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Focusing on violence from assessment, through underlying neurobiology, to treatment and other recommendations for practice, this book will be of interest to forensic psychiatrists, general adult psychiatrists, psychiatric residents, psychologists, psychiatric social workers and rehabilitation therapists.
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A catalog record for this publication is available from the British Library
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Chapter 27 The appropriateness of treating psychopathic disorders Alan R. Felthous
Owing to their assaultive, destructive, and other antisocial acts, individuals with psychopathic disorders inflict untold harm on themselves, acquaintances, and strangers. The damage they inflict and the attempts at safe management by the criminal justice system amount to considerable economic cost to society. Yet the fatalistic conventional wisdom is that no treatment is effective for psychopathic disorders. From this perspective, efforts at treatment are counterproductive and a misuse of limited resources. Attempts to treat and cure the core defect of psychopathy may be futile in light of current medical and behavioral science.
Here the term “psychopathic disorders” is used with the same meaning as that in the comprehensive handbook on the topic [1,2]. The term follows “both taxonomical and dimensional approaches” and includes “diagnostic conditions characterized by antisocial behaviors,” but not “all antisocial or criminal behaviors regardless whether a disorder exists.” More specifically, psychopathic disorders include the Hare psychopathy concept and antisocial personality disorder (APD), as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), now in the fifth edition (DSM-5) [3]. In identifying psychopathic disorders, most of the studies cited in this review relied on either a version of the Psychopathy Checklist or an edition of the DSM diagnostic manual.
The treatment of psychopathic disorders is not so much different from other chronic mental disorders, such as schizophrenia for example. The pathogenesis of the “core defect,” if there is a single underlying defect, is neither fully understood nor curable by current therapeutic modalities. Yet with remarkable success, the more salient and disturbing symptoms of schizophrenia are treated, often with substantial improvement in overall functioning. If, instead of seeking to eliminate or overcome the “core defect” of psychopathy, treatment were to target specific troublesome cognitive, emotional, or behavioral symptoms, enough improvement might be attained to make treatment appropriate and worth the effort.
Reviewers who address the effectiveness of treating psychopathic disorders typically compare outcomes to programmatic approaches. Programs are different, psychopathic disorders vary in characteristics and severity, and follow-up treatment upon completing a given program is often lacking. Unsurprising then, studies produce apparently contradictory results, and reviews result in uncertain conclusions. After a brief summary of reviews of treatment programs, this article’s main focus is on evidence-based pharmacotherapy of the impulsive aggression of psychopathic disorders. To be noted is that outcome studies of treatment programs do not include pharmacotherapy of specific domains of psychopathy as part of the treatment and analysis of effectiveness.
The main focus here will then be on the pharmacotherapy of impulsive aggression, for which evidence-based effectiveness has been demonstrated even within the pathological context of a personality or psychopathic disorder. Whether impulsive aggression is a co-occurring condition (i.e., intermittent explosive disorder), a direct manifestation of the psychopathic disorder for which it is a diagnostic criterion, or a “domain” of the disorder may be more of a semantic or conceptual than a therapeutically practical distinction. At any rate, effective treatment ought not to be withheld because the patient also meets criteria for a psychopathic disorder, such as APD as delineated in (DSM-5) [3].
