Psychopathy: A disorder or an evolutionary strategy?

Psychopathy: A disorder or an evolutionary strategy?I am writing to discuss an interesting construct in psychiatry often referred to as ‘psychopathy’. In psychiatry there is often
lively debate about how we should classify and define psychopathology, influenced by cultural factors as much as scientific
advances. In this letter I wish to explore the somewhat controversial idea that, instead of being a disease or pathology, psychopathy can be viewed as a natural variant in human personality. In other words, psychopathy may be a phenotype resulting from various adaptive strategies occurring throughout evolution.

Psychopathy is a term describing a particular constellation of personality traits and behaviours, sometimes viewed by the medical community and society as a disorder or pathology. The Hare Psychopathy Checklist, Revised (PCL-R) is the traditional measure used to define and assess psychopathy.

Factor 1 traits
Lack of guilt/remorse
Lack of empathy
Factor 2 traits
High impulsivity
Poor behavioural control
Criminal versatility

Box 1. The Hare PCL-R defines psychopathy as a combination of key interpersonal and affective deficits (Factor 1) and socially deviant behaviours (Factor 2) [1]

Although psychopathy is sometimes perceived as being synonymous with the DSM-5 diagnosis of antisocial personality disorder,
this is largely incorrect. Antisocial personality disorder focuses more on outwardly observable criminal behaviours, whereas
psychopathy takes into account personality traits that are less readily observable. These differences have been discussed elsewhere.[3]

The concept of psychopathy as an adaptive strategy is well discussed by Glenn et al. [4] Unlike schizophrenia and other mental
disorders that are clearly harmful or maladaptive for the individual, psychopathy is not so clear-cut. One can even argue
that the greatest danger of psychopathy is harm to society, rather than harm to the affected individual. Certain traits associated with psychopathy (such as fearlessness and superficial charm) may have been beneficial to the individual in the ancestral environment, existing as a social strategy to increase survival and reproductive success.[4] Even in today’s society, it seems that traits such as fearlessness and low stress reactivity may sometimes help a person to perform well in high-stress occupations (e.g. executive management, politics, military).

Psychopathy may be more common than we expect. The idea of ‘successful’ and ‘unsuccessful’ psychopaths further complicates the pathology vs. strategy debate. Most studies have been unable to find a clear correlation between psychopathy and intelligence. [5] According to Hare, ‘successful’ psychopaths are commonly described as intelligent, successful and high-functioning
individuals, with no criminal convictions and variable integration into society. These individuals are usually more difficult
to identify and study. [6] ‘Unsuccessful’ psychopaths typically describe the cohort encountered in forensic settings, individuals who regularly run into trouble with the law (and are hence easier to identify and study). [6] Consequently, it is this population from whom we derive the bulk of our knowledge and research on psychopathy. If we are only identifying a subset of psychopaths, psychopathy on the whole may be more ubiquitous in society than we think.

Further research is still required into many aspects of psychopathy. Whether the traits associated with psychopathy represent true pathology is still open to debate. Although a diagnosis of psychopathy has the practical benefit of directing treatment in the forensic setting (e.g. towards behavioural change and control therapies instead of empathy and social skills training), [7] the psychopath label carries considerable stigma and possible social, psychological and legal consequences for the individual. An example is the difference in criminal sentencing in certain countries. [8] For personality traits to constitute a disorder
in the DSM-5, there must be significant distress or functional impairment caused to the individual. Although psychopathy
is not a personality disorder in the DSM-5, it is interesting to note that ‘successful’ psychopaths may experience neither of these.

In conclusion, the aim of this article was to put forth an alternative view on psychopathy. Rather than to comment on management or the correctness of any particular viewpoint, I hope to have highlighted some of the complexities surrounding human personality and behaviour through this brief discussion on psychopathy.

Conflict of interest

None declared.


K Cheng:


[1] Hare RD. Manual for the Hare Psychopathy Checklist-Revised. 2nd ed. Toronto, ON: Multi-Health Systems; 2003.

[2] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition.

[Internet] 5th ed. Arlington, VA: American Psychiatric Association; 2013 [cited 2014 April 5]. Available from:

[3] Ogloff JRP. Psychopathy/antisocial personality disorder conundrum. Aust N Z J Psychiatry. 2006 Jun;40(6-7):519-28.

[4] Glenn AL, Kurzban R, Raine A. Evolutionary theory and psychopathy. Aggress Violent Behav. 2011 Sep;16:371-80.

[5] Blair J, Mitchell D, Blair K. The psychopath: emotion and the brain. Oxford, UK: Blackwell Publishing; 2005.

[6] Babiak P, Hare RD. Snakes in suits: when psychopaths go to work. New York: Harper Collins Publishers; 2006.

[7] McMurran M. Motivating offenders to change: a guide to enhancing engagement in therapy. UK: John Wiley & Sons; 2002.

[8] Kiehl KA, Sinnott-Armstrong WP. Handbook on psychopathy and law. USA: Oxford University Press; 2013.

