Out of everyone, Martens seems to understand us. Perhaps he is one of us…
Emotional Capacities and Sensitivity in Psychopaths
Willem H. J. Martens, MD, PhD
Director of the “W. Kahn Institute of Theoretical Psychiatry and Neuroscience.”
Beatrixstraat 45, 3921 BN Elst Utrecht, The Netherlands
Although psychopaths demonstrate emotional abnormalities such as shallow affect, lack of empathy, incapacity for love, lack of guilt or remorse, lack of fear, and emotional processing and response deficiencies they may show normal emotional responses or emotional hypersensitive in other areas. The correlates of emotional incapacities, emotional hypersensitivity, and normal emotional activities in psychopaths are studied and discussed in this paper. Emotional hypersensitivity might be linked with: a history of neglect, rejection and abuse; insult; changes which are forced or not under control of the psychopath; obstacles that prevent the psychopath to do what he or she wants to do; narcissistic injury; broken friendships or relationship. Normal emotional functioning might be associate with grief, warm relationship, adequate attention, disease, academic and/or occupational success, impressive events, confrontations, contemplation and maturation, hidden suffering (also as a result of neurobiological determination).
According to Cleckley (1984) the psychopath is able to reproduce the “pantomime” of emotions, without experiencing the emotions itself. But, the author suggests that adequate reproduction of pantomime of emotions requires understanding of the meaning and logic of emotions in specific contexts, and that this is quite remarkable for someone who is not experiencing the emotions itself. The processing of emotional expressions is fundamental for normal socialization and interaction. Adequate emotional functioning requires a) self-consciousness, b) a Self that evaluates changes by means of self-observation and reflection, and c) a cognitive ability to observe, discern, associate, compare, and revoke (Hales et al., 1994). Emotional condition refers to internal processes, which are connected with somatic and physiological activity. It correlates also with observable changes in face, voice, body and activity levels that occurs when the central nervous system is activated by emotional salient stimuli (Lewis & Michelson, 1983). Psychopathy is characterized by emotional deficiencies and correlated neurobiological dysfunctions (Martens, 2002), and abnormal internal and intrapsychic processes (Martens, 1997, 2002c), and severe socialization problems (Martens, 2000; Cleckley, 1984). Martens (1997, 2000) revealed that a history of rejection; neglect; physical and sexual abuse; parental antisocial behavior, – substance abuse, and – divorce; adoption; and a bad and unsafe neighborhood might be linked to emotional deficits in psychopaths. It is argued that different forms of aggressive emotions that are significant in psychopaths may be related to disparate facets of psychopathy such as impulsivity, irritability, social-emotional, and moral incapacities (Martens, 2003a), and that these relationships may be mediated by common dispositional factors (Patrick & Zempolich, 1998) such as negative experiences in childhood and adolescence (Martens, 1997) and neurobiological and genetic determination (Martens, 2002a).
Eidemiller & Yustitky (1987) discovered that following factors may contribute to abnormal emotional development in juvenile psychopaths a) expansion of the sphere of parental emotions, b) preference for the child qualities in an adolescent, c) lack of educational self-confidence, d) parental fear of losing the child, e) underdeveloped parental feelings, f) projection of the parent’s unwanted qualities onto the adolescent, and g) introduction of spousal conflicts into the educational sphere. Moreover, the emergence of abnormal moral emotions later in life may be linked to temperament and attachment deficiencies in early childhood of the psychopath (Saltaris, 2002).
2. Diagnostic features
Psychopathic personality disorder (PPD) has some overlap with antisocial personality disorder (ASPD) according the DSM-IV criteria of the American Psychiatric Association (1994), which is nowadays the official term, but these disorders are not synonymous (Martens, 2000). ASPD (DSM-IV, 1994) and PPD (Cleckley, 1984; Hare et al., 1990; Hare, 1991) is characterized by features like irritability and aggressiveness, impulsivity or failure to planning ahead, reckless disregard for the safety of self and others, pathological egocentricity, lack of guilt or remorse, social maladjustment, poor development of relationships, deceitfulness. Criminality is included in the criteria of ASPD but not of PPD. Furthermore, psychopathic personality disorder is characterized by following traits which do not meet ASPD criteria according the DSM-IV: inadequate motivated antisocial behavior; lack of nervousness and psychoneurotic manifestations; absence of delusions and other signs of irrational thinking; superficial charm and good intelligence; incapacity for love; specific loss of insight; unresponsiveness in general interpersonal relations; fantastic and uninviting behavior with drink and sometimes without; suicide rarely carried out; sex life impersonal, trivial, and poorly integrated; poor judgment and failure to learn from experiences (Cleckley, 1984); manipulative behavior; conning; pathological lying; grandiose sense of self-worth; need for stimulation/ proneness to boredom; shallow affect and/or callousness and lack of empathy; parasitic life-style; poor self-control; promiscuous sexual behavior; many short-term marital relationships; early behavioral problems juvenile criminality and versatility among others (Hare, 1991); poor fear conditioning (lack of fear) (Lykken 1995) and sensation seeking (Zuckerman, 1994); good reality testing ( Dorr & Woodhall, 1986; Fingarette, 1972; Martens, 1997; Wolman, 1987), and hidden suffering (Martens, 2002b).
