Callous and unemotional traits

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Callous-unemotional traits (CU) are distinguished by a persistent pattern of behavior that reflects a disregard for others, and also a lack of empathy and generally deficient affect. The interplay between genetic and environmental risk factors may play a role in the expression of these traits as a conduct disorder (CD). While originally conceived as a means of measuring the affective features of psychopathy in children, measures of CU have been validated in university samples and adults. [1] [2] [3]

Contents

A CU specifier has been included as a feature of conduct disorder in the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the eleventh edition of the International Classification of Diseases (ICD-11). [4]

Symptoms

Core features

CU traits, as measured by the Inventory of Callous-Unemotional Traits (ICU), are in three categories: callous (reflecting ruthlessness and cruel treatment or disregard for others), uncaring (passive disregard for others and lack of prosocial emotion), and unemotional (limited experience and expression of emotion). [5] Unemotional traits are uniquely elevated in cases reflecting "primary psychopathy". [3]

DSM-5's "limited prosocial emotions" specifier and attendant interview measure, the Clinical Assessment of Prosocial Emotions (CAPE), lists the following characteristics:

Associated features

Children with CU traits have distinct problems in emotional and behavioral regulation that distinguish them from other antisocial youth [6] and show more similarity to characteristics found in adult psychopathy. [7] Antisocial youth with CU traits tend to have a range of distinctive cognitive characteristics. [8] They are often less sensitive to punishment cues, particularly when they are already keen for a reward. [9] CU traits are positively related to good intellectual verbal skills. [10]

Classification

A CU specifier for conduct disorder was added to DSM-5. [4] The addition "with limited prosocial emotions" to the conduct disorder diagnosis in DSM-5 is to classify a specific subgroup of antisocial youth with distinguishing antisocial behaviors and psychopathic traits. [6] The provision of the CU specifier for CD youth is claimed to improve the diagnostic power, treatment options, and increase the understanding life-course outcomes. [6] A 2008 review concluded that CU did not have the required evidence base to be included as a new diagnosis in DSM-5. [11]

Causes and pathophysiology

Neural mechanisms

The fearlessness theory of CU traits suggests that low amounts of cortisol lead to underarousal, causing impairments in fear processing, a trait seen in CU individuals. [12] Hypoactivity in the hypothalamic-pituitary-adrenal axis in combination with CU traits seem to cause antisocial behavior even without external hardships. [12]

Genetic

Twin studies have found CU traits to be highly heritable, and not significantly related to environmental factors such as socioeconomic status, school quality, or parent quality. [6] Two twin studies suggested a significant genetic influence for CU, with an estimated average amount of variation (42.5%) in CU traits accounted for by genetic effects. [6] A substantial proportion of this genetic variation occurred independent of other dimensions of psychopathy. [6] Children with conduct problems who also exhibit high levels of CU traits reflect a particularly high heritability rate of 0.81, as reflected in longitudinal research. [9]

A study on a large group of children found more than 60% heritability for callous-unemotional traits and that conduct problems among children with these traits had a higher heritability than among children without these traits. [13] [14] The study also found slight sex differences (boys 64%, girls 49%) in the affective-interpersonal factor. [14] Similarly, the impulsive–antisocial factor was primarily influenced by genetic factors (boys 46%; girls 58%) [14]

Maltreatment and parenting play a role in the development of antisocial behavior, and studies have been shown to prove this. While callous unemotional traits are rooted in genetics, environmental triggers are an important contributing factor for the development of antisocial behaviour in children with the genetic propensity. [15]

Criticism

Primatologist Frans de Waal argues that evolutionary theory postulates that biological altruism in primates evolved for the return-benefits it bears the performer. [16] Some evolutionary biologists, therefore, criticize the psychiatric model of callous-unemotional traits (CU) on the grounds that CU is inconsistent with evolutionary continuity. Rather, these biologists argue that if empathy had evolved through mammalian evolution, beginning with empathy restricted to close relatives and extending over the course of evolution to include more distant relatives, then empathy with other humans could be expected to be necessary but not sufficient for human empathy with nonhuman animals. This evolutionary biology model of altruism and empathy thus contrasts with the psychiatric model of CU because the latter implies that cruelty to animals is a predictor of violence to other humans – but not the other way around. [17] [18]

