Dual Process Model of Psychopathy
- fearlessness, externalizing vulnerability
2. The Externalizing Spectrum
a.
b.
c.
d.
Etiologic basis
Hierarchical model
Brain mechanisms
Links to other problem domains
3. Clinical Implications
4. Future Directions
Biometric (Twin) Analysis of the Externalizing Factor
(Krueger, Hicks, Patrick et al., J Abnormal Psych, 2002)
A
C
.58*
A
C
.62* .25
E
.71*
Conduct
Disorder
Adult Antisocial
Behavior
0
.43*
Externalizing
.78*
0
0
.90*
N = 1,252
o &o
+
(MTFS Mz & Dz
twin pairs)
E
A
.51*
C
.63*
Alcohol
Dependence
.58* .36
E
A
.20
C
Drug
Dependence
.57* .36
E
-.47*
A
.30
C
MPQConstraint
.63* .61*
E
A
0
C
.64*
E
Implications
 Etiology of the general vulnerability (externalizing) is mostly
genetic
– the vulnerability, not its specific manifestation, is heritable
– externalizing vulnerability factor represents a crucial target for biobehavioral research
 Environment is also very important
– main determinant of distinct manifestations = nonshared environment
– however:
– shared environment contributes to CD
– Kendler et al. (2003): evidence of specific genes for alc/drug
 Disinhibitory personality style is also an indicator of
externalizing
– spectrum transcends traditional “normal-abnormal” distinction
What Genes Underlie General Externalizing
Vulnerability?
• Dick et al. (Arch Gen Psychiatry, in press): Linkage
analyses using Externalizing component scores
yielded evidence of a predisposing role for CHRM2—
a muscarinic acetylcholine receptor gene previously
linked to alcohol dependence.
• Dick et al. (Curr Dir Psy Sci, in press): reviewed
evidence that GABRA2, a GABA-A receptor gene on
chromosome 4, is also involved—shows associations
with multiple externalizing disorders.
Outline:
1. Background: Dual Process Model of Psychopathy
- fearlessness, externalizing vulnerability
2. The Externalizing Spectrum
a.
b.
c.
d.
Etiologic basis
Hierarchical model
Brain mechanisms
Links to other problem domains
3. Clinical Implications
Modeling the Externalizing Spectrum
(Krueger, Markon, Patrick et al., J Abnormal Psych, 2007)
• used item response theory (IRT) and confirmatory factor
analysis (CFA) to model the scope and structure of traits &
behaviors reflecting poor impulse control
• developed self-report scales to index a wide array of target
constructs distilled from DSM disorder criteria & other
relevant content domains in the literature
• candidate items and scales were refined across 3 iterative
rounds of data collection and analysis
- overall N = 1,787 (~50:50 male/female; ~50:50 prisoners/
students)
Incarcerated Populations:
- high base rates of: antisocial behavior,
alcohol dependence, drug dependence
(often severe & co-occurring).
Implication: High externalizing individuals
are prevalent in prison settings.
- inclusion of offenders & college students
provides for sampling/modeling of the full EXT
continuum.
Procedure
• Began each wave with mid-level targeted domains
– e.g., aggression, impulsivity, drug use & problems
• Identified unidimensional subfactors within each domain
– Exploratory Factor and Cluster Models
• Used Item Response Theory (IRT) modeling to identify
desirable items for each subfactor
– Desirable items are discriminating and, as a set, provide good
information across a wide range of a dimension
– New items were written in each wave to cover gaps in measurement
– Samejima graded response model fit using MULTILOG
Example: IRT information curves for Destructive Aggression
scale items (e.g., “I have damaged someone’s things because it was exciting.”)
Final Externalizing Inventory
• 23 unidimensional scales comprising a total of 415 items
– scales consist of 9 – 31 items; each indexes a specific expression
(facet) of externalizing as a dimensional construct
– good information coverage and corresponding reliabilities
(ρs = .80-.98, where ρ is proportion of observed trait estimate variance
due to latent trait variance)
Externalizing Inventory Scales: Sample Items
Aggression:
- Relational: "I've made a fool of someone because it made me feel good."
- Physical: "One or more times in my life, I have beaten someone up for bothering me."
- Destructive: "I vandalized someone's house or things because they were rude to me.“
Empathy: "It doesn’t bother me to see someone else in pain." (-)
Blame Externalization: “I get unfairly blamed for things.”
Alienation: "People have avoided blame by taking advantage of me."
Alcohol:
- Use: "A little alcohol makes a good time even better."
- Problems: "People have told me they're worried about my drinking too much alcohol."
Marijuana:
- Use: "I have rolled a marijuana joint."
- Problems: "My marijuana use has led to problems at home, work, or school."
Drug:
- Use: "I don't like being around people who are using drugs." (-)
- Problems: "At some point in my life, I couldn't get high from a drug dose that worked before."
