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Deming P, Griffiths S, Jalava J, Koenigs M, Larsen RR. Psychopathy and medial frontal cortex: A systematic review reveals predominantly null relationships. Neurosci Biobehav Rev 2024; 167:105904. [PMID: 39343080 DOI: 10.1016/j.neubiorev.2024.105904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 08/20/2024] [Accepted: 09/22/2024] [Indexed: 10/01/2024]
Abstract
Theories have posited that psychopathy is caused by dysfunction in the medial frontal cortex, including ventromedial prefrontal cortex (vmPFC), anterior cingulate cortex (ACC), and dorsomedial prefrontal cortex (dmPFC). Recent reviews have questioned the reproducibility of neuroimaging findings within this field. We conducted a systematic review to describe the consistency of magnetic resonance imaging (MRI) findings according to anatomical subregion (vmPFC, ACC, dmPFC), experimental task, psychopathy assessment, study power, and peak coordinates of significant effects. Searches of PsycInfo and MEDLINE databases produced 77 functional and 24 structural MRI studies that analyzed the medial frontal cortex in relation to psychopathy in adult samples. Findings were predominantly null (85.4 % of 1573 tests across the three medial frontal regions). Studies with higher power observed null effects at marginally lower rates. Finally, peak coordinates of significant effects were widely dispersed. The evidence failed to support theories positing the medial frontal cortex as a consistent neural correlate of psychopathy. Theory and methods in the field should be revised to account for predominantly null neuroimaging findings.
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Affiliation(s)
- Philip Deming
- Department of Psychology, Northeastern University, Boston, MA, United States.
| | - Stephanie Griffiths
- Department of Psychology, Okanagan College, Penticton, BC, Canada; Werklund School of Education, University of Calgary, Calgary, AB, Canada
| | - Jarkko Jalava
- Department of Interdisciplinary Studies, Okanagan College, Penticton, BC, Canada
| | - Michael Koenigs
- Department of Psychiatry, University of Wisconsin-Madison, Madison, WI, United States
| | - Rasmus Rosenberg Larsen
- Forensic Science Program and Department of Philosophy, University of Toronto Mississauga, Mississauga, ON, Canada
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Defendini A, Jenkins AC. Dissociating neural sensitivity to target identity and mental state content type during inferences about other minds. Soc Neurosci 2023; 18:103-121. [PMID: 37140093 DOI: 10.1080/17470919.2023.2208879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Predicting and inferring what other people think and feel (mentalizing) is central to social interaction. Since the discovery of the brain's "mentalizing network", fMRI studies have probed the lines along which the activity of different regions in this network converges and dissociates. Here, we use fMRI meta-analysis to aggregate across the stimuli, paradigms, and contrasts from past studies in order to definitively test two sources of possible sensitivity among brain regions of this network with particular theoretical relevance. First, it has been proposed that mentalizing processes depend on aspects of target identity (whose mind is considered), with self-projection or simulation strategies engaging disproportionately for psychologically close targets. Second, it has been proposed that mentalizing processes depend on content type (what the inference is), with inferences about epistemic mental states (e.g. beliefs and knowledge) engaging different processes than mentalizing about other types of content (e.g. emotions or preferences). Overall, evidence supports the conclusion that different mentalizing regions are sensitive to target identity and content type, respectively, but with some points of divergence from previous claims. Results point to fruitful directions for future studies, with implications for theories of mentalizing.
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van de Groep IH, G N Bos M, Jansen LMC, Popma A, Crone EA. Through the looking glass: the neural basis of self-concept in young adults with antisocial trajectories. Soc Cogn Affect Neurosci 2023; 18:7156805. [PMID: 37154430 PMCID: PMC10165683 DOI: 10.1093/scan/nsad016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 02/27/2023] [Accepted: 03/16/2023] [Indexed: 05/10/2023] Open
Abstract
Self-concept is shaped by social experiences, but it is not yet well understood how the neural and behavioral development of self-concept is influenced by a history of antisocial behavior. In this pre-registered study, we examined neural responses to self-evaluations in young adults who engaged with antisocial behavior in childhood and either desisted or persisted in antisocial behavior. A self-concept task was performed by 94 young adults (age range 18-30 years). During the task, participants with a persistent or desistent antisocial trajectory (n = 54) and typically developing young adults (n = 40) rated whether positive and negative traits in different domains (prosocial and physical) described themselves. We examined both the effects of a history of antisocial behavior as well as current heterogeneity in psychopathic traits on self-concept appraisal and its neural underpinnings. Participants endorsed more positive trait statements than negative across domains, which did not differ between antisocial-history groups. However, current psychopathic traits were negatively associated with prosocial self-concept and medial prefrontal cortex activity during self-evaluation. Together, these findings suggest that antisocial tendencies might indeed be reflected in self-concept development of young adults, specifically in the prosocial domain.