Diagnosis

Research has attempted to subtype youth with callous-unemotional traits by distinguishing between those with childhood-onset versus adolescent-onset conduct disorder, conduct disorder co-morbid with attention deficit hyperactivity disorder (ADHD), or by the severity and type of aggression displayed. [7] Children with CU traits have more severe conduct disorder, and respond to different management. [4] The Inventory of Callous-Unemotional Traits (ICU) assesses three independent factors in CU traits: uncaring, callous, and unemotional. [19] The severity of CD has been studied in children rated high on CU traits. [9]

Management

CU traits are relatively stable, though some studies suggest that they may decrease over time through effective treatment. [6] Early intervention is thought to be more effective because CU traits are thought to be more malleable early in life. [20]

Parenting techniques

Parenting interventions are the most commonly used treatment for treating early onset antisocial behaviors and conduct disorder in children, and quality parenting may be able to decrease the manifestation of CU traits. [6] [21] Children with high CU traits are less responsive to time-out and other punishment techniques than are typical children as they are unperturbed by the threat of punishment and time-out does not seem to bother them, so their behavior does not improve. [22] Reward-based disciplining techniques, such as praise and reinforcement, tend to have a greater effect than punishing techniques on children with high CU traits in reducing antisocial behavior. [9]

Prognosis

Childhood-onset CU shows a more aggressive and stable pattern of antisocial behavior with higher rates of CU traits, as well as more severe temperamental and neuropsychological risk factors relative to their adolescent-onset counterparts. [23] Children with combined CD and ADHD are more likely to show features associated with psychopathy, but only in those who have high rates of CU traits. [24] In support of the idea of lifetime persistence of CU traits, childhood-onset delinquency has been more strongly associated with psychopathic traits than adolescent-onset delinquency. [25] A longitudinal twin study of children with CD showed that high or increasing levels of CU traits comorbid with CD presented with the most negative outcomes after twelve years in relationships with peers and family, as well as emotional and behavioral problems, as compared to those with low CU traits or CD alone. [26] In addition, adolescents with CU traits have shown higher likelihood to commit a violent crime within a two-year period of their release from a correctional facility than those without CU traits. [27] Antisocial youth with CU traits tend to show less response to treatment. [9]

A systematic review found that CU traits were associated with poorer outcomes in family-based interventions for conduct problems. This suggests pre-treatment data on CU traits is clinically informative in terms of the prognostic status of children and young people with CU traits. [28]

History

Due to the potential severity of antisocial and violent traits seen in adult psychopathy, research has focused on identifying the associated traits in childhood. In adult psychopathy, individuals with primarily affective and interpersonal deficits show a distinct etiology. [29] Similarly, different subtypes of aggressive and antisocial behaviors in youth may predict distinct problem-behaviors and risk factors. There have been a number of attempts to officially designate psychopathic-like traits in antisocial youths based on the affective and interpersonal traits of psychopathy. The third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III) divided conduct disorder into four subtypes: undersocialized-aggressive, undersocialized-nonaggressive, socialized-aggressive, and socialized-nonaggressive in an attempt to recognize the existence of psychopathic traits in children. [24] The distinction between "socialized" and "undersocialized" children was the most pertinent in distinguishing between psychopathic-like youths. According to these definitions, "undersocialized" children exhibited characteristic behaviors of psychopathy, including: lack of empathy, lack of affection, and inappropriate social relationships (DSM III). This differed from "socialized" individuals, who were able to form healthy social attachments to others, and whose aggressive and antisocial acts typically derived from engagement in a deviant social group (e.g. youth gangs).

