Psychopathy as an Emergent Interpersonal Syndrome: What Is the Function of Fearlessness?

A Randomized Controlled Trial Comparing Mentalization-Based Therapy With the Unified Protocol in the Treatment of Psychopathy and Comorbid Borderline + Antisocial Personality Disorders

BACKGROUND

Those with cooccurring antisocial personality disorder (ASPD) and borderline personality disorder (BPD) are reported to be highly psychopathic and to represent a severe challenge to treatment efforts. In a sample of such individuals, the effects of two treatments, mentalization-based therapy (MBT) and the unified protocol (UP), were investigated on three outcomes: (i) the psychopathy trait domains of meanness, boldness and disinhibition proposed by the triarchic psychopathy model (TPM); (ii) antisocial and borderline symptom severity; and (iii) the severity of their common features including impulsivity, anger expression and self-harm.

METHODS

Of 163 individuals with BPD + ASPD screened for eligibility, 55 were randomized to MBT treatment and 53 to UP treatment. Outcomes of treatment were assessed at 6-month intervals to 36 months.

RESULTS

Short-term reductions were seen following both treatments in traits of psychopathy, antisocial and borderline personality symptom severity, anger dysregulation, impulsivity and self-harm, but both treatment groups showed almost complete relapse of symptoms at the 36-month follow-up. UP had more durable effects than MBT.

CONCLUSIONS

Despite being a considerably shorter treatment, UP was at least as effective as MBT and in some respects superior. Remission of symptoms was not achieved by either treatment in the long term. Psychopathy and borderline/antisocial comorbidity with which it is associated are to some extent remediable through psychotherapy, but only in the short term.

CLINICAL IMPLICATIONS

Patients with high levels of impulsivity and disinhibition are likely to relapse following psychotherapy and should be closely monitored after treatment.

Psychopathy as an Emergent Interpersonal Syndrome: Further Reflections and Future Directions

In our article (Lilienfeld et al., 2019), we hypothesized that psychopathy and some other personality disorders are emergent interpersonal syndromes (EISs): interpersonally malignant configurations of distinct personality subdimensions. We respond to three commentaries by distinguished scholars who raise provocative challenges to our arguments and intriguing suggestions for future research. We clarify the role of folk concepts in our understanding of psychopathy, offer further suggestions for testing our interactional hypotheses, consider the role of boldness in motivational accounts of psychopathy, and discuss future directions for incorporating developmental considerations and the role of victims in our EIS account. We are optimistic that this account will prove to be of heuristic value, and should encourage researchers and theoreticians to explore alternative models of psychopathy and other personality disorders.