Externalizing Inventory Scales: Sample Items
Impulsiveness:
- Planful Control: "I think about things before I do them."
- Impatient Urgency: "I have a hard time waiting patiently for
things I want. "
- Problematic Impulsivity: "I have lost valuable goods or money
because I decided things too quickly. "
Theft: "I have broken into a house, school, or other building."
Fraud: "I have lied to get benefits I didn’t deserve. "
Honesty: "I tell the truth whenever others are involved."
Irresponsibility: "I've missed a rent or mortgage payment."
Dependability: "I let others know if I’m running behind."
Rebelliousness: "Many people consider me a rule breaker."
Excitement Seeking: "I seek out thrills almost everywhere I go. "
Boredom Proneness: "I often get bored quickly and lose interest."
Externalizing Inventory: Scale Structure
Exploratory Factor Analyses of these 23 scales suggested
– Dominant first factor
– Residual factors involving
• Callous aggression
• Substance problems
More formal Confirmatory Factor models were fit using
semi-parametric maximum-likelihood estimation
– Information theoretic (“goodness of fit”) indices showed best fit
for a hierarchical model…
Sample Hierarchical Factor Model
Note: Hierarchical model is suggested when eigenvalues from an
exploratory factor analysis reveal one large dominant factor on which all
variables load, along with smaller factors on which some scales also load.
λ1
λ2
λ3
Irresponsibility
.925
.000
-.011
Dependability
-.661
-.152
.000
Problematic Impulsivity
.913
.000
-.036
Impatient Urgency
.726
.215
.000
Planful Control
-.661
-.074
.000
Theft
.872
.000
.129
Alienation
.487
.012
.000
Blame Externalization
.508
.238
.000
Relational Aggression
.619
.676
.000
Destructive Aggression
.654
.551
.000
Physical Aggression
.740
.412
.000
Empathy
-.482
-.554
.000
Excitement Seeking
.555
.457
.000
Rebelliousness
.794
.305
.000
Boredom Proneness
.593
.283
.000
Honesty
-.541
-.305
.000
Fraud
.870
.264
.000
Marijuana Use
.727
.000
.613
Marijuana Problems
.751
.000
.476
Other Drug Use
.790
.000
.490
Other Drug Problems
.870
.000
.303
Alcohol Use
.449
.000
.357
Alcohol Problems
.690
.000
.237
Externalizing Scale
Implications
 Impulse control problems and disinhibitory personality traits
are indicators of a broad underlying dispositional dimension
(EXT)
– individuals low in EXT exhibit minimal impulse control problems
– individuals high in EXT exhibit severe, co-occurring impulse control
problems
 Broad EXT factor represents a coherent, largely genetic
vulnerability to problems of this kind (Krueger, Hicks, Patrick et
al., 2002)
– however, other independent factors operate to shape the specific
expression of this general propensity in the direction of:
1) Aggression 2) Addictive behaviors…
EXTAggression vs. Addictions:
Determinants?
Aggression:
- role of specific environmental pathogens?
(e.g., early abuse; Caspi et al., 2002, Science)
Addictions:
- evidence for distinct genetic influences (Kendler et al.,
2003, Arch Gen Psychiatry)…
• e.g., proneness to dopamine system sensitization?
(Robinson & Berridge , 2003, Ann Rev Psych)
Outline:
1. Background: Dual Process Model of Psychopathy
- fearlessness, externalizing vulnerability
2. The Externalizing Spectrum
a.
b.
c.
d.
Etiologic basis
Hierarchical model
Brain mechanisms
Links to other problem domains
3. Clinical Implications
Neurobiology of the broad EXT factor
Question: What is the underlying psychological
and neurobiological basis of EXT (i.e., the general
propensity toward impulse control problems?)
Hypothesis: Impairments in cognitive-executive
functioning mediated by anterior brain systems
(including PFC, ACC)
Evidence: Reduced event-related brain response in
tasks involving on-line stimulus processing and
action monitoring…
EXT is associated with reduced P300 brain response
n = 969 o
twins
Patrick, Bernat et al.
(Psychophysiology, 2006)
Moreover: EXT/P300 association is mediated by genes (Hicks, Bernat,
Malone, Iacono, Patrick et al., Psychophysiology, 2007)
Error-Related Negativity (ERN)
• Anterior scalp potential that occurs
following behavioral errors in a speeded
performance task.
• Believed to reflect the activity of an on-line
response monitoring system within the
brain, which operates to detect errors and
prompt corrective action.
• Source localization and brain imaging work
indicates that anterior cingulate cortex
(ACC) is the primary generator.
*EXT is associated with reduced ERN response
(Hall, Bernat, & Patrick, Psych Science, 2007)
*EXT measure = overall EXT-100 screening Q scores
Amplitude of Error-Related Negativity (ERN), by EXT group
(n = 36)
(n = 28)
Key Follow-up Findings:
• P300 reduction for EXT is pervasive across
task stimuli (target, flanker, novel, feedback).