Following the publication of DSM-III, these distinctions prompted research, but there were still issues with the terminology in diagnosing the core features of the undersocialized versus socialized subtype. The word undersocialized was used in order to avoid the negative connotations of psychopathy, but was commonly misinterpreted to mean that the child was not well socialized by parents or lacked a peer group. Also, the operational definition failed to include dimensions that could reliably predict the affective and interpersonal deficits in psychopathic-like youths. Due to these issues, the American Psychiatric Association removed the undersocialized and socialized distinctions from the conduct disorder description in the DSM after the third edition. The only subtypes that have been included in the manual since then relate to the time of onset: childhood-onset (before age 10), adolescent-onset (absence of antisocial traits before age 10), and unspecified-onset. [23]

See also

Related Research Articles

Conduct disorder (CD) is a mental disorder diagnosed in childhood or adolescence that presents itself through a repetitive and persistent pattern of behavior that includes theft, lies, physical violence that may lead to destruction, and reckless breaking of rules, in which the basic rights of others or major age-appropriate norms are violated. These behaviors are often referred to as "antisocial behaviors", and is often seen as the precursor to antisocial personality disorder; however, the latter, by definition, cannot be diagnosed until the individual is 18 years old. Conduct disorder may result from parental rejection and neglect and can be treated with family therapy, as well as behavioral modifications and pharmacotherapy. Conduct disorder is estimated to affect 51.1 million people globally as of 2013.

<span class="mw-page-title-main">Narcissistic personality disorder</span> Personality disorder

Narcissistic personality disorder (NPD) is a mental disorder characterized by a life-long pattern of exaggerated feelings of self-importance, an excessive need for admiration, and a diminished ability to empathize with others' feelings. Narcissistic personality disorder is one of the sub-types of the broader category known as personality disorders. It is often comorbid with other mental disorders and associated with significant functional impairment and psychosocial disability.

Antisocial personality disorder is a personality disorder characterized by a limited capacity for empathy and a long-term pattern of disregard or violation of the rights of others. Other notable symptoms include impulsivity and reckless behavior, a lack of remorse after hurting others, deceitfulness, irresponsibility, and aggressive behavior.

<span class="mw-page-title-main">Remorse</span> Distressing emotion experienced by a person who regrets actions they have done in the past

Remorse is a distressing emotion experienced by an individual who regrets actions which they have done in the past that they deem to be shameful, hurtful, or wrong. Remorse is closely allied to guilt and self-directed resentment. When a person regrets an earlier action or failure to act, it may be because of remorse or in response to various other consequences, including being punished for the act or omission. People may express remorse through apologies, trying to repair the damage they've caused, or self-imposed punishments.

Antisocial behaviours are actions which are considered to violate the rights of or otherwise harm others by committing crime or nuisance, such as stealing and physical attack or noncriminal behaviours such as lying and manipulation. It is considered to be disruptive to others in society. This can be carried out in various ways, which includes, but is not limited to, intentional aggression, as well as covert and overt hostility. Anti-social behaviour also develops through social interaction within the family and community. It continuously affects a child's temperament, cognitive ability and their involvement with negative peers, dramatically affecting children's cooperative problem-solving skills. Many people also label behaviour which is deemed contrary to prevailing norms for social conduct as anti-social behaviour. However, researchers have stated that it is a difficult term to define, particularly in the United Kingdom where many acts fall into its category. The term is especially used in British English.

<span class="mw-page-title-main">Sadistic personality disorder</span> Former personality disorder involving sadism

Sadistic personality disorder was a proposed personality disorder defined by a pervasive pattern of sadistic and cruel behavior. People with this disorder were thought to have desired to control others. It was believed they accomplish this through the use of physical or emotional violence. This diagnosis appeared in an appendix of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). The later versions of the DSM do not include it. It was removed as psychiatrists believed it would be used to legally excuse sadistic behavior.

