psychopathy

The Dark Triad (Psychopathy, Narcissism, Machiavellianism), sexually violent predators, Ted Bundy, and porn.

On this week’s episode of the podcast, I interview...quite a few people! We are covering Ted Bundy, America’s most infamous serial killer, and since the world has been fascinated by him lately, I figured I’d get a group of mental health professionals in a room to talk about him. His horrific acts made the news and have scared people for decades now, and rightfully so. Did media and pornography cause this? What was his diagnosis and was it correct? We have so many questions...


As my special guests and panel of experts, I invited Dr. Tony Angelo, who is head of services for a local prison and in charge of prisoners transitioning into normal life. I also invited Dr. Randy Stinnett, a clinical psychologist who co-manages an outpatient behavioral health department in a local community health clinic. Also with me is Nathan Hoyt and Adam Borecky, 4th year medical students who will be going into psychiatry.


Traits of psychopathic antisocial behavior


Criminals like Ted Bundy are skilled manipulators. They often scope their environment to see who will be the easiest to manipulate. They will treat you like you are their long, lost friend, but everything they do is an attempt to pull you in. They “hook” you so that they can get you to do something for them.

Ted Bundy came off as friendly and charming, described as “one of us.”  A friend of his from Washington State even said, “He’s the kind of person you’d want your sister to marry.” As disturbing as this is, it is a common trait of psychopathic antisocial behavior.

Ted Bundy displayed many traits of psychopathic antisocial behavior. Some of the most recognizable traits were:

  • Viewing others as a pawn in his chess game

  • Master manipulator

  • Desire control/power

  • Sexual gratification in his choices

  • Enjoyed having an audience

  • Calculated predatory aggression

  • Strategic planning

  • Feeling that some other entity is operating inside of him

Empathy qualities:

  • Normal cognitive empathy

  • Very low affective empathy


Someone with low affective empathy will not feel your emotions or know your emotions from a mirror neuron experience. Rather he can only read facial expressions and body language without allowing cognitive but not affective empathy.  


In episode 2 of the Ted Bundy documentary on Netflix, Confessions with a Serial Killer, in his first arrest Ted Bundy said, “A funny thing happened to me on the way to labor law class. I got two weeks on the spa on the labor floor here. And, a yes, I intend to complete my legal education to become a lawyer, and be a damn good lawyer. Uh, I think things are going to work out, thats about all I can say.”


When he said this, he had a right sided smile and outwardly looked fairly happy and calm. According to studies done about microexpressions, the right sided smile is usually demonstrating contempt, but for him does not look as negative, and because in so many of his videos he has it on his face, he likely thought highly of himself and looked down on others.

I have noted that very good liars look positive, but often still leak microexpressions of very subtle negative emotion. Bundy seems to have expressed anger when he felt thwarted. In his statement, he makes a joke, yet showed a flash of fear or sadness while doing so. Bundy’s emotions of fear, anger, sadness, and pain leaked out through the microexpressions on his face, which are always a truth-telling mechanism.

Below is the quote with my inserted microexpressions in it:

“[contempt] A funny [anger] thing happened to me on the way to labor law class. I got two weeks on the spa on the labor floor here [fear or sadness]. And, a yes [contempt, sadness or fear], I intend to complete my legal education to become a lawyer, and [contempt] be a damn good lawyer [anger]. Uh [pain], I think things are going to work out [fear], thats about all I can say.”

*Note it is hard to determine exact expressions from the poor quality of this video- but my microexpression research team discussed the above and this was our consensus.  The fear or sadness comment comes from the eyebrows going up in the middle, but it is hard to determine if there is fear or sadness due to the poor quality of film.


It is believed psychopaths feel little or no fear. Did Ted Bundy feel afraid?

Most of the video of Ted Bundy did not show a physiological reaction to stress. But it is likely to some degree (although much less than others) that he experienced fear.  It is thought that those with primary psychopathy have dysfunctional emotional processing due to issues in their amygdala. Studies show they have less fear then control groups and secondary psychopaths (more the sociopath or baked ones) which have more trait anxiety or fear (Skeem, 2007).    

