Psychiatry & Psychotherapy Podcast - Psychopathy with Michael A. Cummings M.D.

Episode Date: January 29, 2018

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 Biological components in psychopathy The emotion psychopaths fail to see BDNF (brain-derived neurotrophic factor) Prefrontal area (the 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. Warburton, K and Stahl S (Editors).  Violence in Psychiatry.  The Neurobiology of Psychopathy. Cambridge University Press 2016), pp. 200-05 CV of Dr. Michael A. Cummings By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video. Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder Editor: Trent Jones *This podcast is for informational purposes only and is the opinions of the people on this episode.  For full disclaimer go here.  

Welcome to the Psychiatry and Psychotherapy Podcast, the podcast to help you in your journey towards becoming a wise, empathic, genuine, and connected mental health professional. I'm your host, Dr. David Puter, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. In this episode, Dr. Cummings and I discuss psychopathy, the fearless, empathetic-less people, who see people 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, which was edited by Stephen Stahl. Dr. Cummings works at Padden 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 will cover the history of psychopathy, influences of early life traumas, prosocial careers in psychopaths, biological components in psychopathy, the emotions psychopaths fail to see why psychopaths have not been bred out of existence, advice if you were in a relationship with a psychopath, the drugs that make someone look like a psychopath, why more men are violent psychopaths, and the treatment of this group of people to decrease violence.

We will also wrestle with how to shift more psychopaths at an early age into pro-social psychopaths. So this is an extensive and enlightening conversation with a true world expert. I hope you enjoy it. All right. So I'm sitting here with Dr. Cummings, who is a psychiatrist, a forensic expert here at Patton State Hospital. And today we're going to talk about psychopathy. So, yeah, Dr. Cummings, tell me a little bit about psychopathy and your interest in psychopathy. Okay.

Well, I got interested in psychopathy as a component of forensic psychiatry. About 1 to 2% of women and about 2% to 4% of men have significant psychopathic personality features. Particularly in the men, they are the source of a lot of violent, repetitive criminal behavior, and consequently they're a focus of forensic psychiatry. They've also been of interest because aside from confining them, historically, psychiatry has not had a lot of successful treatments in terms of psychopathic individuals. So let's define like how you would do, like how would you define psychopath. And I think there's like a four-factor method you mentioned in your book chapter. Yes.

The history of psychopathy dates back a long way. If you look in literature, you'll find references to people that were kind of callous and an emotional and didn't follow the rules in almost every society. That came to be of interest in particular in the middle of the 20th century to a physician and psychiatrist named Hervey Cleckley. He interviewed several hundred prisoners and noticed that a small number of them met this description that they were callous, unemotional, didn't care about other people, seemed to have no attachment to other people and didn't have much fear of being caught or punished. They were often the most violent in the prison system and the most repetitive in terms of being violent toward other persons.

That narrative description of psychopathy got elaborated and refined by a man named Robert Hare, who's a Canadian, who got interested in this topic and developed. developed a questionnaire, a rating system for psychopathic personality traits known as the psychopathy checklist. It's a 20-item scale. And when they've done statistical analyses of that, it breaks down into four factors. Okay. The four being lack of interpersonal attachment. For the psychopath, other people are not much different than just being objects.

Second is affective deficits. These people lack a fear response. In some ways, these are the people you want, if you want a test pilot, are a bomb disposal expert, but they're also the people who can do very bad things to other people with no emotional response. the criminal psychopaths tend to lack any kind of pro-social element in their personality. They're not really interested in doing things to benefit society or for the advancement of society.

They tend to be very self-focused. And then lastly, because they are rather indifferent to the welfare or rights of others, they're prone to engage in antisocial behavior. for them there's not much difference between swatting a fly and killing a person so tell me a little bit about like the lack of attachment in more detail like how does that actually play out or what questions do they ask to sort of delineate that essentially if you look at the life of most psychopathic individuals they are the the children and the adolescents who don't really attach to other people.

