Discussion group

1
Discussion group

• Neurobiological factors in antisocial personality
  disorder and psychopathy
• Dr Birgit Völlm
• Clinical Lecturer and SpR in Forensic Psychiatry
• Neuroscience and Psychiatry Unit
• University of Manchester

2
Outline

• Reminder of conclusions of this mornings talk
• Clinical
• Legal
• Ethical

3
Conclusions

• Genetic contribution to impulsivity and emotional
  impairment
• Gene environment interaction
• 5-HT modulation of impulsivity and emotional
  responding
• Prefrontal cortex structural and functional
  changes
• DLPFC poor planning / strategy
• Lateral OFC poor behavioural inhibition and
• detection of stop signals, ie anger
• VMPFC impaired choices and response reversal
• Amygdala dysfunction
• impaired emotional learning and responding to
• distress cues in others
• Lack of empathy and moral socialisation (Violence
• inhibition mechanism model)

Reactive aggression
Instrumental aggression
4
Discussion groups

• Legal
• What might be the implications of the
  neurobiological findings presented for legal
  responsibility?

• Ethical
• What might be the risks associated with the
  neurobiological findings presented?

• Clinical
• If there was a neurobiological model of ASPD /
  psychopathy would this change your view on the
  distinction between PD and mental illness?
• What might be the implications of the
  neurobiological findings presented for the
  treatment of ASPD / psychopathy?

5
Clinical implications

• Personality disorder mental illness distinction
• Distinction between ASPD and psychopathy /
  reactive and instrumental aggression
• Prevention strategies for individuals with
  genetic vulnerability?
• Treatment implications
• 5-HT?
• Empathy/emotional training? Cognitive approaches?
• ?

6
BrJPsych 2002

• Disease / disorder / illness
• Socio-political
• Biomedical
• Aetiology
• Time course
• Treatment

7
ASPD psychopathyReactive instrumental
aggression

• Different underlying deficits in different types
  of aggression and between ASPD and psychopathy
  (reviewed by Viding 2004)
• Factor 1 stable over time
• Factor 2 / antisocial behaviour declines over
  time
• High factor 1 scorers less benefit from
  treatment, less impact of environment
• More detailed (dimensional) diagnosis and
  assessment required to inform planning of
  interventions

8
High MAOA protects against adverse effects of
childhood maltreatment (Caspi 2002)
with conduct disorder
Mean composite antisocial z-score
Childhood maltreatment
100
1.00
None
0.80
80
Probable
Low MAOA (163)
Severe
0.60
60
0.40
40
0.20
0.00
20
High MAOA (279)
-0.20
0
-0.40
108
42
13
180
79
20
None
Probable
Severe
Low MAOA
High MAOA
Childhood maltreatment
MAOA VNTR promoter region
9
Malnutrition predisposes to neurocognitive
deficits and antisocial behaviour (Liu 2004)
Birth cohort (N 1795) N 353 malnutrition at
age 3 Behaviour measured age 8, 11, 17
10
Treatment SSRIs

• Fluoxetine decreases impulsivity and anger scores
  in borderline PD (small RCT, Salzman 1995)
• Fluoxetine decreases aggression in 10 impulsively
  aggressive borderline PD patients and increases
  metabolism in orbitofrontal cortex (New 2004)

11
Treatment psychological

• If amygdala dysfunction is the underlying deficit
  in psychopathy
• Victim empathy might not be an effective approach
• Learning from punishment might not be possible
• Anger management, ETS, etc. might not be
  effective as not at core of problem (but for
  ASPD)
• Compensation of emotional deficits by cognitive
  strategies?

12
Vagus nerve stimulation increases advantageous
decision making (Martin 2004)

• Somatic marker theory
• 8 epileptic patients
• Vagus nerve stimulation
• Bechara gambling task
• During stimulation more advantageous choices

13
Legal implications

• In principal everybody held fully responsible for
  actions
• Insanity
• Diminished responsibility

14
Diminished responsibility in psychopathy

• Pro (ie Fine 2004, Glen 2005)
• Like children, not fully responsible
• Lack of guilt, empathy and recognition of
  distress in others
• VIM dysfunctional
• Impaired moral development
• No distinction between conventional and moral
  transgressions
• Psychopaths do not develop moral understanding
  necessary for criminal responsibility

• Contra (ie McSherry 1999)
• Hare psychopathy as aggravating rather than
  mitigating factor
• No impairment of reality perception or reasoning
• Increased sentences, death penalty

15
Diminished responsibility in psychopathy

• A jury convicted Eugene Protsman of first degree
  murder and found the allegations of robbery, and
  use of a deadly weapon were true. He was
  sentenced to life in prison without the
  possibility of parole, plus one year for the
  weapon enhancement. Protsman appeals, contending
  the trial court committed reversible error in
  excluding testimony of one of his defense experts
  regarding the results of a positron emission
  tomography (PET) scan of his brain. We hold the
  court properly excluded this evidence under the
  test articulated in People v. Kelly (1976) 17
  Cal.3d 24 (Kelly), and accordingly, affirm the
  judgment. (www.law.com)
• In the US, a convicted murderer has attempted to
  plead in mitigation the presence of an abnormal
  gene (monoamine oxidase A) (The Guardian)

16
Ethical implications

• Bad ? mad?
• Risk of simplifying neuroscientific findings
• Lombroso criminals to be identified by skulls
• Misuse of diagnosis
• Preventative detention