What was Ted Bundy’s possible diagnosis?

Primary psychopathy: These typically have low affective empathy and low fear, however not all that are primary psychopaths become criminals. They are sometimes able to still follow the rules while not having any fear or empathy and can even be prosocial.

Sociopath (or secondary psychopathy): These are typically “baked” into being anti-social. Sociopaths are typically “made” to be the way they are, often resulting from a traumatic childhood. Abuse and trauma may influence their later life ability to attach to others.  They have higher trait fear, more borderline traits and more mental disorders.

Antisocial Personality Disorder:  This is how the DSM classifies people who have a history of illegal behaviors, deceit, impulsivity, failure to plan ahead, aggressiveness, reckless disregard for safety, irresponsibility and lack of remorse.  This is usually a criminal psychopath or sociopath with repetitive crimes. They display low empathy and low connection with others. Their behavior usually results in crimes against others.  

Ted Bundy’s bipolar diagnosis:

When Ted Bundy was assessed while awaiting his death sentence, he was given a diagnosis of bipolar disorder. However, most depressed people become less violent and don’t have much of a desire to have sex. It is also interesting to note that out of all of the violent events that happen in the US, only 5% of them are due to mental illness (Stuart, 2003). Therefore, we can conclude that most violent acts are not done by people with mental illness.

Could he have been in a manic state?

Most manic states end in death, jail or psychiatric hospitalization. Ted Bundy had no record of being hospitalized in a psychiatric hospital and was only put in jail after he was caught. Bundy was also capable of living a “normal” life. He was an active citizen, joined a church, was married and involved in politics. He played these roles for years.


With mania, this would not have been possible. Those who are manic cannot stop their mania. Also, Ted Bundy displayed reason in the midst of his crimes. He covered his tracks and could pretend to be something he wasn’t. Those who are manic do not have the ability to pretend to be something they are not, nor have the ability to plan and cover up.

DSM 5 antisocial disorder:

Ted Bundy would fall more in line with a DSM 5 antisocial disorder leaning more towards primary psychopathy. With this disorder, you must be 18 years or older and have commited conduct disorder before age 15. Also prevalent is a pervasive pattern of disregard for the rights of others since the age of 15 and psychopathic manifestations. Additionally, they must meet 3 or more of the following behaviors:

  • Fail to conform to lawful behaviors

  • Deceitfulness

  • Impulsivity

  • Irritability

  • Aggressiveness

  • Reckless disregard for the safety of others

  • Irresponsibility

  • Lack of remorse

Nearly all of these traits were displayed in Ted Bundy’s pattern of behavior. Even when he was young he showed predatory aggression (which I discuss in a prior episode) when he set up tiger traps at camp and injured a young girl. Although he prayed with people before his death, Ted Bundy’s memorable quote, “I am in the enviable position of not having to feel any guilt,” showed he was wired with some primary psychopathy.

Low IQ

Although Ted Bundy has been referred to as a criminal “mastermind,” he may have had a average or only slightly above average IQ. The article by Ceci, 1996, found that cognitive ability tends to be a good predictor of academic performance; measures of academic achievement (LSAT, GRE, SAT) correlate very highly with measures of cognitive ability.

Although we do not know Bundy’s actual LSAT score, only that he believed it was “mediocre,” there is certainly no evidence that states he was a genius.  Rather than a genius, I would say he was not impulsive, very calculated, and often planned and put a lot of energy into his criminal actions.

Hearing voices

Ted Bundy often referenced hearing voices that told him to do bad things. However, it is not believed he had schizophrenia. Occasionally antisocials will use this as a way to avoid responsibility for their behaviors.

We call it MBD: minimize, blame and deny

Was pornography to blame?

Ted Bundy blamed his behaviors on pornography. However, pornography is not viewed as a cause of sexual violence. In persons who have preexisting conditions for sexual violence, it is a viewed as a contributing factor.

In Episode 4 of the documentary, he is quoted as saying, “I never said (pornography) made me do it. I said that to get them to help me. I did (murder) because I wanted to do it.”