They lack a sense of empathy. One of the elements that keeps most of us from doing truly bad things to other people is that we identify with the other person and we can't, well, gee, I wouldn't want somebody to do that to me. You know, it would cause pain and suffering and most of us will identify with the other person. That's not true of the psychopath. are able to inflict pain and suffering on somebody else. And essentially it has a very little effect on them.

They're not able to engage that sort of empathetic response to other people or even to imagine what the other person's internal emotional state is. And then you also said kind of callousness. Does that go along with that sort of dehumanizing of other people, seeing people as objects? Yes. Most psychopaths tend to view other people much more as external objects rather than as people per se. Consequently, they're not particularly bothered by what happens to the other person.

And indeed, one of the items on the psychopathy checklist is a callous indifference to the welfare of others. And you also mentioned they would make good, like, bomb disposal experts and, you know, people who basically are in extreme fear situations and can remain calm. Yeah, an interesting area of research in this was done by Adrian Raine, who was a researcher originally at UC San Diego and later at the University of Southern California. he went to the island of Mauritius off the coast of Africa, where he studied children at ages 3, 5, and 8,

and he took these children and he exposed them to a variety of images. Some of the images were frightening in nature, and he found a group of children who had a very limited autonomic response to that. Their pulse rate did not go up, their blood pressure didn't go up, their galvanic skin conductance didn't increase. 75% of the children in that group later went on to become violent criminals. 25% became more pro-social and indeed became things like police officers, firemen, bomb disposal experts, pilots, people who didn't have much of an affective

or emotional or autonomic response to situations that people would inherently find frightening. Yeah, I've heard the special forces tend to collect this type of person on a book on killing, I think it was called. They talked about how there are really good fighters because they will pull the trigger, where a lot of people will have hesitancy. They'll actually thrive in situations of high,

high fear, like special forces type of things. I don't know. Have you heard any stuff on that. Yes, that's true. There are some professions that tend to select people with the underlying, what you might call the biologic underpinnings of psychopathy. Now, these individuals aren't psychopaths in the sense that they've become socialized. They lead pro-social lives.

They do positive things. but the underlying biology is the same as what produces psychopathy, which has been one of the fascinating areas of research, is what makes the difference between somebody who has this sort of lack of reactivity. What's the difference between the ones who become violent serial killers like Ted Bundy and the ones who become astronauts and test pilots and bomb disposal? experts. They are coming from the same biological beginnings. Yeah, how do they make that? But they turn out very differently.

How do they make that, like what allows some people to be prosocial, but others to become criminals? Like, what is that sort of place or what happens there? Well, this may be another example of the importance of early interaction between biology and the environment. They've looked at psychopathic individuals, prisoners largely. Almost all of them have, in addition to their underlying biology, negative environmental influences early on, things like traumatic events or deprivation or distressing circumstances in childhood,

which in these people tends to prompt them to become cruel and controlling and to disobey the rules more often. In contrast to that, people with the same biological underpinnings, if they are very early on pushed into more pro-social environments where they're taught to be responsible and to pursue positive goals, that seems to produce the more pro-social version of somebody who could have been a psychopath with the more negative environment. So there is an environment genetic interaction going on early in life. Unfortunately, many of the psychopaths grow up in environments where they are the offspring of psychopathic individuals. So many of them don't start out with a very positive beginning.

What is there like is there a pattern of deprivation or like you know very sort of difficult childhoods that you see like is it a specific a specific type of trauma or just a lack of attachment with the parents or what is the length there's often a very early lack of attachment and it but it's lack of attachment from both directions the child has a diminished capacity for attachment, but they're often the offspring of parents who also have a diminished capacity for attachment. You know, the person who's destined to become a psychopath, just like normal children, learn by modeling.

And so if you have a callous, indifferent parent who is willing to inflict pain and deprivation as the primary mode of interaction with a child, well, that becomes very often the child's mode of interaction with others. That's not to say that the parents are to blame. There are certainly examples of psychopaths who turn out to be psychopathic, and you look at their early family wife, and there's nothing obvious in some cases that would suggest trauma or deprivation.

an area of research we need to know more about is what are the critical periods in which you can shape somebody who's at risk of becoming a psychopath and perhaps turn them into somebody who has many of the same underlying characteristics but becomes a pro-social, a positive social individual. Very nice clock there. So how would you early identify are there any signs of psychopathy and children, young children, that is actually statistically significant to go on and predict psychopathy later on? Yes.

