What exactly is a psychopath and how does psychopathy manifest ?


Millions recently flocked to the cinema to watch Joker, the origin story of Batman’s notorious nemesis.

Many have commented that the film is a portrait of a textbook psychopath.

But perhaps the bigger question is how many among the audience have similar traits?

Indeed, is it possible that you are a psychopath yourself?

To answer this question, we need to examine the diagnostic criteria for psychopathy presented in the PCL-R, which was developed by Robert Hare in the 1970s.

Thanks to Hare, experts can use the PCL-R to assess whether an individual is exhibiting any of the criteria for psychopathy.

Estimates suggest that about 1% of the population qualifies – although the percentage is thought to be far higher among the prison population (25%) and company chief executives (21%).

The absolute or prototypical psychopath would produce a maximum score of 40 from Hare’s 20-item checklist, while a score of zero would indicate someone with no psychopathic tendencies.

Those with a score of 30 or over should qualify for further assessment and indications of psychopathy, while many criminals score between 22 and 30.

Consequently, psychopathy is perhaps best seen as a spectrum, with all of us exhibiting some traits at some point in our lives.

Ultimately, we cannot assume that nurture – a hard upbringing, for example – will make us psychopathic.

The debate between nature versus nurture has been long discussed in relation to psychopathy and there has yet to be a clear answer.

But it has been suggested recently that while a genetic predisposition is essential for a person to exhibit traits of psychopathy, some environmental factors, such trauma, abuse and rejection by loved ones, could determine the course of the disorder.

Nor should we assume that a person matching some PCL-R criteria is a psychopath.

We must also keep in mind that not all psychopaths are criminals.

Many are successful professionals, so a high PCL-R score does not necessarily make us dangerous or murderous.

Patrick Bateman, the blood-spattered anti-hero of Brett Easton Ellis’s infamous 1991 novel American Pycho, certainly is a psychopath – but not all psychopaths are Patrick Bateman.

Nevertheless, psychopaths are clearly relatively common – so how can we spot one? After all, if a person is a psychopath, they will rarely accept it or advertise the fact.

The psychopath test

The first characteristic of a psychopath according to the PCL-R is glib and superficial charm.

Of course, this can be an apparently positive characteristic.

This is not a trait motivated by a genuine interest or empathy for others, however, but allows psychopaths to charm and manipulate those around them, from work colleagues to romantic partners.

Gaslighting – whereby others are led to question their own actions and beliefs – may be a favoured strategy.

Another key characteristic is a grandiose sense of self-worth. Of course, this profound sense of confidence or self-belief may explain why so many psychopaths appear to thrive in the cutthroat world of business.

Unfortunately for their colleagues and “friends”, however, psychopaths also tend to make themselves look better by belittling those around them and may lie pathologically.

Keep an eye out for narcissists.

Other criteria on the PCL-R checklist include a lack of remorse or guilt, callousness, a parasitic lifestyle and promiscuous sexual behaviour.

Psychopaths, in short, tend to be risk takers and may be less likely to show, or feel, fear.

Consequently, psychopathy is perhaps best seen as a spectrum, with all of us exhibiting some traits at some point in our lives.

But they’re not always cool operators.

One characteristic that is both obvious and common is poor behavioural control, which is perhaps linked to psychopaths being more likely to have a history of juvenile delinquency.

Psychopaths tend to have a good eye for seeing and emulating how others behave, but they may also have outbursts of antisocial behaviour.

Based on the above, my thought is that the Joker – or at least Arthur Fleck, the man behind the makeup – is only a borderline psychopath, with other mental health problems that would warrant further investigation first.

There are certainly more real-life psychopaths that would score higher in Hare’s test.

The key question is, based on the above, whether you might be one of them and how you intend to use these traits and skills.

Personality disorders (PDs) can be described as the manifestation of extreme personality traits that interfere with everyday life and contribute to significant suffering, functional limitations, or both.

They are common and are frequently encountered in virtually all forms of health care. PDs are associated with an inferior quality of life (QoL), poor health, and premature mortality.