The research confluence theory states men with hyper masculinity that also involves psychopathic tendencies have low agreeableness, abuse, hostility towards women, impersonal sexuality combined with sexual permissiveness. When you have a confluence of those two things and violent pornography it may be a contributing factor to Ted Bundy’s violent, abhorrent behavior.

It is important to note that pornography has not been present in our society for very long. Yet, crimes against women have been happening since the beginning of time. It is because of this fact that many doubt that pornography is to blame for crimes of this nature.

Hald, 2010,  found that the correlation between violent pornography and attitudes supporting violence against women (r=0.24) was significantly higher (P< 0.001) than the correlation between nonviolent pornography and attitudes supporting violence against women (r=0.13): however these are still low correlations.  

Antisocial personality disorder and psychopathy as a mental illness:  

Just because antisocial personality disorder is in the DSM, it doesn’t mean it should be viewed the same way we view schizophrenia, bipolar, major depressive disorder, etc. Largely, antisocial personality disorder is not something that is treated by psychiatrists. There is no medication for it and most with this disorder are not interested in help. If they come to see a psychiatrist, it is typically because they want something from you.

Narcissism diagnosis:

Ted Bundy had traits of narcissism as displayed in the DSM 5 criteria: a pervasive pattern of grandiosity, lack of empathy and a need for admiration which begins by early adulthood. To meet the criteria, 5 or more of the following behavioral features must be met:

  • grandiose sense of self-importance

  • preoccupied with fantasies of unlimited success and power

  • special or unique and can only associate with high status entities

  • requiring excessive admiration

  • sense of entitlement

  • exploitative

  • lack of empathy

  • often envious of others and believes others envy him or her

  • arrogance and haughtiness

I would add that some narcissists are low-self esteem, but I believe he was a high self-esteem psychopathic narcissist.  

Machiavellianism

Machiavellianism overlaps with narcissism and antisocial disorders. They are more likely to deceive and manipulate others for their own personal gain. They see people as objects for use and manipulation. They will have normal amounts of empathy unless they have traits of psychopathy.

The opposite of machiavellianism are people who display honesty and altruism.

In viewing Ted Bundy, it is highly probable that he displayed high Machiavellianism with traits of psychopathy and narcissism—thus having all the dark triad.

How did Ted Bundy come to be this way?

Home-grown sociopaths don’t necessarily have a need to be seen and appreciated by others. They often have been made the way they are due to horrific abuse, and usually prefer to be left alone. But, psychopaths who are born with low physiological arousal, have more of the predatory aggression which we see in Ted Bundy.

A person with primary psychopathy can either choose to live in society and do things to help, although without empathy and with difficulty attaching to others. Or they can choose to do illegal things to get their drives met. Whichever one they choose will write their brain and pattern of behavior that they will follow. These people can be incredibly helpful to society or incredibly harmful.

Determinism versus free will

It often comes down to determinism versus free will. In other words, did he make the choices or did his mental illness cause them? Ted Bundy went to prison for the choices he made, not the psychological predisposition that he had. However, when one goes into determinism, they will blame others for the choices that they made.

It is important to remember these people do have a choice. Because, ultimately, there is another dimension here, which is the moral dimension. We all have the responsibility to others and to society.

However, there are people who have less choice than others. For example, a person with a frontal lobe injury will have less “choice” than someone who does not. Ultimately, choice must be in line with responsibility. But I have known people to “check themselves in” for desires to do bad things, and get help. Sometimes we only have a small choice to change our environment.

Treatment

With the Ted Bundy type of psychopath, therapy will most likely not benefit them. This type of person should be put in prison for life.

Therapists must be especially on guard with someone like this, which can be uncomfortable for therapists and clinicians. You must view your interactions with them like a chess match. Because, everything about your interactions is a game to them.

Towards their therapists, they may exhibit these types of behaviors:

  • Play into your desire to “make a difference,” which is fertile ground for them to manipulate you.

  • Express prosocial behaviors.

  • Trap you by making you believe you have reached them in a way no one else has.