3. Correlates of Psychopathic Emotional Incapacity
Although the precise nature of emotional deficits in ASPD and PPD is unknown (Herpertz & Sass, 2000, Herpertz et al., 2001; Martens, 1997), research indicated that these patients demonstrate abnormal emotional functioning and processing (Habel et al., 2002; Steuerwald & Kosson, 2000) such as:
· Lack of empathic emotions (Cleckley, 1984, Hare, 1991; Lewis, 1991; Martens, 1997). Empathy impairment (Blair et al., 2001b) and other (related) affective abnormalities (Kiehl et al., 2001) in psychopaths may be linked to amygdala deficiencies (Blair et al., 2001b), or to deficient or weakened input from limbic structures (Kiehl et al., 2001);
· Inappropriate emotions (Cleckley, 1984; Lewis, 1991; Martens, 1997);
· A pronounced lack of fear in response to aversive events (Herpertz et al., 2000, 2001; Martens, 2000; Patrick, 1994), which may correlate with low autonomic activity/reactivity (Blair et al., 1997; Fowles, 2000; Martens, 2000), and lesions of the dorsal hippocampus (Laakso et al., 2001);
· Difficulties in emotional processing and expressions. Psychopaths demonstrate poor control of emotional expression (Fowles, 2000), general deficit in processing affective information, regardless of whether stimuli are negative or positive (Christianson et al., 1996; Herpertz et al., 2001; Patrick et al., 1993) that manifests itself independently of affective report (Patrick et al., 1993). They show also affective imaginary deficiencies (Patrick et al., 1993, 1994), and lower generalized emotional responsivity (Day & Wong, 1996; Sutton et al., 2002) in comparison with normal controls. Sonderstrom et al., (2002) revealed neurologic determined (such as reduced frontotemporal perfusion) affective unresponsiveness (Sonderstrom et al., 2002) and/or psychophysiological determined (such as ventromedial prefrontal dysfunction) diminished emotionality (Barrash et al., 2000).
· Specific deficits in nonverbal emotional processing (Kosson et al., 2002). Psychopaths show less facial expression (Herpertz et al., 2001), and reduced responsiveness to the facial expressions of sadness and fear has been implicated in the development of psychopathy (Blair et al., 2001b; Stevens et al., 2001).
· “semantic dementia,” which is characterized by a discordance between the language values and experiential values of emotions. According to this concept, psychopaths would have an appropriate cognitive representation of the lexical meaning of emotions, but not the affective value normally attached to them (Johns and Quay, 1962). Semantic and (associated) emotional processes are dissociated in psychopaths (Patrick, 1994; Patrick et al., 1994). Kiehl et al., (1999b) revealed that psychopathy is associated with abnormal processing of semantic and affective verbal information. Louth (1998) and Blair et al. (2002) discovered that psychopaths did not differentiate, in voice emphasis, between neutral and affective words. These results could be interpreted with reference to the low-fear and violence inhibition mechanism models of psychopathy (Blair et al., 2002). Furthermore, these findings are consistent with the developing view that psychopaths are insensitive to the emotional connotations of language. In addition, their vocal characteristics may be part of a self-presentation mode designed to manipulate and control interpersonal interactions (Louth et al., 1998). Williamson et al. (1991) discovered that psychopaths extract less information from affective words than do other individuals (Williamson et al., 1991). They show also lower word responsively (Day & Wong, 1996), their lexical decisions were relatively unaffected by emotion cues, and their lexical decisions were relatively unaffected by affectively neutral word-frequency cues compared with non-psychopaths (Lorenz & Newman, 2002).
· a lack of capacity for self-dialogue (Miller, 1987; Martens, 1997), which may have adverse consequences for a) the development of morality and conscience and associated social-emotional awareness, understanding and abilities, b) evaluation of self and other people’s behavior/intentions, and emotions c) the creation of realistic image of Self and others, d) utilization of feedback of other people, e) self-control;
· Emotional deficiency which may predispose to violence in several ways (Herpertz & Sass, 2000). The author suggests that abnormal emotional functioning may be linked to significant correlates of violence such as lack of empathy, indifferent attitude, disregard of rights and safety of others, lack of emotional control and associated rage, common neurobiological determination of emotional deficiencies and violence (Martens, 2002a).