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Affiliation(s)
- Ilse H van de Groep
- Erasmus School of Social and Behavioural Sciences, Erasmus University, Rotterdam 3062 PA, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden University, Leiden 2300 RC, The Netherlands
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Center, 1100 DD Amsterdam Zuidoost, The Netherlands
- Developmental and Educational Psychology, Faculty of Social and Behavioural Sciences, Leiden University, Leiden 2333 AK, The Netherlands
| | - Marieke G N Bos
- Leiden Institute for Brain and Cognition, Leiden University, Leiden 2300 RC, The Netherlands
- Developmental and Educational Psychology, Faculty of Social and Behavioural Sciences, Leiden University, Leiden 2333 AK, The Netherlands
| | - Lucres M C Jansen
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Center, 1100 DD Amsterdam Zuidoost, The Netherlands
| | - Arne Popma
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Center, 1100 DD Amsterdam Zuidoost, The Netherlands
| | - Eveline A Crone
- Erasmus School of Social and Behavioural Sciences, Erasmus University, Rotterdam 3062 PA, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden University, Leiden 2300 RC, The Netherlands
- Developmental and Educational Psychology, Faculty of Social and Behavioural Sciences, Leiden University, Leiden 2333 AK, The Netherlands
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Deming P, Heilicher M, Koenigs M. How reliable are amygdala findings in psychopathy? A systematic review of MRI studies. Neurosci Biobehav Rev 2022; 142:104875. [PMID: 36116578 DOI: 10.1016/j.neubiorev.2022.104875] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/31/2022] [Accepted: 09/13/2022] [Indexed: 10/31/2022]
Abstract
The amygdala is a key component in predominant neural circuitry models of psychopathy. Yet, after two decades of neuroimaging research on psychopathy, the reproducibility of amygdala findings is questionable. We systematically reviewed MRI studies (81 of adults, 53 of juveniles) to determine the consistency of amygdala findings across studies, as well as within specific types of experimental tasks, community versus forensic populations, and the lowest- versus highest-powered studies. Three primary findings emerged. First, the majority of studies found null relationships between psychopathy and amygdala structure and function, even in the context of theoretically relevant tasks. Second, findings of reduced amygdala activity were more common in studies with low compared to high statistical power. Third, the majority of peak coordinates of reduced amygdala activity did not fall primarily within the anatomical bounds of the amygdala. Collectively, these findings demonstrate significant gaps in the empirical support for the theorized role of the amygdala in psychopathy and indicate the need for novel research perspectives and approaches in this field.
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Affiliation(s)
- Philip Deming
- Department of Psychology, Northeastern University, 360 Huntington Ave., Boston, MA 02115, USA.
| | - Mickela Heilicher
- Department of Psychiatry, University of Wisconsin-Madison, 6001 Research Park Blvd., Madison, WI 53719, USA
| | - Michael Koenigs
- Department of Psychiatry, University of Wisconsin-Madison, 6001 Research Park Blvd., Madison, WI 53719, USA
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Yoder KJ, Harenski CL, Kiehl KA, Decety J. Psychopathic traits modulate functional connectivity during pain perception and perspective-taking in female inmates. Neuroimage Clin 2022; 34:102984. [PMID: 35276604 PMCID: PMC8907686 DOI: 10.1016/j.nicl.2022.102984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 03/03/2022] [Accepted: 03/04/2022] [Indexed: 11/25/2022]
Abstract
PCL-R scores are associated with altered functional connectivity in female inmates. PCL-R Factor 1 and Factor 2 subscores predicted opposite shifts in connectivity. Functional connectivity in the salience network is altered during pain perception. Connectivity in the social cognition network is altered during perspective-taking.