Mario Amore
Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health, University of Genoa, Genoa, Italy
Allen Azizian
Coalinga State Hospital, Coalinga, and Department of Criminology, California State University, Fresno, California, USA
Shannon M. Bader
California Department of State Hospitals, and Patton State Hospital, California, USA
Michael W. Barsom
Department of State Hospitals (DSH) – Metropolitan, Norwalk, California, USA
Nicole R. Bartholomew
Psychology Services, Federal Bureau of Prisons, Big Spring, Texas, USA
Amlan Basu
Broadmoor High Secure Hospital, West London Mental Health NHS Trust, and Institute of Psychiatry, King’s College, London, UK
Charles Broderick
California Department of State Hospitals, Sacramento, California, USA
Rosalie S. Brooman-White
Medical Sciences Division, John Radcliffe Hospital, University of Oxford, Oxford, UK
Darcy Brown
The School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
Leslie Citrome
Department of Psychiatry and Behavioral Sciences, New York Medical College, Valhalla, New York, USA
Emil F. Coccaro
Clinical Neuroscience & Psychopharmacology Research Unit, Department of Psychiatry (MC#3077), Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
Michael A. Cummings
Department of State Hospitals–Patton, Department of Psychiatry, Patton, California, USA; Department of Psychiatry and Human Behavior, University of California, Irvine, Orange, California, USA
Stephen E. Cummings
Department of Psychiatry, San Mateo Medical Center, San Mateo, California, USA
Pál Czobor
Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
Laura J. Dardashti
California Department of State Hospitals, and Metropolitan State Hospital, California, USA
Mrigendra Das
Broadmoor Hospital, West London Mental Health Trust, Berkshire, amd School of Psychiatry, Oxford Deanery, Oxford, UK
Darci Delgado
California Department of State Hospitals, and Vacaville Psychiatric Program, California, USA
Sean E. Evans
Psychology Department, Department of State Hospitals, Patton, California, and Psychology Department, La Sierra University, Riverside, California, USA
Thomas Fahy
Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
Jennifer R. Fanning
Clinical Neuroscience & Psychopharmacology Research Unit, Department of Psychiatry (MC#3077), Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
Alan R. Felthous
Division of Forensic Psychiatry, Department of Neurology & Psychiatry, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
E. Fuller Torrey
Department of Psychiatry, Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland, USA; Stanley Medical Research Institute, Chevy Chase, Maryland, USA
David Goldman
Laboratory of Neurogenetics, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
Jordan H. Grafman
Rehabilitation Institute of Chicago, Chicago, Illinois, USA
Nitin Gupta
Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
Margaret Guyer
Central Office Research Review Committee, Massachusetts Department of Mental Health, Massachusetts Mental Health Center Division of Public Psychiatry, and Harvard Medical School/Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
Colin A. Hodgkinson
Laboratory of Neurogenetics, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
Brian J. Holoyda
Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, Sacramento, California, USA
Matthew J. Hoptman
Schizophrenia Research Division, Nathan Kline Institute for Psychiatric Research, Orangeburg, Department of Psychiatry, New York, USA, and University School of Medicine, and Department of Psychology, City University of New York, New York, USA
Deborah Horowitz
Office of Training and Development, Massachusetts Department of Mental Health, Westborough, Massachusetts, USA
James E. Hotham
Medical Sciences Division, John Radcliffe Hospital, University of Oxford, Oxford, UK
Sharon A. Humphreys
Broadmoor High Secure Hospital, West London Mental Health NHS Trust, London, UK
James L. Knoll IV
Division of Forensic Psychiatry, Department of Psychiatry, SUNY Upstate Medical University, Syracuse, New York, USA
Rebecca Kornbluh
California Department of State Hospitals, Sacramento, California, USA
Frank Krueger
Molecular Neuroscience Department, George Mason University, Fairfax, and Department of Psychology, George Mason University, Fairfax, Virginia, USA
Fintan Larkin
Broadmoor Hospital, West London Mental Health Trust, Berkshire, UK
Royce Lee
Clinical Neuroscience & Psychopharmacology Research Unit, Department of Psychiatry (MC#3077), Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
K. Luan Phan
Department of Psychiatry, University of Illinois College of Medicine, Mental Health Service Line, Jesse Brown Veterans Administration Medical Center, and Departments of Psychology, and Anatomy and Cell Biology, University of Illinois at Chicago, Chicago, Illinois, USA
Barbara E. McDermott
Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, Sacramento, California, USA