If you look at the DSM, the diagnostic and statistical manual for psychiatry, those children that very early on display a lack of attachment to others, cruelty to other children, indifference to the suffering of others, cruelty to animals, fire setting. The kid who can't seem to comply with the rules or seems indifferent to rules in social environments like kindergarten and the early years of school, those are the kids who are at risk of turning out to be the psychopathic individuals later on. Now, interestingly, if you go to be.

go back and look at Adrian's rain, Adrian Raines work, all he did was measure blood pressure, pulse, and galvanic skin response. And that was pretty good at identifying people in this category. You could use those

as screening methods. If you were to have a child like this identified, let's say you were a parent listening to this and you're like, you know, I think that's my child, what would you do differently? I think you need to set that child up with special attention to the issues of becoming socially integrated

and focus on indeed promoting development of pro-social activities for that child. These children do respond to basically talks by their parents about being pro-social, joining groups that engage in pro-social activities and essentially not being allowed to engage in more antisocial or psychopathic behaviors. I think the earlier on that parents and the social support system for that child can become aware that they're at risk

and indeed there are a lot of programs these days that are labeled at being for at-risk youth. this group in particular is important to identify because like most later adults, all of us are more malleable, more easily shaped during childhood and very early adolescence, then we will be in later adolescence or as adults. Often by the time you get to the late teens or 20s with these individuals, In many ways, the battle is lost by that point. They become less easily influenced by the external environment.

Once they get into later adolescents, a number of studies of delinquent adolescents have basically demonstrated that while they're not untreatable, they're far more difficult to influence than younger children are. Yeah, I don't know if you know, but I'm really interested in like micro expressions and emotion. And one of the things that I saw in the literature is that the one facial affect that a group of criminal psychopaths had a difficulty seeing was discussed. They were able to identify anger and fear in other people, but compared to a control group, disgust was the one emotion that they recognized very, very poorly in other people's faces. and I wonder if you had any thoughts on that in particular.

Well, that is an area that has been studied in these individuals. Their brain is abnormal in the sense that they don't truly understand the affective state of other people. All of us have a set of what are called mirror neurons in the anterior part of our brain. And that's the part that we're using when we imagine how somebody else, is feeling or somebody says, I know what they're thinking. For the psychopath, that's a very difficult thing to do. Part of that network is the fusiform gyrus, which helps people interpret facial expression. And indeed, for the psychopaths, they do worse than the general population on almost all facial expressions, but they do especially badly with facial expressions that are

expressing disgust or contempt or disappointment, they just don't read those. That feeds into an even larger issue with the psychopath. For all of us, when we're judging what we should or shouldn't do, one of the things that happens is our temporal lobes, the part, indeed of the brain just below the frontal lobes, first makes an evaluation of essentially the emotional context of whatever is being contemplated, something we're thinking about doing.

In the normal individual, that information, the outcome of that appraisal is fed forward to the middle part of the frontal lobe, which considers that in terms of, well, does this fit the rules? Does it not fit the rules? is this a moral decision or an immoral decision? The connection between the temporal lobe and the frontal lobe and the psychopathic individual is very weak. That information doesn't really get communicated, and the amygdala nucleus in the temporal lobe basically doesn't respond

to emotional situations very well. That's part of their indifference. And consequently, the part of their brain that's making a judgment doesn't get a lot of information about, is this a good thing or a bad thing? You know, I'm drawing the connection now because there's been some really cool research done on disgust and kind of moral reasoning. You know, disgust, when I think of disgust, I usually think of like a child puts in something that's foul tasting and gets an expression of disgust. and then but subsequently like as we kind of learn moral decision making disgust and moral decision making are kind of wrapped together which you know one could look at like a lot of the Old Testament laws