However, the “baked” sociopaths, or those with features of antisocial behaviors, can benefit from therapy. Clients will very rarely be as healthy and whole as you want them to when they leave therapy.


However, the goal is for them to leave with better connection to people, not use sex as a coping strategy, be more intimate (non-sexually) with humans, and relate better to authority. This will lower their risk of sexual violence, and help them on a track to be able to fit into society.

Approaching therapy

You can give all the tests you want, but one of the most valid tests of psychopathy is the “hair on the back of your neck” test. You just know it when you’re in the presence of psychopathy. It will alarm your body’s natural detection mechanisms. You can just “feel” it. I know that isn’t technical jargon, but it’s so true.

The goal in therapy should be to change their mindset away from objectifying people. It is suggested that you get access to their large criminal history in order to learn what they have done and use that strategically in their treatment. This will arm you with the knowledge of what they have done and what they are capable of.

Approaching them with the idea that they are likely to continue their cycle of behavior unless they do something to change it is an ideal approach. Discussing the importance of change itself and how change occurs can be helpful.

Focus primarily on the dynamic risk factors or “stable factors”:

  • Issues with authority

  • Intimacy

  • Hostility and attitudes towards women

Targeting those aspects one by one and digging into each one is a strategic approach. Improvement in each of these areas will lessen their risk of continuing their behaviors significantly.

Final Thoughts

There will always be that one in a million person who will use their predisposition to harm others and create a life of criminal behavior.

However, the glamorization of criminals like Ted Bundy from the media tend to breed a culture focused on the fear of these one in a million criminals.

It is important to remember that the media carries a bi-directional quality. Where the consumer drives what the media will pay attention to. Limiting the attention we give these types of criminals will lessen their need to be publicized and noticed.

For Nate Hoyt’s extensive notes on this episode - go here

Questions, comments, thoughts? Please comment on the picture that corresponds to this post on my instagram: @Dr.DavidPuder




How to treat violent and aggressive patients

Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic

On this week’s episode of the podcast, I interview Dr. Michael Cummings. Dr. Cummings works at a state psychiatric hospital for the criminally insane, so he has extensive experience in treating patients for aggression and violence.

The different types of aggression

The words “aggression” and “violence” are sometimes used synonymously, but in reality, aggression can be physical or non-physical, and directed either against others or oneself. Violence is more of a use of force with an intent to inflict damage.

One study looked at the principle types of aggression and violence that occur in psychiatric patients, and broke it down into three categories:

  • Impulsive violence (the most common category)

  • Predatory violence (purposeful and planned violence)

  • Psychotically-driven violence (least common)

Within 5 state hospitals, 88 chronically or persistently violent patients with 839 assaults, the rate of impulsive violence was 54%, and predatory violence was 29%. Psychotically driven patients logged 17% of total violence (Meyers, M. Cummings et al., 2013). Studies show psychotically driven violence decreases the longer the patients are in care and medicated.

Predatory Violence

Predatory violence is what people typically think of when they think of psychopathy, or someone with antisocial personality disorder. It is violence with a purpose, and that purpose is usually to gain something. They typically show a lack of fear and very little autonomic arousal even when they are being violent.  The amygdala and the temporal lobe is underactive and the communication between them has a weak signal. People with predatory violence also have lower affective empathy.

Some of the early research done by Adrian Reign measured blood pressure, galvanic skin response and heart rate when showing neutral, frightening or peaceful pictures to children. Of those who lacked effective response or autonomic response to those pictures, 75% percent of those individuals became violent criminals by age 18. Interestingly, 25% of them became prosocial and entered jobs as police officers, bomb disposal experts, and so forth.

True psychopaths are a very tiny part of the population. About 2% of women score significantly on the psychopathy checklist. About 2-4% of men have elevated scores on the psychopathy checklist. Not all of those individuals, however, are violent, and many persons who are psychopathic are more interested in profit. Some become the crime bosses (not actually doing the violence themselves) and others end up in politics.