Jonathan M. Meyer
Department of Psychiatry, University of California–San Diego, San Diego, California Department of State Hospitals, and Patton State Hospital, California, USA
John Monahan
School of Law, University of Virginia, Charlottesville, Virginia, USA
Robert D. Morgan
Department of Psychological Sciences, Texas Tech University, Lubbock, Texas, USA
Debbi A. Morrissette
Neuroscience Education Institute, Carlsbad, California, Department of Biology, California State University, San Marcos, California, and Department of Biology, Palomar College, San Marcos, California, USA
Jennifer A. O’Day
California Department of State Hospitals, and Metropolitan State Hospital, California, USA
Mark E. Olver
Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
Matteo Pardini
Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health, and Magnetic Resonance Research Centre on Nervous System Diseases, University of Genoa, Genoa, Italy
Debra A. Pinals
Law and Psychiatry Program, Department of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts, USA
George J. Proctor
California Department of State Hospitals, and Patton State Hospital, California, USA
Cameron D. Quanbeck
Department of Psychiatry, San Mateo Health System, San Mateo, California, USA
Vanessa Raymont
Department of Medicine, Imperial College London, London, UK
Phillip J. Resnick
Division of Forensic Psychiatry, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
Jose L. Romero-Ureclay
Broadmoor Hospital, West London Mental Health Trust, Berkshire, UK
Benjamin Rose
California Department of State Hospitals, and Napa State Hospital, California, USA
Daniel R. Rosell
Department of Psychiatry, Icahn Medical School, Mount Sinai, New York, and Special Evaluation Program of Mood and Personality Disorders, Icahn Medical School, Mount Sinai, New York, USA
Callum C. Ross
Broadmoor Hospital, West London Mental Health Trust, Berkshire, UK
Kathy Sanders
Clinical and Professional Services, Massachusetts Department of Mental Health, and Harvard Medical School/Massachusetts General Hospital, Boston, Massachusetts, USA
Robert J. Schaufenbil
California Department of State Hospitals, Sacramento, California, USA
Marie Schur
California Department of State Hospitals, and Atascadero State Hospital, California, USA
Eric H. Schwartz
California Department of State Hospitals, and Vacaville Psychiatric Program, California, USA
Charles L. Scott
Division of Psychiatry and the Law, Department of Psychiatry and Behavioral Sciences, University of California–Davis School of Medicine, 5 Sacramento, California, USA
Samrat Sengupta
Broadmoor Hospital, West London Mental Health Trust, Berkshire, UK
Larry J. Siever
Department of Psychiatry, and Special Evaluation Program of Mood and Personality Disorders, Icahn Medical School, Mount Sinai, New York, and Department of Psychiatry and the VISN3 Mental Illness Research, Education, and Clinical Center (MIRECC), James J. Peters VA Medical Center, Bronx, New York, USA
Patrick J. D. Simpson
Medical Sciences Division, John Radcliffe Hospital, University of Oxford, Oxford, UK
Jennifer L. Skeem
School of Social Welfare & Goldman School of Public Policy, University of California–Berkeley, Berkeley, California, USA
Stephen M. Stahl
California Department of State Hospitals, Sacramento, University of California San Diego, California, USA, and University of Cambridge, Cambridge, UK
Maren Strenziok
Department of Psychology, George Mason University, Fairfax, Virginia, USA
Katalin A. Szabo
Department of Psychiatry, San Mateo Health System, San Mateo, and Behavioral Health and Recovery Services, San Mateo, and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
John Tully
Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
Richard A. Van Dorn
Research Triangle Institute International, Research Triangle Park, Durham, North Carolina, USA
Susan Velasquez
California Department of State Hospitals, and Patton State Hospital, California, USA
Morris Vinestock
Broadmoor Hospital, West London Mental Health Trust, Berkshire, UK
Jan Volavka
Department of Psychiatry, New York University School of Medicine, New York, USA
Raziya S. Wang
Behavioral Health and Recovery Services, San Mateo, California, USA
Katherine D. Warburton
California Department of State Hospitals, Sacramento, and Division of Psychiatry and the Law, University of California, Davis, California, USA
Eric M. Wassermann
Behavioral Neurology Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
Christopher L. White
Department of Psychiatry, San Mateo Health System, San Mateo, and Behavioral Health and Recovery Services, San Mateo, California, USA
Stephen C. P. Wong
Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada, School of Medicine, University of Nottingham, Nottingham, UK, and Centre for Forensic Behavioural Science, Swinburne University of Technology, Melbourne, Australia