The aetiology of PDs is complex and is influenced by genetic and environmental factors.

The clinical expression varies between different PD types; the most common and core aspect is related to an inability to build and maintain healthy interpersonal relationships.

This aspect has a negative impact on the interaction between health-care professionals and patients with a PD.

From being discrete and categorical disease entities in previous classification systems, the current concept of PD, reflected in the newly proposed ICD-11, is a dimensional description based on the severity of the disturbed functioning rather than on the type of clinical presentation.

Insight about the characteristics of PDs among medical practitioners is limited, which is partly because persons do not seek health care for their PD, but instead for other medical issues which are obscured by their underlying personality problems.

What needs to be emphasized is that PDs affect both the clinical presentation of other medical problems, and the outcome of these, in a negative manner and that the integrated effects of having a PD are a shortened life expectancy. Accordingly, PDs need to be recognized in clinical practice to a greater extent than previously.


In everyday clinical practice persons who think, feel, behave, or relate to others differently than the average person are identified. This deviation from the norm is a central feature in all personality disorders (PDs). Although using slightly different formulations over the years, PDs are roughly characterized by ‘a pervasive pattern of thought, feeling and behaviour that characterize an individual’s unique lifestyle and mode of adaptation, which deviates markedly from the expectations of the individual’s culture’ (1). Such characteristics obviously create problems for those who bear them. PDs are likely to have an onset in adolescence or early adulthood, appear to be stable over time, and lead to impairment or distress (1,2).

This review, which is an overview on PDs and the core problems these ultimately lead to, is commenced with some background information about the concept of personality and on the attempts that have been made to understand and to describe different characteristics of personality, how these characteristics can be structured and understood, and about the deviations in normal personality that form the basis for the different types of PD.

Above all, the paper focuses on problems met in primary and specialist health care. Such problems are common, and persons with PDs are known to be under-treated with respect to physical health (3) and are over-represented in the group categorized as the ‘difficult patient’ (4,5).

ems are common, and persons with PDs are known to be under-treated with respect to physical health (3) and are over-represented in the group categorized as the ‘difficult patient’ (4,5).

The present paper argues that all health-care professionals need basic knowledge about manifestations of different personality traits, above all in the form of manifest PDs, as we know that such pathology has a negative effect on the interaction between the patient and health-care professionals in terms of communication, clinical assessment, treatment, and outcome (6).

The patients’ suffering is considerable, and generally they report a low QoL (7,8). Having a PD also infers a risk factor for premature mortality (9,10), which affects individuals and incurs a high cost to society (11).

A historic perspective of aberrant personalities

The large variation in the way individuals think, feel, and behave has been recognized throughout antiquity. The terms for these characteristics have been diverse. For instance, Confucius (551–479 BCE) used the combination of ‘blood and vital essence’. The Greek philosopher and naturalist Theophrastus (c. 371 to c. 287 BC) used the term ‘characters’, and in eighteenth-century France the Galenus–Hippocrates term ‘temperament’ was reinstituted. The term ‘personality’ has been used since the eighteenth century to label distinguishing qualities of a person (12).

Pathological personalities have also generated interest over the years. Since the fourth century BC, philosophers have been trying to understand what it is that makes ‘us’ what we are. Theophrastus, a scholar of Plato and Aristotle, was the first to publish a systematic description of the multifaceted nature of personality types (12).

A few hundred years later, Aelius Galenus (130–200 AD) linked Hippocrates’ four humours to personality characteristics in his description of sanguinephlegmaticcholeric, and melancholic temperaments. He proposed that each of these four body fluids held a combination of two properties split along two axes: temperature (hot/cold) and humidity (wet/dry).

The humoral pathology system influenced the view among European doctors until the breakthrough of medical science in the nineteenth century.

In the early nineteenth century, Franz Joseph Gall (1758–1828), a German neuroanatomist, thought that some brain areas were associated with specific functions. He also thought that measurements of the skull represented differences in the individual’s personality (13).