Impulsive violence

Impulsive violence or aggression is actually the most common, and in many ways the most complex, form of violence that occurs in a variety of mental illnesses, including:

  • psychosis

  • mood disorders

  • personality disorders

  • anxiety disorders

  • PTSD

It is essentially an imbalance in impulse generation and a failure of the prefrontal cortex to evaluate the impulse and weigh the consequences. All of us generate a variety of impulses, some good and some bad, including impulses driven by our irritability and anger.

In predatory aggression there is increased medial prefrontal cortex activity whereas in reactive aggression there is decreased activity.

What can cause impulsive violence to be an issue:

  • Traumatic brain injury

  • Some of the dementias including frontotemporal dementias

  • Anoxic brain injury

  • Intellectual disability

  • Personality disorders

  • Drugs

  • Drug detox

Psychotic aggression

Psychotically driven aggression is most often a result of delusional ideation or the belief the person holds that they are in some way being persecuted and being taken advantage of. Psychotic or mentally ill people do have an increased rate of violence compared to the general population. The mentally ill are responsible for around 5% violent crimes, meaning non mentally ill people are responsible for 95%.

Psychotic Delusions leading to violence

Ones study looking specifically at the first episodes of psychosis found that in about 458 patients, anger was associated with certain types of delusions that led to the violence (Coid, 2013).

The underpinnings of delusion-driven violence usually stems from when people have delusional beliefs that are persecutory in nature. When they believe that someone is out to get them, it removes inhibitions against acting out violently, because that person’s view is they are protecting themselves. Typically, this violence comes from the belief they are being spied on or persecuted.

Persecutory delusions associated with a command hallucination is a particularly potent precursor to violent behavior. If your delusion tells you your neighbor is the devil, and your command auditory hallucination is that God is telling you to “kill him and save the world from destruction”  it can lead to a very bad outcome.

IQ and aggression

There is also an association between the IQ and aggression (Huesmann, 1987).

A recent study in state hospitals looked at what correlated with persisting violence, and across all of the types of violent behavior, cognitive deficits (particularly impairments and executive functioning) were associated with elevated rates of violence.

Men are more violent than women

Men are likely more violent than women because they have historically been the hunters, which involves violence. Women were gatherers more often than not, and consequently, men have a standing evolutionary tendency toward more frequent use of violence. Women can be violent, but if you look at the rates of violence between men and women, men are clearly more violent.

The purpose of aggression  

You could say the healthiest outcome for our aggressive and violent impulses is when we use our innate ability to be aggressive to engage in things like a healthy competition. Or even to provide motivation and drive to achieve.

In the beginning, humanity formed tribes, and aggression allowed someone to climb up the dominance hierarchy within the tribe. It also allowed them to protect themselves from other tribes. It was basic for survival.

If we look at animal psychology, there is a lot we can learn about the aggression and dominance hierarchy, like how apes interact with each other, or form alliances. As a way of creating alliances, often an alpha ape will groom other males.  The violence comes out when the clans come against each other. When one ape is wandering from its clan, two apes from another clan may attack one single ape viciously.

In other circumstances, if a dominant ape is taken away from his clan for a couple of days and brought back into the clan, a couple of other apes may have formed a new alliance against the prior leader and attack him.

As human beings, we are also like this. Many of our social interactions and group structures have the same kinds of alliances and effects of absence can play out similarly. Of course as humans, we do have higher verbal centers, and philosophy or spirituality, that allows an individual to be less violent and to transcend their base instincts.

Aggression and autism

People with intellectual challenges most often exhibit impulsive violence, particularly those on the autistic spectrum. The person may have a greater difficulty processing or understanding their own emotions if there are significant intellectual deficits. They may also have elements of not being able to judge a response or to moderate a response. The general pathophysiology of the autistic spectrum disorder suggests that the connections between neurons and the autistic brain is not what it should be, and they are not differentiated so that information processing can be fragmented.

Treatment of aggression

Psychotic aggression treatment

Treating with an antipsychotic medication is helpful and decreases violent episodes. In one study, clozapine helped psychotic aggressive patients with executive dysfunction more, compared to using haldol or olanzapine (Krakowski, 2011).   