and kind of associate high disgust with a lot of the laws so it's kind of interesting thinking about how psychopaths can't read disgust and then but and they also have difficulty with moral decision making yes oh and indeed for the psychopathic individual, you know, they're not intellectually impaired. They can understand when you talk about morality or disgust or that some things are not accepted by the society they live in. But for them, it's an abstract concept. You're doing something very similar to what you would be doing if you were explaining that for traffic lights, red is on the top and green is on the

bottom. Most people experience red and green. They know what those colors are. For the colorblind individual, yeah, you can teach them that the red is on the top, the green is on the bottom, but they've never actually seen those colors. For the psychopath, talking about disgust and fear is very much the same thing. You're talking about something that they can understand in the abstract, but they don't experience it. Yeah, I want to, I want to, um, ask you about brain-derived neurotrophic factor. Because in the chapter in the book that you wrote, you talked about how this could be part of what's going on.

So can you tell me a little bit about what is brain-derived neurotrophic factor and how is that different in a psychopath? Okay. Brain-derived neurotrophic factor is a protein. It's made by neurons and glial cells in the brain. and essentially it supports both the growth and activity levels of brain cells. In psychopathic individuals, one of the characteristics they have is a genetic variant for the building of this protein. It has a substitution that gives them a less active form of brain-derived neurotrophic factor,

and as a consequence, if you look at MRI scans of people with psychopathy or psychopathic brains, they have areas that are not as well developed. The cortical thickness, the thickening of the layer of nerve cells on the outside of the brain, it's not as thick, it's not as active. And that may indeed be one factor that leads them to do a poorer job of problems, some of the information we've been talking about. They're the prefrontal area that's supposed to be making moral judgments. Well, it doesn't quite live up to its potential.

Some other areas like the amygdala also tend to be physically smaller, possibly in part because they don't have as much brain-derived neurotrophic factor. Now, there are a whole host of genetic and biological abnormalities in the, the psychopathic brain. So that particular protein may just be one component of many that's influencing this person's brain to not function as well. That's very fascinating. I first learned about brain-derived neurotrophic factor

when studying like the mechanism of antidepressants, which can sometimes increase it, or exercise, which can sometimes increase it. and I found it very interesting. I think of it as like the miracle growth for the brain. So without it and with it being kind of less functional in this population, they're really not sprouting new growth in the brain as well as an average person is what you're saying. No, they're not.

Although they produce normal amounts of the protein, the protein that they're producing has a couple of amino acid substitutions that make it a less, active growth factor. Okay, yeah, that's good. They also have abnormalities in some receptors for things like serotonin as well as abnormalities in the strength of connection

among some neural circuits, all of which go together to make a person who isn't as able to empathize with others, isn't as able to identify with how others may be feeling or thinking. They wind up with a very narcissistic worldview because if you can't perceive other people's needs and wants and mental states, well, you're left with your own.

So talk to me specifically about the amygdala and how that relates to fear and negative emotions. I know it's decreased in people with, in this population. But tell me a little, like, what is the amygdala? What is its function first and foremost? Okay. The amygdala is a small group of nerve cells

buried deep in the interior of the temporal lobe. It looks not unlike the meat of a walnut. It is engaged in helping to monitor the environment for threats. you know as a primate species many of our ancestors were frankly prey we had we had good reason to want to monitor the environment to be sure we weren't about to be lunch for something and in large part the amygdala plays an important role in that in the temporal lobe it monitors the environment for threat and also helps generate the anxiety response when a threat is present. In the psychopathic individual, the amygdala is smaller than normal. It's also hyperreactive.

It doesn't respond to things in the environment that should cause it to respond. That was a large part of the basis for the children that Adrian Raine studied. Sorry. Dr. Cummings? we can always cut out portions okay that was a large part of

the reason that the children who Adrian Rain studied who didn't respond with increased heart rate or increased sweating or increased blood pressure when they were shown frightening pictures is basically their amygdala was not responding it didn't light up their temporal lobe and say this is a dangerous thing that you're looking at when I think about this

and I think about like the survival benefit, I think there's a, there's definitely, makes sense that having some fear would keep us from harming ourselves. But I also think there would be a survival benefit in a certain group, a certain percentage of the population to have no fear.