Philippe Pinel (1745–1826), a French physician, was the first to include an aberrant personality in the nosology of psychiatry (14). Pinel introduced the term ‘manie sans délire’ (mania without delusion).

During that time, the term ‘mania’ was employed to refer to states of agitation. Pinel described a few of his male patients who were disposed to bursts of irrational anger and impulsive violence in response to minor irritation. In the same intellectual environment Jean-Étienne Dominique Esquirol (1772–1840) introduced the concept monomanie raisonnante and the Englishman James Cowles Prichard (1786–1848) used the term moral insanity.

These three physicians were obsessed by the practical question at that time whether psychiatry could explain abnormal behaviour in persons lacking acute psychiatric symptoms who had committed a violent crime (14).

During the late nineteenth and early twentieth century, several conceptual systems for normal and abnormal personalities emerged as the result of the work of European psychologists and psychiatrists (e.g. Ribot, Heymans, Lazursky, Schneider, and Sjöbring).

Théodule Ribot (1839–1916), a French psychologist, described normal and abnormal characters. He pointed out that a person’s character is stable from childhood into adult life. Ribot described three primary personality types: the sensitive, the active, and the apathetic, all three of which were divided into subtypes (15).

The Dutch scientist Gerard Heymans (1857–1930) applied empirical methods to the study of personality. He developed the Cube of Heymans, a description of a personality typology. He defined personality types in three dimensions: ‘activity level’, ‘emotionality’, and ‘primary versus secondary functioning’, with the last-mentioned dimension comparable to ‘extroversion/introversion’. These three dimensions are represented on the x-, y-, and z-axes of the Heymans cube, where all combinations of the three dimensions defined eight personality types (16).

The contributions of Aleksandr Lazursky (1874–1917), a Russian psychologist, were not widespread because most of his publications were in Russian and because of the political climate of the time. His major contribution was the description of the ‘endopsychic’ and ‘exopsychic’ aspects of personality. The endopsychic components represent the psychological functions (e.g. perception, memory, attention, thinking) that are mainly inborn; the exopsychic components are the consequence of the interaction with the outside world. The interplay between these two aspects of personality determines how a person functions in an integrated social context (17).

The German psychiatrist Kurt Schneider (1887–1967) focused on diagnostic issues that included concepts of ‘psychopathy’, which he had broadly equated to PDs. Based on his clinical views (18), he vaguely defined abnormal personality as a statistical deviation from the norm. He proposed 10 psychopathic personalities, all of which are very similar to those in the current classifications of PDs in the DSM-5 and ICD-10 (19).

Henrik Sjöbring (1879–1956), a Swedish psychiatrist, suggested four constitution factors of the personality: capacity (intelligence), validity (psychic energy), stability (balance in keynote), and solidity (firmness, tardiness, tenacity). By these variables, all persons can be categorized as either normal, super-, or sub-: e.g. subcapable (unintelligent), subvalid (lack of psychic energy), normosolid, superstable, and so on (20).

The first modern attempt to determine the structure of human personality was credited to the English scientist Sir Francis Galton (1882–1911). He used a lexical approach to the dimensions of personality based on the assumption that those personality characteristics important to a group of people will eventually be represented in their language (21). This work was continued by several others (22), and the lexical hypothesis constitutes the basis for how current approaches describe personality dimensions. It is also important to mention the work of the psychologists Raymond Bernard Cattell (1905–1998) (23) and Gordon Willard Allport (1897–1967) (24) who independently used advanced statistics (e.g. factor analysis) to discern dimensions of personality.

Modern concepts of personality disorder and personality

Before discussing this issue, it needs to be re-emphasized that the description of personalities is based purely on observations, or rather expressions, of the individual’s way to think, feel, behave, or relate.

As a corollary, it follows that PDs are diagnoses based on symptoms described by the persons themselves, by persons in their surroundings, or are objectively observed in study situations.

This circumstance accounts for why the validity and reliability of the current diagnostic instruments lack optimality (25).

