James Fallon: The Psychopath Inside Q&A

Professor James Fallon has written an exciting new book combining his background in neuroscience with his personal experience having many characteristics (and the brain scan) of a psychopath. THE PSYCHOPATH INSIDE: A Neuroscientist’s Personal Journey into the Dark Side of the Brain (Kindle version here) is part memoir and part scientific review of both the recent genetic and neuroscience research that has been done on psychopaths.

As a special offer to this blog's audience, Dr. Fallon has graciously offered to answer some of your questions. If you have a question for Dr. Fallon, please post it in the comments addressed to "Dr. Fallon:". I will collect your questions (or a representative sample) and send them to him. When I receive his answers, I will post them in a future blog post.

Here is an except from his book:

I was thinking about putting something up about the book and then asking my readers and twitter followers if they had any questions in particular that they would like to ask him. I could select a representative sample, if he would be willing to give his thoughts? 

One October day in 2005, as the last vestiges of an Indian summer moved across Southern California, I was inputting some last-minute changes into a paper I was planning to submit to the Ohio State Journal of Criminal Law. I had titled it “Neuroanatomical Background to Understanding the Brain of a Young Psychopath” and based it on a long series of analyses I had performed, on and off for a decade, of individual brain scans of psychopathic murderers. These are some of the baddest dudes you can imagine—they’d done some heinous things over the years, things that would make you cringe if I didn’t have to adhere to confidentiality agreements and could tell you about them. 

But their pasts weren’t the only things that separated them from the rest of us. As a neuroscientist well into the fourth decade of my career, I’d looked at a lot of brain scans over the years, and these had been different. The brains belonging to these killers shared a rare and alarming pattern of low brain function in certain parts of the frontal and temporal lobes—areas commonly associated with self-control and empathy. This makes sense for those with a history of inhuman violence, since the reduction of activity in these regions suggests a lack of a normal sense of moral reasoning and of the ability to inhibit their impulses. I explained this pattern in my paper, submitted it for publication, and turned my attention to the next project. 

At the same time I’d been studying the murderers’ scans, my lab had been conducting a separate study exploring which genes, if any, are linked to Alzheimer’s disease. As part of our research, my colleagues and I had run genetic tests and taken brain scans of several Alzheimer’s patients as well as several members of my family, who were serving as the normal, control group. 

On this same October day, I sat down to analyze my family’s scans and noticed that the last scan in the pile was strikingly odd. In fact it looked exactly like the most abnormal of the scans I had just been writing about, suggesting that the poor individual it belonged to was a psychopath— or at least shared an uncomfortable amount of traits with one. Not suspicious of any of my family members, I naturally assumed that their scans had somehow been mixed with the other pile on the table. I generally have a lot of research going on at one time, and even though I try to keep my work organized it was entirely possible for things to get mixed up. Unfortunately, since we were trying to keep the scans anonymous, we’d coded them to hide the names of the individuals they belonged to. To be sure I hadn’t mixed anything up, I asked our lab technician to break the blind code. 

When I found out who the scan belonged to, I had to believe there was a mistake. In a fit of pique, I asked the technician to check the scanner and all the notes from the other imaging and database technicians. 

But there had been no mistake. 

The scan was mine.

Reprinted from THE PSYCHOPATH INSIDE: A Neuroscientist’s Personal Journey into the Dark Side of the Brain by James Fallon with permission of Current, a member of Penguin Group (USA) LLC, A Penguin Random House Company. Copyright (c) James Fallon, 2013.

Mind blame

Nobel Prize winning neuropsychiatrist writes an op-ed for the NY Times "The New Science of Mind" about the biology of mental disorders. He first uses the example of how psychotherapy and anti-depressant pharmaceuticals both change the structure and functioning of the brains of depressives, but one works better than the other depending on the neurological roots of the patients' depression. He also uses the genetic example of how an extra copy of genetic sequence means an increased risk of autism and its accompanying anti-social tendencies or a missing copy of the same sequence leads to Williams syndrome and its accompanying intense sociability.

Our understanding of the biology of mental disorders has been slow in coming, but recent advances like these have shown us that mental disorders are biological in nature, that people are not responsible for having schizophrenia or depression, and that individual biology and genetics make significant contributions.

The result of such work is a new, unified science of mind that uses the combined power of cognitive psychology and neuroscience to examine the great remaining mysteries of mind: how we think, feel and experience ourselves as conscious human beings.

This new science of mind is based on the principle that our mind and our brain are inseparable. The brain is a complex biological organ possessing immense computational capability: it constructs our sensory experience, regulates our thoughts and emotions, and controls our actions. It is responsible not only for relatively simple motor behaviors like running and eating, but also for complex acts that we consider quintessentially human, like thinking, speaking and creating works of art. Looked at from this perspective, our mind is a set of operations carried out by our brain. The same principle of unity applies to mental disorders.

In years to come, this increased understanding of the physical workings of our brain will provide us with important insight into brain disorders, whether psychiatric or neurological. But if we persevere, it will do even more: it will give us new insights into who we are as human beings.