You know, they're the ones I would see as like the warriors, the people who could, you know, not be hindered from fear and almost have more courage. Is that kind of your line of thinking Well, people have wondered that, you know, because obviously, genetically people have wondered, why do the genes that underlie psychopathy or psychopathic features, why have those been preserved? Why haven't they simply been bred out of existence?

And it may indeed be that societies benefit by having members who have less fear, who are able to go and dispose of. of bombs or venture into space or fly new aircraft or indeed serve as special forces in the military so that there is reason for these things to be preserved. Obviously, the serial killers and the more negative aspects are there as well. but there is a positive aspect to this, and certainly enough that psychopathy genes have been preserved. Now, there is another element that helps promote that, is that psychopaths, while they don't form good attachments,

not long-term, stable relationships, they do tend to be sexually promiscuous, and likelihood is produce a lot of pregnancies over time. Yeah, I imagine, there's going to be someone out there who's listening to this who's in a relationship and they're like, am I in a relationship with a psychopath? And if so, what do I do about that? How do I manage that? I don't know if you have any insight or any thoughts about that. Well, first, this brings up an issue. Psychopathy has been looked at in two different ways. One is categorical. Somebody is a psychopathic.

or they're not. Now, statistically on the psychopathy checklist, if somebody scores greater than 30, 40 is the highest score you can have, then they get categorized as 95% probability of being a psychopath. But people in general tend to have some psychopathic features. And so people have also looked at psychopathy as a dimensional personality characteristic. Yeah. Because obviously some people are scared of their shadow and, you know, it doesn't take much to frighten them at all. On the other hand, you have people in the middle who have ability to control their fears, although they may have a fearful response to others and be pro-social. And then you have out at the extreme, of course, the psychopaths who are unemotional and callous. And that exists

as a range. Now, if you truly are in a relationship with somebody who is a psychopath, the best advice I would give to the person is to leave because it's going to be a one-way relationship and a potentially dangerous relationship. If the person has psychopathic characteristics, that may be possible to work with if the person has, if you will, adequate pro-social features as part of their personality. I think people in relationships, of course, need to be honest, and you need to realize that if you have somebody who tends to be somewhat less emotional, less attached,

that may be them, and you'll have to work hard to work with them in that relationship. I think probably the most difficult relationships are those in which people fall into the relationship because often psychopathic individuals are superficially kind of glib and charming but they don't form good stable relationships those people who get into a relationship thinking they're going to oh i'll change them are deluding themselves they're not going to change so you have to be honest with yourself and say well this is the kind of person that

is, is that something I can live with, work with, because you're not going to change them into a different sort of individual? Do you think that there's any cocktail of illicit substances that make someone look more psychopathic? Well, first, the rates of comorbid substance abuse among psychopaths is quite high. One of the characteristics of the psychopathic individual is that their pleasure center, the nucleus accumbens in the brain, is hypoactive. It is underactive. So they tend to be somewhat anhydonic at baseline.

That drives them frequently to seek out thrilling, risk-taking behavior. And that can include things like gambling. and can also include things like taking risks in warfare, and it can include illicit substances. Now, one of the things that happens with many of the illicit substances, including things like the stimulants and alcohol and a-opioids, is those drugs themselves change the pleasure circuit in the brain, the nucleus accumbens and its projections in a negative direction.

it basically makes between the highs that system harder and harder to stimulate so that the person derives less and less pleasure from ordinary everyday events. Oh, yeah. You know, if that system is gradually getting turned off, so it takes bigger and bigger stimuli, well, it becomes harder to enjoy an ice spring day or, you know, a walk in the woods. those just don't do it for the individual anymore. And indeed, one of the things that has driven some of the psychopaths who become serial killers, I think Ted Bundy was a good example of this. In the article I wrote, I quoted him where he talks about being with somebody as they're drawing their last breath and he's looking in their eyes. And he just found that experience thrilling.