Current knowledge on pathological personalities is primarily based on studies from four perspectives, all of which are necessary to create an in-depth template of what characterizes personality pathology.

The first perspective is the clinical picture, i.e. the integrated presentation of the clinical symptoms that are either expressed or witnessed.

This perspective is what constitutes the basis for the clinical structured diagnosis according to classification systems. The second perspective entails a determination of underlying dysfunctional personality traits as well as dysfunctional limitations on capacity and functionality in the brain’s cognitive, emotional, and impulse control systems.

The third perspective relates to the brain’s biological systems and their functions; this third perspective has highly benefited from the rapid development of brain imaging techniques (26).

The fourth perspective denotes the underlying genetic contribution to the above-mentioned phenomena (27), which is currently approached in whole-genome association studies (28).

Not unexpectedly, studies have shown that the aetiology of personality pathology is complex. Overwhelming evidence supports the idea that an interaction between genetic and environmental factors is necessary for the development of human personality.

The relation between the dimensions of normal personality and PD is not clear, however. Even if a PD has been viewed as an overexpression of personality traits to the extent that they lead to clinically significant distress or impairment, it has recently been demonstrated that a moderate-to-sizable proportion of the genetic influence underlying PD is not shared with the domain constructs of normative personality (29).

Based on the hypothesis that the domains of dysfunction in PDs are linked to specific neural circuits, neuroimaging techniques have been used over the past decade to examine the neural integrity of these circuits in personality-disordered individuals.

Currently, the literature is flooded with information acquired through this approach. Most studies are done to explore borderline PD (30). In general, the studies have thus far demonstrated deviations in neuronal circuitry in areas previously found to be active in the symptomatology that characterizes the specific type of PD. Even if the results of such studies contribute to an understanding of underlying physiological processes, they are not yet ready to be used in clinical practice.

Several studies have examined the effects of being exposed to childhood adversities and the risk to develop PD. Just to mention one such study, we recently showed that exposure to cumulative childhood adversity was incrementally associated with a diagnosis of PD in young adulthood (31).

Furthermore, childhood or adolescent psychiatric disorders have been suggested to trigger a chain of behaviours and responses that foster the more persistent psychopathology of a PD (32,33).

To determine the importance of genetic and environmental factors in early childhood in personality pathology the relationship between vulnerability to child abuse and antisocial personality patterns in adulthood was investigated (34).

It was shown that individuals with a gene polymorphism that resulted in a low activity in monoamine oxidase A (MAOA) were more vulnerable to developing an antisocial personality pattern than those who had high activity in the MAOA gene, given that they had been exposed to child abuse.

This gene–environment interaction has subsequently been confirmed (35). Moreover, a similar interaction for the effects of child maltreatment on antisocial behaviour has also been shown for other genes (36,37).

There is thus reason to consider genetic and environmental factors as interacting systems of crucial importance in the development of functional and dysfunctional personality traits.

Classification of personality disorders

The differences in the types of aberration in thought, feeling, and behaviour have been the basis for the classification of different PDs.

The characteristics described by Galenus, and later by e.g. Pinel and Schneider, are very similar to contemporary classification systems. What today are referred to as PDs were earlier called ‘pathological personalities’ or ‘persona pathologica’ and were found under that heading in earlier versions of the ICD (up to ICD-8). These diagnoses were used rarely, in part because of their stigmatizing connotations.

Up to now, classification of PDs has been based on fulfilling a specified number of defined and ‘specific’ criteria for each PD, resulting in a categorical description; if a defined number of these criteria were met, a disorder was acknowledged, else not.

Over time, there has been an intraprofessional dispute on whether the classification of PDs should be based on the defined and specific characteristics or on the severity of the functional aberration. Historically, and currently, in the ICD-10 (which is from 1992) and in the current American DSM-5 (38) (from 2013) classification is based on types of symptom, i.e. characteristics of the clinical presentation, represented by the abovementioned ‘specific’ criteria for each PD. ICD-10 describes nine discrete and specific (as well as one unspecified) types of PD (Table 1).