Like most other mental disorders, sociopaths are characterized by both genetic and neurological differences that distinguish them from neurotypicals. I'm not saying that sociopaths aren't responsible for their actions, but they're certainly not responsible for being sociopaths. 

DSM-5 = "lack of validity"

Says the Dr. Thomas R. Insel, director of the National Institute of Mental Health. From the NY Times:


While the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., is the best tool now available for clinicians treating patients and should not be tossed out, he said, it does not reflect the complexity of many disorders, and its way of categorizing mental illnesses should not guide research.

“As long as the research community takes the D.S.M. to be a bible, we’ll never make progress,” Dr. Insel said, adding, “People think that everything has to match D.S.M. criteria, but you know what? Biology never read that book.”

Insel describes the problem of all psychiatric diagnoses:

“Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever.”

It's interesting, a lot of people will come on here and baldly assert, "sociopaths don't do this" or "that's not what borderline personality disorder is." And that's fine. I understand the flaws and ambiguities in my own working definitions of psychiatric disorders. And I also understand that despite the fuzziness of the definitions, it's still useful to acknowledge that there seems to be commonalities between certain categories of people that deserve further explanation. But I do believe that people have used the DSM unquestioningly for far too long, taking it to the level of being DSM apologists rather than accepting new information with an open-mind, and I'm glad that there is now more pressure to provide actual science behind the various assertions.

For more on the DSM-5's explicit rejection in one instance of actual scientific proof of a separate psychiatric disorder, see this New Yorker article's discussion of melancholia:

[T]he inclusion of a biological measure [for melancholia] would be very hard to sell to the mood group." Coryell explained that the problem wasn’t the test’s reliability, which he thought was better than anything else in psychiatry. Rather, it was that the D.S.T. would be "the only biological test for any diagnosis being considered." A single disorder that met the scientific demands of the day, in other words, would only make the failure to meet them in the rest of the D.S.M. that much more glaring.
***
This notion—that the apparent mental condition is all that can matter—underlies not only the depression diagnosis but all of the D.S.M.’s categories. It may have been conceived as a stopgap, a way to bide time until the brain’s role in psychological suffering has been elucidated, but in the meantime, expert consensus about appearances has become the cornerstone of the profession, one that psychiatrists are reluctant to yank out, lest the entire edifice collapse.

"What can be asserted without evidence can be dismissed without evidence."

Brain trials

A reader sent me this article from a legal publication regarding the use of neuroscience evidence in the courtroom. I've discussed before about how the diagnosis of psychopath is often used in parole hearings as an argument against granting the prisoner parole (see also this NPR article about a prisoner named Robert Dixon). This article was a fun read because it uses stories that illustrate the difficulties well:


Take the case of a 40-year-old married schoolteacher from Virginia who during the year 2000 inexplicably began to have a sexual interest in children. He surreptitiously collected and viewed child porn on the Internet and was convicted of trying to molest his stepdaughter. The night before sentencing, he complained of horrible headaches. At the hospital he talked of suicide, made sexual advances to staff, spoke of raping his landlady and urinated on himself.

An MRI revealed that the teacher had a large orbitofrontal tumor, a growth on an area of his brain associated with social behavior. After surgeons removed the tumor, he was no longer considered a threat and completed a sexual rehab program. But a year later, he began getting headaches and once again collected pornography. Another MRI showed the tumor had regrown, and it was removed again.

Dr. Russell Swerdlow, a neurologist who treated the teacher at the hospital and later wrote about the case in the Archives of Neurology, says that such radical behavioral changes are not surprising. “But it was the first case in which the bad behavior was pedophilia,” says Swerdlow, a neuro-scientist and professor at the University of Kansas. “What was so striking about this was his inability to act on his knowledge of what was right or wrong.”

Swerdlow says when pathways are broken between the orbitofrontal lobe and the amygdala, a part of the brain involved in emotional responses and decision-making, the result can be impulsive behavior. “You don’t get the feedback that controls your decisions. You don’t have the brakes on your behavior,” he says.

Morse says that while the teacher may deserve some mitigation in sentencing because of his ailment, it’s not clear whether he lacked the ability to control his impulses, or simply chose not to. “People want to say his tumor made him do it. He made him do it. There is always a reason people do it,” Morse says. “We don’t give a pass to the other pedophiles. He felt an urge, which he understood and did not resist, but acted on it.”

While it’s true that not everyone who suffers brain damage commits criminal acts, there are plenty of anecdotal cases in medical literature showing that it causes behavioral changes, including impulsiveness, depression, aggression, inappropriate sexual behavior, lack of thought control and violence among people who prior to their injuries did not exhibit such behaviors. But how that should be considered in criminal culpability—and what science can truly explain—remains murky.

I love this story because when you start reading it you think, this poor guy. He's not the one making the decisions, it's his broken brain. Then you get to the part about how we don't give a pass to the other pedophiles and then it becomes clear that this issue is thornier than most people have considered. For instance, lucky you (most of you) to have not been born with a sexual lust for children. But just wait until you get some crazy brain tumor! Then you are truly up Shit Creek.