Psychopathy is a mental health condition characterized by persistent antisocial behavior, impaired empathy and remorse, and bold, disinhibited, and egotistical traits. Different conceptions of psychopathy have been used throughout history that are only partly overlapping and may sometimes be contradictory.

<span class="mw-page-title-main">Psychopathy Checklist</span> Psychopathy scale

The Psychopathy Checklist or Hare Psychopathy Checklist-Revised, now the Psychopathy Checklist—revised (PCL-R), is a psychological assessment tool that is commonly used to assess the presence and extent of the personality trait psychopathy in individuals—most often those institutionalized in the criminal justice system—and to differentiate those high in this trait from those with antisocial personality disorder, a related diagnosable disorder. It is a 20-item inventory of perceived personality traits and recorded behaviors, intended to be completed on the basis of a semi-structured interview along with a review of "collateral information" such as official records. The psychopath tends to display a constellation or combination of high narcissistic, borderline, and antisocial personality disorder traits, which includes superficial charm, charisma/attractiveness, sexual seductiveness and promiscuity, affective instability, suicidality, lack of empathy, feelings of emptiness, self-harm, and splitting. In addition, sadistic and paranoid traits are usually also present.

<span class="mw-page-title-main">Dark triad</span> Offensive personality types

The dark triad is a psychological theory of personality, first published by Delroy L. Paulhus and Kevin M. Williams in 2002, that describes three notably offensive, but non-pathological personality types: Machiavellianism, sub-clinical narcissism, and sub-clinical psychopathy. Each of these personality types is called dark because each is considered to contain malevolent qualities.

Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's culture. These patterns develop early, are inflexible, and are associated with significant distress or disability. The definitions vary by source and remain a matter of controversy. Official criteria for diagnosing personality disorders are listed in the sixth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).

In psychology, grandiosity is a sense of superiority, uniqueness, or invulnerability that is unrealistic and not based on personal capability. It may be expressed by exaggerated beliefs regarding one's abilities, the belief that few other people have anything in common with oneself, and that one can only be understood by a few, very special people. The personality trait of grandiosity is principally associated with narcissistic personality disorder (NPD), but also is a feature in the occurrence and expression of antisocial personality disorder, and the manic and hypomanic episodes of bipolar disorder.

In psychology, manipulation is defined as subterfuge designed to influence or control another, usually in a manner which facilitates one's personal aims. The methods used distort or orient the interlocutor's perception of reality, in particular through seduction, suggestion, persuasion and non-voluntary or consensual submission. Definitions for the term vary in which behavior is specifically included, influenced by both culture and whether referring to the general population or used in clinical contexts. Manipulation is generally considered a dishonest form of social influence as it is used at the expense of others.

The Levenson Self-Report Psychopathy scale (LSRP) is a 26-item, 4-point Likert scale, self-report inventory to measure primary and secondary psychopathy in non-institutionalised populations. It was developed in 1995 by Michael R. Levenson, Kent A. Kiehl and Cory M. Fitzpatrick. The scale was created for the purpose of conducting a psychological study examining antisocial disposition among a sample of 487 undergraduate students attending psychology classes at the University of California, Davis.

Psychopathy, from psych and pathy, was coined by German psychiatrists in the 19th century and originally just meant what would today be called mental disorder, the study of which is still known as psychopathology. By the turn of the century 'psychopathic inferiority' referred to the type of mental disorder that might now be termed personality disorder, along with a wide variety of other conditions now otherwise classified. Through the early 20th century this and other terms such as 'constitutional (inborn) psychopaths' or 'psychopathic personalities', were used very broadly to cover anyone who violated legal or moral expectations or was considered inherently socially undesirable in some way.

George Everett Partridge was an American psychologist credited with popularizing the term sociopath in 1930 that Karl Brinbaum had suggested in 1909. He worked with the influential G. Stanley Hall at Clark University. One year after his death, the George Everett Partridge Memorial Foundation was incorporated in 1954 by the Partridge family to memorialize his life's work in the study and treatment of mental and personality disorders. The Foundation focused on developing programs to promote treatment centers for mentally disabled children, often referred to as the "forgotten children." Partridge schools were established. The first of which was in Herndon, Virginia, for older boys with moderate mental retardation resulting from brain damage. However, the foundation was forfeited in 1991.