The ability to share and understand the distress of others is critical for successful social interactions and is a fundamental building block of morality. Psychopathy is a personality disorder that includes lack of empathy and concern for others. In the present study, functional MRI was used to examine neural responses and functional connectivity associated with empathy and affective perspective-taking in female inmates (N = 109) with various levels of psychopathic traits, as measured with Psychopathy Checklist-Revised (PCL-R). Participants viewed hands and feet in painful or non-painful situations while adopting a first person or third person perspective. All participants demonstrated robust neural responses in anterior insula (aINS), anterior cingulate (ACC), temporoparietal junction (TPJ) and supplementary motor area (SMA) when viewing pain, both during imagine-self and imagine-other blocks. Psychopathy shifted the functional connectivity seeded in core nodes of the salience and social cognition networks. Perceiving stimuli depicting somatic pain led to decreased functional coupling from right temporoparietal junction to superior temporal sulcus, which correlated with scores on PCL-R Factor 1 (Affective/Interpersonal). In contrast, connectivity from right insula to precuneus increased with Factor 2 (Lifestyle/Antisocial) scores. When adopting a third-person perspective, psychopathic traits modulated connectivity from the social cognition network, but not the salience network, with Factor 1 scores associated with increased connectivity to sensorimotor cortex and temporal pole, while Factor 2 scores were associated with decreased connectivity with ACC/SMA and inferior frontal gyrus. Overall, these results demonstrate that psychopathic traits in incarcerated females are associated with atypical functional connectivity within the salience network during pain-empathy processing and within the social cognition network during affective perspective-taking.
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Affiliation(s)
- Keith J Yoder
- Department of Psychology, University of Chicago, Chicago, IL, United States.
| | - Carla L Harenski
- The Mind Research Network and Lovelace Biomedical, Albuquerque, NM, United States; Department of Psychology, University of New Mexico, Albuquerque, NM, United States
| | - Kent A Kiehl
- The Mind Research Network and Lovelace Biomedical, Albuquerque, NM, United States; Department of Psychology, University of New Mexico, Albuquerque, NM, United States
| | - Jean Decety
- Department of Psychology, University of Chicago, Chicago, IL, United States; Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, United States
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Sokołowski A, Kowalski J, Dragan M. Neural functional connectivity during rumination in individuals with adverse childhood experiences. Eur J Psychotraumatol 2022; 13:2057700. [PMID: 35432784 PMCID: PMC9009929 DOI: 10.1080/20008198.2022.2057700] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Childhood adversity has been associated with greater risk of developing psychopathology, altered processing of emotional stimuli, and changes in neural functioning. Although the neural correlates of rumination have been previously described, little is known about how adverse childhood experiences are related to brain functioning during rumination. OBJECTIVE This study explored differences in neural functional connectivity between participants with and without histories of childhood adversity, controlling for tendency to ruminate, during resting-state and induction of rumination. METHOD A total of 86 adults (51 women) took part. Based on a diagnostic clinical interview, participants were divided into groups with and without adverse childhood experiences. All participants underwent resting-state imaging and a functional magnetic resonance imaging scan where they performed a rumination induction task. RESULTS Individuals with childhood adversities differed from those without adverse experiences in seed-based functional connectivity from right angular gyrus and left superior frontal gyrus during the rumination task. There were also group differences during resting-state in seed-based functional connectivity from the right angular gyrus, left middle temporal gyrus, and left superior frontal gyrus. CONCLUSIONS Childhood adversity is associated with altered brain functioning during rumination and resting-state, even after controlling for tendency to ruminate. Our results shed light on the consequences of early adversity. People who experienced childhood adversities differ from those with no adverse experiences in brain functional connectivity when engaged in negative repetitive self-referential thinking.
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Affiliation(s)
- Andrzej Sokołowski
- Department of Neurology, Memory and Aging Center, UCSF Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Joachim Kowalski
- Experimental Psychopathology Lab, Institute of Psychology, Polish Academy of Sciences, Warsaw, Poland
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Connections that characterize callousness: Affective features of psychopathy are associated with personalized patterns of resting-state network connectivity. NEUROIMAGE-CLINICAL 2020; 28:102402. [PMID: 32891038 PMCID: PMC7479442 DOI: 10.1016/j.nicl.2020.102402] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/18/2020] [Accepted: 08/25/2020] [Indexed: 11/29/2022]
Abstract
There was significant heterogeneity in participants’ neural networks. Psychopathy associated with default mode-central executive network connectivity. Associations were specific to affective psychopathic traits.