Book Reviews

Good Medical Practice: Professionalism, Ethics and Law

Breen KJ, Cordner SM, Thomson CJH, Plueckhahn VD. Good Medical Practice: Professionalism, Ethics and Law. Port Melbourne: Cambridge University Press; 2010.

RRP: $75.00

Anyone brave enough to write a textbook about Australian law quickly runs into an almost insurmountable obstacle: federalism. In effect, Australia has nine jurisdictions. The number of activities that are illegal in one jurisdiction (usually Queensland) whilst positively encouraged in another (usually the ACT) is myriad. Producing a textbook for a national audience that covers these jurisdictional variations comprehensively without boring the reader senseless is a challenge.

Not satisfied with simply exploring the complexities of the Australian legal system as it affects medical practice, however, the authors of Good Medical Practice: Professionalism, Ethics and Law decided to examine ethics and professionalism as well. Drawing together these three systems that govern appropriate conduct was surely a Herculean task, but it has resulted in a thoroughly readable and useful book.

The authors’ decision to combine ethical, legal and professional principles has allowed them to distil key concepts and provide comprehensive, practical guidance without overwhelming the reader. For example, a chapter on the complex legislative regimes surrounding the issue of privacy could usually be expected to leave the reader confused, or possibly even sobbing. Here, the heavy legal content of the chapter is rendered almost redundant by the authors’ perceptive preface that doctors who adhere to ethical principles of preserving patient confidentiality are unlikely to fall foul of privacy law. If you choose to stop reading after that point is made, you probably already know enough to avoid a major problem.

This “all-in-one” approach acknowledges the interaction between law, ethics and being a good doctor. It is the key to the success of this book. Complex legal and ethical ideas are conveyed succinctly, within the framework of practical advice on how to conduct oneself professionally. The authors’ tips on preventing unfortunate outcomes – such as formal complaints, lawsuits or drug-fuelled meltdowns – are sensible and worth reading even if you skip just about everything else.

First-year medical students and international graduates will find the chapter explaining the ins and outs of Australia’s health system valuable; a chapter on the professional responsibilities and regulation of other health care workers is also useful for those experiencing their first exposure to multi-disciplinary teams. Chapters covering issues relevant to clinical research, prescribing, entering practice, and the ethical allocation of health care resources are likely to be useful to later-year students and junior doctors.

There are a few problems with the text, however. For example the chapter on the Australian legal system appears towards the end of the book. I’d suggest reading it first, to avoid confusion when legal terms are encountered. In addition, unfortunate timing has meant that the chapter on the regulation of the profession does not address the new regime of national registration, but the general principles it outlines are still relevant.

Overall, the book is well-structured, easy to use, and succinct without sacrificing clarity. For those who would like more information, there are some good resources suggested at the end of each chapter. For the most part, however, it will be unnecessary to consult an additional text if one requires simply a good working knowledge of relevant ethical and legal principles.

It is perhaps disappointing that a book exploring ethical concepts is not more thought-provoking (in this line, I’d recommend Annas’ excellent, if somewhat dated, book [1]), but it seems that the authors have elected to guide rather than challenge their readers. In this they have been successful.

In short, Good Medical Practice delivers exactly what its title promises: succinct information about the ethical and legal responsibilities of medical practitioners (and students) within a broader professional context. The intended audience of medical students and junior doctors is likely to benefit from some time spent reading this book.

Conflicts of Interest

None declared.


[1] Annas GJ. Standard of Care: The Law of American Bioethics. New York: Oxford University Press; 1997.

Original Research Articles

A survey of the ophthalmic presentations and their outcomes to a general hospital Emergency Department over twelve months


Aim: To survey the diagnoses and discharge status of the ophthalmic presentations to a general emergency department (ED). To compare the ED diagnosis with the ophthalmologist diagnosis of referred patients. Methods: A retrospective analysis of all the ophthalmic presentations to the Gosford District Hospital from 1 January 2005 to 31 December 2005 was carried out. All referrals to and admissions by ophthalmologists were reviewed for the final diagnosis. These outcomes were compared to the initial ED diagnosis. Results: There were 509 ophthalmic presentations to the ED in 2005: 51% had corneal trauma, 14% had an unspecified red or painful eye, 9% had an unspecified eye injury and 5% had blurred vision. Most patients were discharged without referral. Twenty-two percent of patients were referred to an ophthalmologist. Four percent were admitted and transferred to Sydney Eye Hospital. In those who were referred, 13% did not have records at the specified ophthalmologist, 24% were not recorded to which specialist they were referred and 26% had significantly different specialist opinion. Conclusions: More than half of ED ophthalmic presentations were for corneal trauma and only 22% of patients were referred to an ophthalmologist, while most were treated solely in the ED or referred to general practice. Potentially vision-threatening misdiagnoses included three cases of iritis, three of keratitis and two of retinal artery occlusion. ED diagnoses of corneal problems matched exactly with ophthalmic opinion. Interestingly, recording of the visual acuity occurred in only 27% of cases.