Psychopathy: What Mental Health Professionals Need to Know

The media commonly uses the term “psychopath” to refer to persons, generally criminals, who act outside of the moral sphere. They may be real, like Ted Bundy or Charles Manson, or characters such as Hannibal Lector or Dexter Morgan – the lines between the fanciful and the factual can become blurred in our imagination. However, psychopathy is an important concept in forensics, and is increasingly prominent in mental health studies, and thus deserving of measured consideration.

Characteristically, a psychopath is defined as having such traits as charming, manipulative, deceitful, emotionally shallow, callous, impulsive, irresponsible, blasé, extravagant, and directionless (Hare, 2003). While the prevalence of psychopathy among the general population is estimated to be around 1-2% (Newman & Hare, 2008), it is thought to exist in around 30% of prison populations (Hart & Hare, 1997). Mental health professionals must be aware of several key points when dealing with the label of psychopathy.

  • Although considered to be a disorder of personality, there has never been an entry for psychopathy in the Diagnostic and Statistical Manual of Mental Disorders (DSM) as of its fifth edition. Psychopathy is sometimes considered to be similar to Antisocial Personality Disorder, which is an Axis II disorder in the DSM; yet, there are a number of important differences.  Namely, Antisocial Personality Disorder does not feature the emotional deficits and lack of complex human emotions and attachments that are the hallmark features of psychopathy.
  • When psychopaths are portrayed in the media, it is often as violent serial killers (i.e. Dexter, Hannibal Lector). However, violence and criminality are actually not diagnostic features of psychopathy (Skeem & Cooke, 2010).  Individuals with psychopathic personality features can be found in a number of professions such as business, politics, law enforcement, and entertainment (Lykken, 1995).
  • Psychopathy is often assessed using the Psychopathy Checklist, which is a 20-item semi-structured interview that takes about three hours to administer (PCL-R; Hare, 2003). The assessment must be administered by a trained clinician.  Each item is scored as a 0, 1, or 2, and a total score above 30 typically classifies an individual as a psychopath.  The PCL-R is used for assessing psychopathy in a wide variety of clinical, legal, and research settings.
  • Many scholars believe that there is more than one type of psychopath. A common distinction is between primary psychopaths (who show an emotional deficit and are charming, grandiose, and cunning) and secondary psychopaths (who show an emotional disturbance and are impulsive, irresponsible, and have poor behavioral control) (Skeem, Polaschek, Patrick, & Lilienfeld, 2011).  Theoretically, primary psychopathy is more biologically based, resulting in an emotional deficit.   In contrast, secondary psychopathy is more environmentally based, resulting in an emotional disturbance.
  • Studies have found that psychopathy is about 50% genetic and 50% environmental (Blonigen, Hicks, Krueger, Patrick, & Iacono, 2005). Environmental risk factors include child abuse, social disadvantage, and lack of parental involvement (Peterson, Skeem, Kennealy, & Camp, under review).
  • For many years, psychopathy was considered impossible to treat. However, new studies are showing that although psychopaths are difficult to treat (as they are often unpleasant, disruptive, noncompliant), they still show improvement if they receive adequate doses of treatment (Salekin, 2002). Cognitive-behavioral programs to treat psychopathy are currently being developed and evaluated.

There are a number of controversies still surrounding the definition, assessment, and treatment of psychopathic individuals.  For example, is psychopathy a category of people, or should psychopathic personality features be scored along a continuum?  Are there “successful psychopaths” who do not engage in antisocial behavior?  Whether the designation of psychopath is valid across gender, race, and culture is also unsettled.

For mental health professionals, “psychopath” is a label that may carry important implications for treatment and programming.  Rather than cast aside psychopathic individuals as untreatable, it is important to understand that there are different forms of psychopathy with different etiological backgrounds.  Psychopathic patients can be approached in mental health settings as high-risk individuals who are appropriate targets for intensive services.

Jillian Peterson, Ph.D., is an Assistant Professor of Criminology and Criminal Justice at Hamline University in St. Paul, where she teaches classes in forensic psychology and research methods.  She has a Ph.D. in Psychology and Social Behavior from the University of California, Irvine with an emphasis on Psychology and Law.  Dr. Peterson previously worked as a special investigator on death row cases in New York City, as a research coordinator at the University of Minnesota, and as a jury and trial consultant.  She has published multiple articles related to risk assessment, psychopathy, mental illness and crime, and school shootings. 

Jerrod Brown, MA, MS, MS, MS, is the Treatment Director for Pathways Counseling Center, Inc. Pathways provides programs and services benefiting individuals impacted by mental illness and addictions. Jerrod is also the founder and CEO of the American Institute for the Advancement of Forensic Studies (AIAFS), lead developer and program director of an online graduate degree program in Forensic Mental Health from Concordia University, St. Paul, Minnesota, and the Editor-in-Chief of Forensic Scholar Today.  Jerrod is currently in the dissertation phase of his doctorate degree program in psychology.


Blonigen, D. M., Hicks, B. M., Krueger, R. F., Patrick, C. J., & Iacono, W. G. (2005). Psychopathic personality traits: Heritability and genetic overlap in internalizing and externalizing psychopathy. Psychological Medicine, 35, 637-648.

Hare, R. D. (2003). The Hare Psychopathy Checklist-Revised (PCL-R) manual (2nd ed.).  Toronto, Ontario, Canada: Multi-Health Systems.

Hart, S.D., & Hare, R.D. (1997). Psychopathy:  Assessment and association with criminal conduct. In D.M. Stoff, J. Breiling, & J. Maser (Eds.) The handbook of antisocial behavior (pp. 22-35). New York: Wiley.

Lykken, D.T. (1995).  The Antisocial Personalities.  Hillsdale, NJ:  Lawrence Erlbaum Associates Inc.

Neumann, C.S., & Hare, R.D. (2008). Psychopathic traits in a large community sample:  Links to violence, alcohol use, and intelligence.  Journal of Consulting and Clinical Psychology, 76(5): 893–9.

Peterson, J.K., Skeem, J.L., Kennealy, P., & Camp, J. (in press). Primary and secondary psychopathy: Exploring the role of neighborhood factors.  Criminal Justice and Behavior.

Salekin, R.T. (2002).  Psychopathy and therapeutic pessimism: Clinical lore or clinical reality?  Clinical Psychology Review, 22, 79-112.

Skeem, J., & Cooke, D. (2010). One measure does not a construct make: Toward reinvigorating psychopathy research. Reply to Hare & Neumann (2010). Psychological Assessment, 22, 455-457. doi:10.1037/a0014862

Skeem, J., Polaschek, D., Patrick, C., & Lilienfeld, S. (2011). Psychopathic personality: Bridging the gap between scientific evidence and public policy. Psychological Science in the Public Interest, 12, 95-162.

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