And that's part of what drove him to kill. dozens of women. Didn't he say something like it felt like I was God or something like that? Yes. Yes, that ability to have the control over the other person was a thrilling, very powerful experience for him. Oh, chills. So one of my thoughts was like alcohol and methamphetamines at the same time.

I've noticed some of the patients do more antisocial acts with that combination. I don't know if you've seen that in your forensic work. Yes. It's a dangerous combination in the sense that, of course, the alcohol is very good at turning off the prefrontal cortex, the part where you're supposed to be making judgments about what's good, what's bad. Basically, your prefrontal cortex spends an awful lot of time telling you no.

In some ways, it's almost like the parent of the brain. when you have an impulse to do something, most of the time your prefrontal cortex evaluates and goes, that's not a good idea. Don't do that. And really don't do that, you know. Because all of us are the more central part of our brain down around the nucleus accumbens and the ventral tegmentum.

That area generates a lot of impulses. Well, let's do this. Let's do this. Let's do this. And that area feeds forward to the prefrontal cortex. the prefrontal cortex spins most of its ongoing, no, don't do that. Well, if you turn that off, of course, then you have no breaks. At the same time, if you take a drug that increases dopamine, like the amphetamines,

you're pushing that part that generates the impulses into a higher level of activity. So now you've taken your foot off the brake and you've pushed the accelerator all the way to the floor. that's an especially dangerous combination of things to do. The other one was cocaine. Sometimes I see more like people who chronically use cocaine. There's some sort of development of more antisocial traits. Cocaine acts in the same way as the amphetamines in terms of increasing central dopamine. And for all human beings, if you increase dopamine activity in the hypothalamine,

you will increase the impulse to, one, just engage in behavior. One of the ways in animals you can tell if a drug has dopamine properties is if you give it to the animal and the animal simply becomes physically more active, odds are it's a dopamine drug. You're driving, as I said, the gas pedal, you're generating more impulses, some of which will be antisocial because your ventral tegmentum, the hypothalamus, doesn't have a sense of right and wrong. It's not making that judgment. It's simply generating impulses.

Oh, I see a pretty girl. I want to go to bed with her. Oh, I see money. I want to take that. Oh, there's food over there that guy has. It smells pretty good. I want his food. It's the frontal lobe that looks at each of those impulses

and goes, you know, that's a considerable. we can't do that, that'll get us in trouble. So you're constantly having this conversation going on in the brain between the prefrontal cortex and the hypothalamus. If you do something that disturbs the balance of that conversation in the direction of acting on the impulses, well, then you get antisocial behavior. Okay, yeah, that's good, that's good.

Wow, this is such an interesting discussion. Why do you think men have more antisocial than women? Or the psychopathy? Well, yeah, the psychopathy rate is higher in men. That's a fairly consistent finding. The other thing I think that makes the men more easily identified is men, whether psychopathic or not, tend to be more prone to overt violent behavior. and I think that has to do with social roles

going all the way back to our hunter-gatherer days. The guys were the hunters, went out and fought with things, hunted things, fought the other hunter-gatherer groups for dominance, whereas the women were more pro-socialally occupied with maintaining stability of the family, gathering food stuffs and other supplies. you know, I don't want to come off as, oh, this is the way men and women should be, because you know, people can certainly move more fluid than that, but we do live with the, if you will,

the long-term biology that women tend to be more empathetic, more nurturing. Men inherently tend to be a little less so. Now, there's a huge overlap. but in the men who are psychopaths, they're more likely to be overtly violent or destructive. And I think because men are already tending in that direction somewhat, they become more overtly psychopathic. So you think there's like one and archetypal sort of reality here

of the warrior sort of thing. What about testosterone? Testosterone also does play a role in this. You know, any number of studies demonstrate that testosterone tends to increase aggressiveness in general, not only in humans, but in most species. And if you give testosterone to women, they will become more aggressive as well. On the other hand, if you give men oxytocin and estradiol, they'll become less aggressive. these aside from supporting the development of secondary sexual characteristics these sex hormones do directly influence neuron signaling in the brain and indeed the testosterone tends to increase signaling in those circuits that are more associated with physical activity aggressiveness dominance whereas the estrogens tend to produce more activity in those areas of the brain that are associated with being social, being accepting, being supportive.