• P300/EXT relation is maximal at frontal sites.
• Positive slow wave ERP to novel affective
stimuli is not reduced in high EXT individuals.
• ERN-like response to explicit loss feedback
is not reduced in high EXT individuals—
although subsequent P300 response to
same feedback stimulus is reduced…
Loss Feedback Response by Externalizing
(Bernat et al.,
submitted)
Interpretation of ERP findings to date:
• most real-life contexts: processing occurs in
parallel along 2 streams—a ‘lower’ stream along
which immediate stimulus features are processed,
prompting actions as required; and a higher
stream along which deeper elaborative
processing occurs.
We hypothesize that this higher stream …
• involves comparing and integrating transient
cognitive/affective representations with
representations stored in long-term memory.
• is instantiated by anterior brain regions including
PFC & ACC.
• is fundamental to anticipation, reflection, and
self-regulation.
Hypothesis for Externalizing:
• lower (immediate stimulus) processing,
including coding of explicit affect cues, is
intact…
• …but high EXT is marked by an impairment in
higher elaborative processing of stimuli and
events.
- specifically: an impairment in a natural form of
extended working memory (cf. Ericsson & Kinsch,
1995), involving representations of distal goals and
consequences, that subserves adaptive behavior.
Outline:
1. Background: Dual Process Model of Psychopathy
- fearlessness, externalizing vulnerability
2. The Externalizing Spectrum
a.
b.
c.
d.
Etiologic basis
Hierarchical model
Brain mechanisms
Links to other problem domains
3. Clinical Implications
What other problem behaviors might
represent expressions (facets) of EXT?
• ADHD (conduct DO subtype)
• pathological gambling
• nicotine dependence
• reactive (impulsive) aggression
… suggested by clinical and
epidemiological studies.
Internalizing vs. Externalizing subtypes?
EXT as a key contributor to, or moderator of, clinical
presentation…
• PTSD (Miller et al., Psy Assess, 2003; JAP, 2004)
• suicidality (Verona, Sachs-Ericsson, & Joiner,
Amer J Psychiatry, 2004)
• borderline personality DO?
- border of INT & EXT (vs. neurosis & psychosis)
• compulsive sexual behavior?
• eating disorders?
Psychopathy and Externalizing:
Hare’s Psychopathy Checklist-Revised
Emotional-Interpersonal
Antisocial Deviance
• charm, grandiosity
• child behavior
• lying, manipulation
problems
•
remorse
• juvenile delinquency
•
emotional depth
• boredom, impulsivity
•
empathy
• irresponsibility
• violent behavior
Modeling the Relation between Psychopathy & Externalizing
(Patrick et al., J. Personality Disorders, 2005)
testlet 1
testlet 2
testlet 5
.64*
testlet 6
testlet 3
testlet 4
PCL-R Factor 1
(Emot-Interp)
PCL-R Factor 2
(Beh Deviance)
N = 219
o federal
prisoners
.78*
Adult Antisocial
Behavior
testlet 8
.94*
-.16
testlet 7
Externalizing
.63*
Conduct
Disorder
.37*
Alcohol
Use/Abuse
.52*
-.35*
Drug
Abuse
MPQConstraint
Outline:
1. Background: Dual Process Model of Psychopathy
- fearlessness, externalizing vulnerability
2. The Externalizing Spectrum
a.
b.
c.
d.
Etiologic basis
Hierarchical model
Brain mechanisms
Links to other problem domains
3. Clinical Implications
Implications for Clinical Case Conceptualization:
• Use this model to rework classification and
conceptualization of externalizing problems
– Spectrum transcends literatures and sections of DSM
– Spectrum transcends
• “Axis I” or “clinical disorders”
• and “Axis II” or “personality disorders”
• New way of thinking about the issue of comorbidity:
– comorbidity = diagnostic noise, but rather systematic
covariation reflecting underlying level of vulnerability
• Relevant to both research and front-line clinical work
– Focus clinical case conceptualization and research design
on both
• unifying dimension and
• distinctive manifestations (facets)
Implications for Assessment:
Externalizing Inventory provides for fine-grained (IRTbased) assessment of:
1) Broad Externalizing (EXT) Factor
- general liability underlying various
types of problems
2) Specific facets
- distinctive phenotypic expressions
Profile of scores (EXT factor, Agg/Add subfactors, specific
facets) vs. binary diagnotic classification.
- e.g., high alcohol problems score would have differing
implications if patient was low vs. high on broad EXT factor
Implications for
Treatment
Summary:
Distinctive components of psychopathy
reflect different underlying mechanisms:
1) Weak defensive system (low “trait fear”)
- associated with traits of high dominance and low
distress, fearfulness, depression.