Background Psychopathic traits are hypothesized to be associated with dysfunction across three resting-state networks: the default mode (DMN), salience (SN), and central executive (CEN). Past work has not considered heterogeneity in the neural networks of individuals who display psychopathic traits, which is likely critical in understanding the etiology of psychopathy and could underlie different symptom presentations. Thus, this study maps person-specific resting state networks and links connectivity patterns to features of psychopathy. Methods We examined resting-state functional connectivity among eight regions of interest in the DMN, SN, and CEN using a person-specific, sparse network mapping approach (Group Iterative Multiple Model Estimation) in a community sample of 22-year-old men from low-income, urban families (N = 123). Associations were examined between a dimensional measure of psychopathic traits and network density (i.e., number of connections within and between networks). Results There was significant heterogeneity in neural networks of participants, which were characterized by person-specific connections and no common connections across the sample. Psychopathic traits, particularly affective traits, were associated with connection density between the DMN and CEN, such that greater density was associated with elevated psychopathic traits. Discussion Findings emphasize that neural networks underlying psychopathy are highly individualized. However, individuals with high levels of psychopathic traits had increased density in connections between the DMN and CEN, networks that have been linked with self-referential thinking and executive functioning. Taken together, the results highlight the utility of person-specific approaches in modeling neural networks underlying psychopathic traits, which could ultimately inform personalized prevention and intervention strategies.
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Moreno-Rius J. Opioid addiction and the cerebellum. Neurosci Biobehav Rev 2019; 107:238-251. [DOI: 10.1016/j.neubiorev.2019.09.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 09/06/2019] [Accepted: 09/10/2019] [Indexed: 01/10/2023]
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Furuichi A, Kawasaki Y, Takahashi T, Nakamura K, Tanino R, Noguchi K, Kurachi M, Suzuki M. Altered neural basis of self-reflective processing in schizophrenia: An fMRI study. Asian J Psychiatr 2019; 45:53-60. [PMID: 31505454 DOI: 10.1016/j.ajp.2019.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 08/22/2019] [Accepted: 08/22/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Impaired self-awareness has often been described in schizophrenia. Recent neuroimaging studies examining the self-reflection processes in schizophrenia have produced inconsistent results. METHOD We examined the self-reflective neural network using self- and other-evaluation tasks in schizophrenia. Fifteen schizophrenia patients and fifteen age- and sex-matched healthy subjects underwent functional magnetic resonance imaging. Subjects were required to decide whether the sentence described their own personal trait (self-evaluation) and that of their close friends (other-evaluation). RESULTS Unlike normal control subjects, the schizophrenia patients did not have greater activation of the left posterior cingulate gyrus and hippocampus during self-evaluation than during other-evaluation. On the other hand, the schizophrenia patients had higher activation of the right superior frontal and right supramarginal gyri during self-evaluation than control subjects. Only the patient group exhibited hyperactivation in the left hippocampus and right external capsule associated with the other-evaluation task. CONCLUSIONS These findings provide evidence for an altered neural basis of self-reflective processing, which may underlie the self-awareness deficits in schizophrenia.
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Affiliation(s)
- Atsushi Furuichi
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan.