And I think that underlies some of the inherent differences between men and women at baseline. You know, that's not to say that people have no choices, because I've frankly, I've been in the military, and I've known female officers who were superb military officers and were every bit as dangerous as their male counterparts, if not more so. But in general, if you look at human societies and other primate groups as well, it tends to be the women. who are the supportive empathetic groups and the men are more loners more likely to be aggressive.

Yeah. Yeah. And I hope this doesn't offend anyone, but we're just looking at kind of generalities within science and, you know, sort of differentiations of, you know, it's a spectrum. It's a bell curve.

So maybe the bell curve is shifted one direction for one group more than the other, whereas like men are more aggressive. and assertive, and women are more empathic and open. Yes. You know, and that indeed goes back to perhaps the selections that, aside from men having, on average, more upper body strength, made them the hunters, you know,

and frankly to be hunting and take risks, as we were pointing out earlier, some degree of callousness and fearlessness, is a positive in that context. On the other hand, if you're the person who's organizing the home and being sure that, gee, we're not going to starve to death next winter, it can be very useful to have greater capacities for empathy and social support and group interactions.

And I think those fits, the classic stereotypic models of male and female activity. But those are huge categories with a great deal of flexibility. So one of the sort of shift a little bit to treatment of this group. What are some of your thoughts on pharmacologic treatment of aggression in an antisocial person? There was a study done in the Broadmoor Hospital outside of London, a case series. They took seven psychopathic individuals.

These persons had no other psychopathology. They were not psychotic. They were not mood disordered. All seven were incredibly violent. For example, I think all seven had attempted to kill their roommates at one point or another. They put them all on the antipsychotic medication, Clozapine, which is a very unique molecule. Six of the seven became non-violetion. The seventh had about a two-thirds reduction in their rate of violent behavior.

The area that they think was being affected by this is clozapine increases the signaling of the brain's main on neurotransmitter glutamate. And that tends to improve or increase the activity level in the frontal lobe. The area that we've been talking about is making moral judgments. Um, it's hard to argue a whole lot from a case series because you don't have a control group and you have only seven cases, but it was a pretty impressive result. Uh, that's led people to think about maybe if we could modulate glutamate in the anterior part of psychopathic brains, we could make them a lot less psychopathic. Uh, there's also been research done looking at, um, um,

neurohormones like oxytocin, which tends to support affiliative behaviors. If you give any group oxytocin, they'll tend to become more trusting, more friendly, more empathetic. Some early studies done in psychopathic individuals with oxytocin doesn't make them perfect, doesn't make them entirely normal, but it tends to move them a little bit along that same spectrum. So people are beginning to look at some of these and go, well, you know, especially early on, maybe when they were more adaptable early in their life, what if we began treating them with drugs that

would modulate glutamate or oxytocin, or even if we could learn to stimulate this particular circuits in the brain that we need to be more active? In some ways, this goes all the way back around to the beginning of interest in this. The case of Phineas Gage in 1848, he was a railroad engineer who was using a tamping rod to tamp down an explosive charge

in a rock. The explosive detonated and drove the tamping rod right through the frontal part of his brain. He went from being a very sober, straight-laced, responsible individual to being a somewhat carousing, violent drunk.

Interestingly, however, he got better after a couple of years and actually worked as a stagecoach driver in Chile before he died of status epilepticus in 1860. The area of his brain that got disrupted by this metal rod was really the first evidence that altering those frontal circuits had a profound effect on personality. Yeah, that story really was a very challenging story for me initially to think about how just without that piece of the brain

he became such a different person. Yeah, well, I think it points to, again, this balance, this conversation that's going on between the frontal lobes, the temporal lobes, and the hypothalamus, the balances in those circuits in many ways are what give us our personality characteristics and if you, on his case, this was a 1.1 meter metal rod that was about a half centimeter wide at the end that entered his head and about two centimeters wide at the other end

it literally took a good portion of his frontal lobe and it landed a good 80 yards away from him, disrupting those circuits. Now, some of them were able to heal to some extent, which is likely why he became less of an impulsive, violent, heavy drinking sort of individual after a couple of years.