Psychopathic aggression treatment

A predatory-violent individual needs to be contained in prison if there is a demonstrated past of persistent violence.

There is evidence that by enhancing intellectual empathy, psychopaths will be less violent. There is also interesting research that by giving oxytocin, the hormone that increases affiliation and collaboration, may have a moderating effect on some psychopathic individuals.

However, in terms of psychopharmacology, we don’t have any specific medications to control that behavior. Some medications, such as clozapine, can affect the underlying issues behind psychotic behavior and thereby reduce it, but there is no direct treatment for psychopathic violence pharmacologically.   

Impulsive aggression treatment

Dr. Cummings discussed the use of Mood stabilizers helping in persons with borderline personality disorder, SSRIs and trazodone helping in dementing illness in the elderly and alpha 2 agonists in people with things like autism or TBI. Alpha 2 agonists (clonidine) can fool the brain stem into thinking enough norepinephrine has been released, then less norepinephrine is secreted, making the brain stem calm down.

Essentially, in an emotional disorder, if you change the affective (limbic) tone, you can decrease the likelihood of emotionally reactive aggression, for example, by using mood stabilizers lithium and divalproex.  

Using an antipsychotic, and not just a mood stabilizer, doesn’t show any benefit for traumatic brain injury patients. Antipsychotics have been used for people with autism spectrum disorder, and some evidence shows that drugs like risperidone can be helpful to control outburst issues. If there is evidence of sexual aggression (or aggression occurring at women after puberty), using an GnRH agonist—antiandrogen treatment—can sometimes be necessary).

Psychotherapy for aggression

There have been a number of anger management therapies that have been used over time. Therapists can help people be aware of their anger and manage their impulses, or push their anger and aggression toward a more prosocial response.

For people with borderline personality disorder, dialectical behavioral therapy, mentalization based therapy or transference therapy are important. For schizophrenic patients, a good therapeutic alliance is important to create medication compliance. I have touched on how to process anger in my microexpression series and will have future episodes focusing more on the psychotherapy approaches to anger.  

Overall in therapy, we must assume that our patients will lie to us sometimes because they are afraid, and double check to insure they are following our prescribed protocol. We must also work hard to build trust and a therapeutic alliance.

Final Thoughts

Violence and aggression deserve much more attention as a specialty than we have given it in the past. It is a major burden for family members and friends.

Please submit any questions you have and we will submit them to Dr. Cummings and to answer.

(In the podcast details about specific medications are discussed for psychiatrists who are interested in advanced psychopharmacology.)

Further reading:

Link to Ideal blood levels are found in Resource Library

“California State Hospital Violence Assessment and Treatment (Cal-VAT) guidelines”




Psychopathy with Michael A. Cummings M.D.

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In this episode, Dr. Cummings and I discuss psychopathy: the fearless, empathyless people, who see others as objects, and have the inability to attach within relationships. Dr. Michael Cummings recently contributed to a book called “Violence in Psychiatry,” detailing the biological aspects of psychopathy, edited by Stephen Stahl. Dr. Cummings works at Patton State Hospital, one of the biggest forensic hospitals in the world. He is the Yoda of the psychiatric world, with many other psychiatrists bringing him their most complex and difficult cases.   

 

In this episode we cover:

  • History of psychopathy

  • Influence of early life traumas

  • Prosocial careers of psychopaths

  • The emotion psychopaths fail to see

  • Biological components in psychopathy

    • BDNF (brain-derived neurotrophic factor)

    • Prefrontal area (parent of the brain that warns us “that is not a good idea”)

    • Amygdala

  • Why psychopathy has not been bred out of existence

  • Advice when you are in a relationship with a psychopath

  • What drugs make someone look psychopathic

  • Effect of alcohol andmethamphetamines on the brain

  • Influence of cocaine on the brain

  • Why more men are violent psychopaths

  • And treatment of this group of people (clozapine’s influence on glutamate)

  • The Story of Phineas Gage

We also wrestle with how to increase the percentage of psychopaths that end up helping society vs percentage that become criminals.

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