- associated with lack of fear-potentiated startle.
2) High “Externalizing” vulnerability
- associated with traits of impulsivity,
irresponsibility, alienation, and aggression.
- associated with weak frontal-executive
function but normal emotional reactivity.
In children as young as 4-5 years:
Psychopathy is also manifested in terms of
distinctive components:
Callous-unemotional features:
narcissism, lack of normal affect
Impulsive conduct problems:
externalizing tendencies
(e.g., work of Paul Frick,
Essi Viding, etc.)
Implications for Treatment:
1) Multiple targets for intervention
General Externalizing (EXT) Factor:
- target impairments in impulse control,
emotion regulation; alienation, urges
- e.g., pause & reflect; detect emotional
arousal; reframe interactions; interrupt urges
- external feedback is crucial; but for
effects to persist, need to enhance deeper
processing activity (e.g., “brain training”).
- role for medications (e.g., methylphenidate,
phenytoin: normalize P300 in high-EXT individuals)
Multiple targets for intervention
- separate from general EXT factor,
target residual factors that contribute to:
Aggressive Behaviors
- callousness/thrill-seeking; overlap with
Emotional/Interpersonal factor of psychopathy?
Addictions
- reward-seeking factor? (need for specialized
interventions?)
• also: may need to target distinctive contributing/maintaining factors associated
with specific expressions of EXT (e.g., alcohol vs. drug vs. nicotine dependence)
Multiple targets for intervention
Emotional/Interpersonal features of psychopathy:
- obstacle to treatment: low distress/
dissatisfaction; dominant, manipulative
- evidence that traditional treatments may
enhance recidivism (cf. Harris & Rice, 2006)
- alternative approaches needed:
. behavioral: modify expression of agentic
(controlling/manipulative) tendencies?
. drugs: enhance negative emotional
reactivity/sensitivity?
Other ideas?
Implications for Treatment:
2) Emotion/motivation vs. cognition
Need to consider underlying motivations for
behavior:
e.g., anger/revenge vs. stress reduction
agency/control vs. boredom vs. addictive
cravings
vs.
Emotion lies closer to action than
cognition (e.g., Lang; LeDoux; Berridge).
Implications for Treatment:
3) Different interventions required
for different subgroups of “dangerous”
offenders with differing underlying
motivations…
PCL-R Psychopathy
Subtypes
(Hicks, Markon, Patrick et al., 2005)
Identifying Psychopathy Subtypes using
Model-Based Cluster Analysis
• Study sample = 96 criminal psychopaths
(PCL-R Total score > 30).
– also: 125 nonpsychopathic control prisoners
(PCL-R score < midpoint for Total and each
Factor)
• Cluster analysis variables: trait scales of the
Multidimensional Personality Questionnaire
(MPQ; Tellegen, in press)…
Multidimensional Personality Questionnaire (Tellegen, in press)
Positive Emotionality
(PEM)
effectance
Social Potency
Achievement
affiliation
Well Being
Social Closeness
Negative Emotionality
(NEM)
Stress Reaction
Alienation
Aggression
Constraint
(CON)
Control
(vs. Impulsivity)
Harm Avoidance
Traditionalism
Data Analysis
• employed model-based cluster analysis
to test for the presence of subtypes in
the psychopath sample using the MPQ
primary scales as cluster variables
• provides a quantitative (“goodness of
fit”) criterion for determining the # of
clusters and their parameters
Type I Psychopath: “Emotionally Stable Type”
• MPQ trait correlates reflect boldness and
resiliency:
– immune to negative events (low Stress
Reaction)
– socially dominant, ambitious (high PEMEffectance)
• The “classic” (primary) psychopath—cf.
Cleckley’s Mask of Sanity?
- may appear well-adjusted in some contexts
(e.g., occupations that require autonomy and
coping with stressful circumstances)
Type II Psychopath: “Externalizing Type”
• MPQ trait and external correlates consistent
with high externalizing:
–
–
–
–
aggressive, alienated, & stress reactive (high NEM)
poor impulse control (low Constraint)
lacks close social relations (low Communal-PEM)
earlier crime, lower So, > fights, > alcoholism
• Adult manifestation of the early onset, life
course persistent offender (Moffitt, 1993)?
Cortical Reactivity
Dual Process Model
of Psychopathy:
Psychopathy
Trait Fear
Blink Startle
The End
Krueger (Archives of General Psychiatry, 1999):
- factor analyzed DSM diagnostic data from the NCS (N =
8,098 men and women).
- found 2 general factors that accounted for systematic comorbidity among the most common DSM disorders:
1) Internalizing factor: anxiety disorders, mood
disorders
2) Externalizing factor: antisocial personality disorder,
alcohol dependence, drug dependence
Note: These two general factors were positively correlated
(~ .5).