Yeah, I think this leads to another sort of, I'd be curious where you're at in this conversation. Because we've talked about both, the developmental trajectory. You know, you have these individuals maybe that are wired to have less fear. And then they're subjected to some, you know, kind of torturous childhoods. And so what do you think in terms of like, like, you know, how do we both have empathy and understanding for these people, but also protect ourselves from these people?

And what's the balance there? And, you know, what? Any thoughts? I think one of the major impetus for looking for more effective treatments to both prevent or at least make pro-social versions of persons who have psychopathic characteristics. Well, one, that's protective, of course. If we can turn them into people who aren't criminals, aren't violent, but contribute to society by being our test pilots and our soldiers and so forth, that's one outcome.

for those who are on a pathway to become criminal, that's a good reason to want to look at things like chlozapine or other glutamate drugs or oxytocin or means for shaping their behavior into something that's less dangerous. Because up to this point in time, our primary means for dealing with psychopathic individuals after they commit crimes has been either to execute them, as in the case of, again, Ted Bundy, are John Wayne Gacy and others, or to confine them.

The problem is that most people who are psychopathic, even if they're confined for a period of time, they still wind up returning to the community where they continue to be dangerous. And in fact, even when they are confined, in many cases, they're talented at manipulating others, and they often wind up doing harm even when confined. And so we have a lot of motivation to try to seek ways to produce more pro-social versions of these individuals who start out with this particular biologic substrate. Yeah, so I really see that as a society, you know, as we progress and as we sort of, you know, develop programs to kind of early identify these people, bring them into pro-social groups where there's a lot of structure and a lot of, positive reinforcement to doing good things. I think that's kind of what we're concluding.

Yeah, and I think that may be the way we're going. You know, these are not a group, and I'm not sure that we want to turn them into the the uber empathetic, touchy-feely, utter nice person, because, one, I don't think that's a realistic goal. I think if we can make them people who use whatever nature has given them

in terms of their biologic substrate for positive goals, that may be ultimately the best we can come up with. If we can, right now, at least in Adrian Raine's data, it was 75% criminal, 25% pro-social, if in the long run we can shift that percentage toward more pro-social, less criminal, less violent, then all of us in society will benefit. Yeah, so I think this might be a good place to kind of wrap things up.

I think it's been a really interesting talk and thank you for your time. Oh, you're certainly welcome. This is an area that's, of course, endlessly fascinating in both forensic psychiatry and in the criminal justice system. I think my hope is that maybe someone would listen to this and be inspired to kind of think through what would be the best ways of identifying and then maybe helping this population. shifting it from that 25, 75% split to something more along lines of, you know, maybe 90% turn out to be prosocial. Because I think, you know, this is both, you know, something that could be seen as a detriment to the person who has it,

but also it could be incredibly useful for society to have this group of people protecting the population with fearlessness and doing jobs we don't need fear. Yeah. Yeah. There is, you know, it all has to do with context. Certainly, you know, people who have this sort of lack of response to them is probably one of the most pro-social groups. If you go back to the book and the movie The Right Stuff, Well, the stuff they had was the ability to maintain control under very stressful circumstances. Yeah, wow. Well, I think we'll leave it there.

But thank you, Dr. Cummings, and we'll have you back for another topic. Okay. And all right. Okay. Well, I hope you have enjoyed this episode as much as I have and have learned as much as I have. If you have any questions that come up, feel free to follow one of my social media links and put it on the post that corresponds with this episode. If you have any interest in the book that Dr. Cummings co-authored, violence and psychiatry, I will put a link in my show notes. I will also put a link to Dr. Cummings' CV in my show notes and the list of his multiplicity of awards and papers he's written, which definitely show that he is truly a world expert.

Until next time, have a great day.