The DSM-5 (38) identifies 10 PDs of similar structure. The DSM system has gone one step further in classification by grouping the different disorders in three clusters based on some overall common features. To illustrate, cluster A contains odd and eccentric personalities, cluster B includes dramatic, impulsive, emotional personalities, and cluster C fearful and anxious personalities.

Table 1.

Personality disorders in the ICD-10 (2).

CodeDisorderCharacteristics in brief
F60.0ParanoidExcessive sensitivity to setbacks, unforgiveness of insults, recurrent suspicions without justification regarding the sexual fidelity of the spouse or sexual partner, and a combative and tenacious sense of personal rights.
F60.1SchizoidWithdrawal from affectional, social, and other contacts, preference for fantasy, solitary activities, and introspection. Limited capacity to express feelings and to experience pleasure.
F60.2DissocialDisregard for social obligations, callous unconcern for the feelings of others. Gross disparity between behaviour and prevailing social norms. Behaviour not readily modifiable by adverse experience, including punishment. Low tolerance to frustration; low threshold for discharge of aggression, including violence; tendency to blame others, all leading to conflict with society.
F60.3Emotionally unstableA tendency to act impulsively and without consideration of the consequences; unpredictable and capricious mood. Liability to outbursts of emotion and incapacity to control the behavioural explosions. Tendency to quarrelsome behaviour and to conflicts with others. Two types are distinguished: the impulsive type with emotional instability and lack of impulse control; and the borderline type, with added disturbances in self-image, aims, and internal preferences, chronic feelings of emptiness, intense and unstable interpersonal relationships, and a tendency to self-destructive behaviour, including suicide gestures and attempts.
F60.4HistrionicShallow and labile affectivity, self-dramatization, theatricality, exaggerated expression of emotions, suggestibility, egocentricity, self-indulgence, lack of consideration for others, easily hurt feelings, and continuous seeking for appreciation, excitement, and attention.
F60.5AnankasticFeelings of doubt, perfectionism, excessive conscientiousness, checking and preoccupation with details, stubbornness, caution, and rigidity. There may be insistent and unwelcome thoughts or impulses that do not attain the severity of an obsessive-compulsive disorder.
F60.6Anxious [avoidant]Feelings of tension and apprehension, insecurity and inferiority. A continuous yearning to be liked and accepted, hypersensitivity to rejection and criticism with restricted personal attachments, and a tendency to avoid certain activities by habitual exaggeration of the potential dangers or risks in everyday situations.
F60.7DependentPervasive passive reliance on other people to make one’s major and minor life decisions, great fear of abandonment, feelings of helplessness and incompetence, passive compliance with the wishes of elders and others, and a weak response to the demands of daily life. Lack of vigour may show itself in the intellectual or emotional spheres; often a tendency to transfer responsibility to others.
F60.8Other specificEccentric, ‘haltlose’ type, immature, narcissistic, passive-aggressive, psychoneurotic.
F60.9UnspecifiedDiffuse symptoms, not fully qualifying for specific PD, but with the general criterion fulfilled.

A basic feature common for the different classification systems is that the aberration must be severe enough to cause a functional impairment in everyday life. This is the ‘general criterion’ for all PDs and overrides other perspectives. In other words, even the observance of very odd behaviour or feelings is not enough for a clinical diagnosis of a PD unless it can be ascertained that they lead to impairment or distress in everyday life.

Currently, there is somewhat of a paradigm shift in that more and more arguments speak for the relevance of a dimensional classification of PD based on the severity of symptoms rather than on the specific characteristics (19). Studies have, thus, shown that the conceptualization of PDs into discrete categories results in an insufficient description of the problem.

Rather, it seems that within each discrete PD category the level of dysfunction is dimensional and dependent on the number of criteria fulfilled (39). Furthermore, only about half of all individuals with diagnosable PD fulfil criteria for a specific PD and are thus given a diagnosis of unspecified PD (40). In addition, the expression of different symptoms evolves continuously across the lifespan (41).

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