The author hypothesizes that emotional incapacities and/or shallow emotions may be the result of negative, painful experiences in the past and de-sensibilization in order to avoid further excessive suffering. In psychopaths in remission a normalization of emotional functioning (and probably associated neurobiological correlates) can be observed (Martens, 1997, 2002b). The author speculates that the patient is able to influence his or her neurobiological functioning in order to adapt it to his or her emotional needs (Martens, 2001c). Furthermore, research in remitted psychopaths discovered that emotional maturation is linked to other dimensions of maturation (social-emotional, moral, spiritual development, and growth of self-insight and authenticity), which may interrelate with relevant neurobiological processes that determine emotional capacities (Martens, 1997, 2001a, 2002b, 2003c, 2003e).
4. Dimensions of Emotional Hypersensitivity and Normal Affective Functioning in Psychopaths
Although psychopathic personality disorder is characterized by emotional deficits, there is sufficient evidence that psychopaths can be emotionally normal and/or even very sensitive in specific areas, indeed.
Hypersensitivity in psychopaths might be the result of:
Narcissistic injury (Kohut, 1971; Kernberg, 1970, 1972, 1992). Psychopathic patients show some narcissistic features (such as grandiose sense of self-worth, pathological egocentricity, lack of empathy and shallow affect, anger when other people do not want to cooperate with them), and are excessive sensitive to lack of respect or attention of others, and to other people’s doubt on or disregard for his or her uniqueness, great capacities and physical and/or intellectual attractiveness;
Rejection by other people, especially relatives, friend or partner may have very great impact on the patient’s emotional life and might bring about intense feelings distress, depression, desperation, and anger (Martens, 1997), and might be significantly involved in the etiology of psychopathy (Martens, 2000). Because many psychopaths have a history of rejection and neglect (Martens, 2000) every further rejection in their life might revive those traumatic experiences of the past, and may bring about intense anger, rage, distress and related emotions;
Changes of circumstances or events, which are not completely under control of the patients, especially when these are accompanied by restrictions. Significant changes such as divorce, incarnation or forensic psychiatric treatment may likely result in psychopathic patients in severe regression (Conacher & Fleming, 1996; Martens, 1997, van Marle, 1995), and/or aggressive acting out (Martens, 1997; van Marle, 1995). The author hypothesizes that the grandiose Self of psychopaths functions as a defense-structure, by which they can deny their dependency on other people. In uncontrollable circumstances their defense collapses, because they cannot deny their dependency on other’s anymore and might regress to a lower personality organization;
Confrontation or association with their trauma (that could be linked to a history of physical, sexual or emotional abuse), which may play a role in the etiology of their disorder. For example, dependence of an authority might be linked to traumatic experiences in some psychopathic individuals. Some psychopaths were adopted or raised by substitute parents. This experience might have been very traumatic when these substitute parents behave themselves inhuman, harsh, and abusive. When a psychopath with such experiences becomes again dependent on (for example) an employer who demonstrate some of these characteristics or who is too authoritarian her or she past traumatic experience may become vivid (Martens, 1997). It was discussed before that dependence of other people in psychopaths could bring about regression. Such a regression might be characterized by emotionally hypersensitivity, and aggressive acting out;
Unforeseen or uncontrollable external (by means of music, film, literature, impressive events) and internal (as a consequence of dreams, disease) influences may break through the psychopath’s defense against depression and anxiety. As a result of lack of experiences with processing and/or regulation of normal, wide-range emotions (as a result of chronic emotional suppression, and severe affective inhibition, incapacities and/or supercooling) “free flowing” emotions will become unbridled and turbulent and may bring about hypersensitivity and even sentimentality in psychopaths (Martens, 1997, Masters, 1993, 1995);
Long-lasting, unbearable loneliness might also bring about abnormal emotional sensitivity (Martens, 1997; Masters, 1993, 1995), because severe loneliness brings about serious emotional suffering and associated emotional awareness and stimulation in some areas. Severe loneliness may cause episodically emotional explosions such as rage because of being rejected by everyone, extreme fear for being left alone in spare moments when the patient is in company, emotional suffering because of their social-emotional limitations/incapacities, intense need for love and affection, and even sentimental feelings and compassion for and identification with their eventual victims. Dennis Nilsen was so lonely that he killed for company. He talked with and watched TV with the dead bodies, and he wrote poems for them (Masters, 1995);
Normal, healthy sensitivity may be brought about by:
Grief. Death of a friend, relative or partner (Martens, 1997) or other beloved persons may bring about by the psychopath guilt, self-reflection, and social-emotional and moral maturation. For example, the author observed this development in a forensic psychiatric patient who was divorced from his wife because of his irresponsible and unreliable behavior. This man lost his 14 years old sun who died in a traffic accident. As a reaction to this event he felt for the first time since his forensic psychiatric residence guilty for his selfish and irresponsible life-style and he realize that could never redeem his errors for his son. As a response he became very motivated to change his attitude and he gradually recovered and demonstrated remarkable emotional, and associated social and moral maturation;
Impressive events such as confrontation with fellow-patients (Martens, 1997, 2000, 2001b) that may stimulate social-emotional development, because these events may awake their a) awareness of their social-emotional incapacities and related problems and social isolation, b) and motivation to change;
Long-lasting, warm relationships (Martens, 1997; McCord & McCord, 1956) that form a healthy basis of attachment, and development of trust, loyalty, sympathy, empathy and other emotions, which in turn may be paired with elimination of pathological anger and hostility in these patients;
Getting adequate attention. As a result of adequate attention the psychopath gets out of his or her isolated social-emotional and moral world, and he or she is invited to start real interaction with the other who provides attention. As a result of this interaction the patient might develop, show and cherish normal emotions (Martens, 1997). They feel gradually more comfortable and in safe hands and are willing to become normal.