<span class="mw-page-title-main">Essi Viding</span> Professor of Developmental Psychopathology

Essi Maria Viding FBA FMedSci is Professor of Developmental Psychopathology at University College London in the Faculty of Brain Sciences, where she co-directs the Developmental Risk and Resilience Unit, and an associate of King's College London's Institute of Psychiatry, Psychology and Neuroscience. Viding's research focuses on development of disruptive behaviour disorders, as well as children and young people's mental health problems more broadly. She uses cognitive experimental measures, brain imaging and genetically informative study designs in her work.

Evolutionary psychiatry, also known as Darwinian psychiatry, is a theoretical approach to psychiatry that aims to explain psychiatric disorders in evolutionary terms. As a branch of the field of evolutionary medicine, it is distinct from the medical practice of psychiatry in its emphasis on providing scientific explanations rather than treatments for mental disorder. This often concerns questions of ultimate causation. For example, psychiatric genetics may discover genes associated with mental disorders, but evolutionary psychiatry asks why those genes persist in the population. Other core questions in evolutionary psychiatry are why heritable mental disorders are so common how to distinguish mental function and dysfunction, and whether certain forms of suffering conveyed an adaptive advantage. Disorders commonly considered are depression, anxiety, schizophrenia, autism, eating disorders, and others. Key explanatory concepts are of evolutionary mismatch and the fact that evolution is guided by reproductive success rather than health or wellbeing. Rather than providing an alternative account of the cause of mental disorder, evolutionary psychiatry seeks to integrate findings from traditional schools of psychology and psychiatry such as social psychology, behaviourism, biological psychiatry and psychoanalysis into a holistic account related to evolutionary biology. In this sense, it aims to meet the criteria of a Kuhnian paradigm shift.

Externalizing disorders are mental disorders characterized by externalizing behaviors, maladaptive behaviors directed toward an individual's environment, which cause impairment or interference in life functioning. In contrast to individuals with internalizing disorders who internalize their maladaptive emotions and cognitions, such feelings and thoughts are externalized in behavior in individuals with externalizing disorders. Externalizing disorders are often specifically referred to as disruptive behavior disorders or conduct problems which occur in childhood. Externalizing disorders, however, are also manifested in adulthood. For example, alcohol- and substance-related disorders and antisocial personality disorder are adult externalizing disorders. Externalizing psychopathology is associated with antisocial behavior, which is different from and often confused for asociality.

<span class="mw-page-title-main">Machiavellianism (psychology)</span> Psychological trait

In the field of personality psychology, Machiavellianism is a personality trait characterized by interpersonal manipulation, indifference to morality, lack of empathy, and a strategic focus on self-interest. Psychologists Richard Christie and Florence Geis named the trait after Niccolò Machiavelli, as they used edited and truncated statements inspired by his works to study variations in human behaviors. Their Mach IV test, a 20-question, Likert-scale personality survey, became the standard self-assessment tool and scale of the Machiavellianism construct. Those who score high on the scale are more likely to have a high level of deceitfulness and a cynical, unemotional temperament.

The influence of childhood trauma on the development of psychopathy in adulthood remains an active research question. According to Hervey M. Cleckley, a psychopathic person is someone who is able to imitate a normal functioning person, while masking or concealing their lack of internal personality structure. This results in an internal disorder with recurrent deliberate and detrimental conduct. Despite presenting themselves as serious, bright, and charming, psychopathic people are unable to experience true emotions. Robert Hare's two factor model and Christopher Patrick's triarchic model have both been developed to better understand psychopathology; however, whether the root cause is primarily environmental or primarily genetic is still in question.

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Further reading