| | - Yasuhiro Kawasaki
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan; Department of Neuropsychiatry, Kanazawa Medical University, Uchinada, Japan
| | - Tsutomu Takahashi
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Kazue Nakamura
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan; Hoshiicho Mental Clinic, Toyama, Japan
| | - Ryoichiro Tanino
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan; Tanino Gozan Hospital, Toyama, Japan
| | - Kyo Noguchi
- Department of Radiology, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Masayoshi Kurachi
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan; Arisawabashi Hospital, Toyama, Japan
| | - Michio Suzuki
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
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Is there an "antisocial" cerebellum? Evidence from disorders other than autism characterized by abnormal social behaviours. Prog Neuropsychopharmacol Biol Psychiatry 2019; 89:1-8. [PMID: 30153496 DOI: 10.1016/j.pnpbp.2018.08.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/23/2018] [Accepted: 08/24/2018] [Indexed: 12/13/2022]
Abstract
The cerebellum is a hindbrain structure which involvement in functions not related to motor control and planning is being increasingly recognized in the last decades. Studies on Autism Spectrum Disorders (ASD) have reported cerebellar involvement on these conditions characterized by social deficits and repetitive motor behavior patterns. Although such an involvement hints at a possible cerebellar participation in the social domain, the fact that ASD patients present both social and motor deficits impedes drawing any firm conclusion regarding cerebellar involvement in pathological social behaviours, probably influenced by the classical view of the cerebellum as a purely "motor" brain structure. Here, we suggest the cerebellum can be a key node for the production and control of normal and particularly aberrant social behaviours, as indicated by its involvement in other neuropsychiatric disorders which main symptom is deregulated social behaviour. Therefore, in this work, we briefly review cerebellar involvement in social behavior in rodent models, followed by discussing the findings linking the cerebellum to those other psychiatric conditions characterized by defective social behaviours. Finally, possible commonalities between the studies and putative underlying impaired functions will be discussed and experimental approaches both in patients and experimental animals will also be proposed, aimed at stimulating research on the role of the cerebellum in social behaviours and disorders characterized by social impairments, which, if successful, will definitely help reinforcing the proposed cerebellar involvement in the social domain.
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Johanson M, Vaurio O, Tiihonen J, Lähteenvuo M. A Systematic Literature Review of Neuroimaging of Psychopathic Traits. Front Psychiatry 2019; 10:1027. [PMID: 32116828 PMCID: PMC7016047 DOI: 10.3389/fpsyt.2019.01027] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 12/30/2019] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Core psychopathy is characterized by grandiosity, callousness, manipulativeness, and lack of remorse, empathy, and guilt. It is often comorbid with conduct disorder and antisocial personality disorder (ASPD). Psychopathy is present in forensic as well as prison and general populations. In recent years, an increasing amount of neuroimaging studies has been conducted in order to elucidate the obscure neurobiological etiology of psychopathy. The studies have yielded heterogenous results, and no consensus has been reached. AIMS This study systematically reviewed and qualitatively summarized functional and structural neuroimaging studies conducted on individuals with psychopathic traits. Furthermore, this study aimed to evaluate whether the findings from different MRI modalities could be reconciled from a neuroanatomical perspective. MATERIALS AND METHODS After the search and auditing processes, 118 neuroimaging studies were included in this systematic literature review. The studies consisted of structural, functional, and diffusion tensor MRI studies. RESULTS Psychopathy was associated with numerous neuroanatomical abnormalities. Structurally, gray matter anomalies were seen in frontotemporal, cerebellar, limbic, and paralimbic regions. Associated gray matter volume (GMV) reductions were most pronounced particularly in most of the prefrontal cortex, and temporal gyri including the fusiform gyrus. Also decreased GMV of the amygdalae and hippocampi as well the cingulate and insular cortices were associated with psychopathy, as well as abnormal morphology of the hippocampi, amygdala, and nucleus accumbens. Functionally, psychopathy was associated with dysfunction of the default mode network, which was also linked to poor moral judgment as well as deficient metacognitive and introspective abilities. Second, reduced white matter integrity in the uncinate fasciculus and dorsal cingulum were associated with core psychopathy. Third, emotional detachment was associated with dysfunction of the posterior cerebellum, the human mirror neuron system and the Theory of Mind denoting lack of empathy and persistent failure in integrating affective information into cognition. CONCLUSIONS Structural and functional aberrancies involving the limbic and paralimbic systems including reduced integrity of the uncinate fasciculus appear to be associated with core psychopathic features. Furthermore, this review points towards the idea that ASPD and psychopathy might stem from divergent biological processes.
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Affiliation(s)
- Mika Johanson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Olli Vaurio
- Department of Forensic Psychiatry, Niuvanniemi Hospital, Kuopio, Finland.,Department of Forensic Psychiatry, University of Eastern Finland, Kuopio, Finland
| | - Jari Tiihonen
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Forensic Psychiatry, Niuvanniemi Hospital, Kuopio, Finland.,Department of Forensic Psychiatry, University of Eastern Finland, Kuopio, Finland
| | - Markku Lähteenvuo
- Department of Forensic Psychiatry, Niuvanniemi Hospital, Kuopio, Finland
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