Disease (Black et al., 1995, Robins, 1966). A serious or chronic disease will likely bring about a radical change in the psychopath’s life and attitude. Serious disease might be paired with substantial physical limitations that may prevent a range of antisocial behaviors. As a consequence some psychopaths may become more contemplative (Martens, 1997). As a result of these changes their social-emotional attitude may change too;
Hidden suffering as a result of the unbridgeable gap between themselves and the rest of the world (Martens, 2002b). The hidden suffering makes social-emotional growth possible because the pain may provoke radical solutions of crucial social-emotional problems and associated transformation of antisocial into social features;
Academic and/or occupational success (Martens, 1997; Robins, 1966), because such success may be easily accompanied with a growth of self-esteem, positive feedback and pro-social experiences, increase of social-emotional interaction skills, and development of positive coping;
Consideration of the spoiled changes (partly as a consequence of their abnormal neurobiological functioning, see Martens, 2000, 2001c, 2002a) and reflection on impulsive, sensation seeking, restless, reckless, irresponsible and harmful lifestyle (Martens, 2002b, 2003a, c, d, e). This may result in a) a motivation to change attitude and consequently b) development of social-emotional and moral capacities;
Burned-out syndrome in many aged psychopaths (Martens, 1997, Davidson & Neale, 1994). Many aged psychopaths are unable to continue their former energy-spoiling life-style. Furthermore, this burned-out syndrome might be associated with age-related neurobiological changes and/or maturation that may determine (in combination with stimulating psychosocial factors and growing self-insight) social-emotional development;
Recovery, improvement and correlated increase of moral-emotional (Martens, 2001a, 2003b), social-emotional and/or spiritual-emotional (Martens, 2003c) awareness and capacities;
Good or bad luck (Martens, 1997). Every development of social-emotional capacities is dependent of favorable or unfavorable influences. The author observed some very motivated patients whose therapeutic progression was undermined by bad luck (disturbing influences of fellow-patients, fatal change of therapist or mentor, release before treatment program was completed). On the other hand, he observed in “untreatable” and unmotivated psychopaths remarkable improvement and even remission as a result of unexpected friendships, confrontations with fellow-patients/offenders, disease, death of a partner, and so on (Martens, 1997);
Psychopathy is diagnostically characterized by serious emotional deficiencies, which may interrelate with other diagnostic features such as incapacitiy for love, lack of empathy, shallow emotions, social-emotional incapacities (lack of interactional skills), pathological egocentricity, grandiose sense of self-worth, irresponsibility, impulsivity, and aggression. Despite their disturbed emotional world some psychopaths may exhibit normal emotional experiences such as normal feelings for pets, relatives, art, sports, and so on. In current and past studies the healthy aspects of emotional life in psychopaths are underexposed. It is, however of major interest to examine the etiological, psychosocial, neurobiological correlates, conditions of normal emotional functioning in different categories of psychopaths, and in what particular circumstances it can happen and flourish. It could be useful for the psychotherapist to direct towards these healthy emotional elements and try to expand or relate them to other emotional and related social and moral areas.
Emotions are hardly objectively measurable, and it is possible that psychopaths “emotional incapacities” in some cases could be better explained as fundamental different emotional functioning rather than emotionally “inferior” or affectively “cold.” Furthermore, there is some evidence that not all “pure” psychopaths demonstrate abnormal emotionality (Martens, 1997). Clear psychopaths (PCL-R scores between 30 and 40) do not necessarily meet all diagnostic features (Hare, 1991), and may show normal emotions. And some psychopaths report that they have normal emotional experiences, while they are unable to show affections (Martens, 1997). This may lead to observations of “shallow” emotions.
More research is needed into effective therapeutic stimulation of emotional development in distinctive categories psychopaths, such as violent non-sexual, violent sexual, frauds, and non-violent and non-criminal psychopaths, which are characterized by their own specific emotional abnormalities which are linked to their crimes and/or personality/behavior patterns (Martens, 1997).
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