The Prosocial Psychopath

In the decade that has passed since I discharged from Army Special Operations, I have spent hundreds of hours reflecting on my experiences in uniform in an attempt to process, codify, rationalise, and where possible, grow from them. These hours have been spent meditating, journaling, and discussing these experiences both informally with others who have similar backgrounds, as well as formally with mental health professionals.

The cause and effect of most of my experiences is clear.

I had plenty of good experiences that I reflect upon fondly, as well as my fair share of traumatic ones that have left proportionately appropriate scars.

However, there are notable outliers.

The first, somewhat odd, deviation from cause and effect is the fact that I never actually felt any fear in situations that rationally should have warranted it. If anything, my enduring memories of being in life-threatening situations such as gunfights and a helicopter crash (albeit a minor one) are paradoxical feelings ranging from complete mindful calm through to a sense of euphoria.

I don’t mention this in any way to sound tough, and my initial assessment of those situations was that I was too daft to register what was going on in the moment and therefore didn’t fire a fear response! It was only through deeper analysis of the psychology at play (and access to my Special Forces psychological screening results) that I began to formulate a different hypothesis.

The second confronting reflection was my cold-blooded ability to approach the most horrific of battlefield injuries with a complete absence of emotion. In those scenarios, it was as though I switched into a robotic pattern of response, moving through a programmed sequence of medical assessments and interventions with zero recognition that the casualty was a human being. It was as though they were a puzzle that needed to be assembled or a scrambled Rubix’s Cube that needed to be solved.

Rather than a sense of anxiety overcoming me during battlefield casualty response it was the polar opposite, being a sense of overwhelming calm and intense mindfulness. External stimuli dulled and my focus sharpened. If anything, it was pleasurable.

If you recognise, as I did, that fearlessness and emotional coldness are two of the diagnostic criteria of psychopathy, you’d be correct!

Accessing my psych file on discharge revealed that I scored high on sensation seeking, another common trait of psychopaths, as well as other assessed metrics of sociopathy.

Initially I found these results concerning and potentially erroneous. As I dug a little deeper however, they became somewhat liberating.

Up until that point I had held the common (mis)conception of a psychopath in my mind.

I had run into them from time to time on psychiatric wards during my medical schooling and training as a junior doctor and, like all of us, had moulded my impression of psychopaths through how they are portrayed in popular culture in films such as American Psycho and The Silence of the Lambs.

I clearly wasn’t one of them, I was a loving husband and father and a doctor capable of empathy.

Yet, under certain circumstances, I was equally as clearly capable of acting like one of them.

What I now know, and the scientific community over the past few decades has revealed, is that our generalised impression of psychopaths is incomplete. The consensus is that this incomplete early impression stemmed from the initial research and diagnostic criteria of psychopathy coming from incarcerated criminal psychopaths.

It had vaguely occurred to me some time ago that the math didn’t add up when I had read Dave Grossman’s excellent book On Killing: The psychological cost of learning to kill in war and society (If you’re reading this article and you haven’t read On Killing, I highly recommend that you do!) Grossman makes mention of the commonly cited statistic that around 1% of the population meet the diagnostic criteria for psychopathy (some authors suggest this figure might be as high as 2%[i]).

Grossman discusses factors that can determine the social trajectory of a psychopath, suggesting intelligence and socioeconomic status to be key factors.

For example, an individual meeting diagnostic criteria for psychopathy who is of low intelligence and raised in a low socioeconomic environment, is likely to end up engaged in criminal behaviour and on a trajectory towards incarceration or death. Indeed, statistics from incarcerated populations show an overrepresentation of psychopaths, who are twenty to twenty-five times more likely than non-psychopaths to wind up in prison[ii] (forming the criminal psychopath population that was initially studied).

On the other hand, an individual with similar psychopathic traits who is of high intelligence and raised in a middle to upper-class socioeconomic environment, is more likely to resist urges to act on their antisocial impulses and channel them in more socially acceptable ways, such as contact sports. Grossman proposes (and recent studies support[iii]) that a high proportion of these individuals move into roles such as military, law enforcement, and other first response organisations, especially the pointy end of these organisations including military Special Operations and Police Tactical Groups, where they can scratch their psychopathic itches in a prosocial manner.

Grossman’s work and the emerging literature around prosocial or successful psychopaths in military environments is possibly not based on new observations.

The ancient Greek philosopher Heraclitus (circa 500 AD) made the following observation on warriors:

“Out of every one hundred men, ten shouldn’t even be there, eighty are just targets, nine are the real fighters, and we are lucky to have them, for they make the battle. Ah, but the one, one is a warrior, and he will bring the others back.”

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My interpretation of Heraclitus’ quote is that he had identified the same adaptive nature of psychopathy in the context of battle that Grossman has picked up on two and a half thousand years later.

Grossman goes on to categorise society into Sheep, Wolves, and Sheepdogs.

?Applying the emerging science on psychopathy, these categories might equate to:

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·????? Sheep – the 98-99% of the population who don’t meet diagnostic criteria for psychopathy.

·????? Wolves –? a sub-percentage of the 1-2% of psychopaths in society, with criminal tendencies and intent to harm the sheep.

·????? Sheepdogs -? the remainder of the 1-2% of psychopaths in society without criminal tendencies.

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As mentioned above, when I first read Grossman’s work, the math didn’t add up.

Assuming the original view of all psychopaths as having criminal intent, and that they represent 1-2% of our population, then why aren’t our prisons bursting at the seams (more than they already are that is!)?

By that rationale, taking Australia’s population of approximately 26 million people and using the conservative estimate of 1% diagnostic psychopaths, we should by rights have 260,000 criminals roaming around. Yet Australia’s incarcerated population hovers around the 43,000 mark[iv]. Even a generous doubling of that figure to account for clever criminal psychopaths who haven’t been caught, it still leaves around 160,000 Australian psychopaths unaccounted for!

?So where are they?

A bold 2011 study in the UK set out to answer this very question. Dr Kevin Dutton, prolific researcher in the field of psychopathy and author of The Wisdom of Psychopaths: Lessons in life from saints, spies, and serial killers, ran the Great British Psychopath Survey, which he offered to the entire national workforce.

His results make for interesting reading, with the top ten occupations of workers meeting diagnostic criteria for psychopathy (based on results from the Levenson Self-Report Psychopathy Scale) listed below:

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1.??????? CEO

2.??????? Lawyer

3.??????? Media (TV/Radio)

4.??????? Salesperson

5.??????? Surgeon

6.??????? Journalist

7.??????? Police Officer

8.??????? Cleric

9.??????? Chef

10.? Civil Servant

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Based on Dutton’s findings, and somewhat ironically, it may be that the police officer arresting an individual and the lawyer prosecuting or defending them could very well be as, if not more, psychopathic than the criminal themselves!

So, what determines which side of the law a psychopath falls?

Expanding on Grossman’s recognition that intelligence and socioeconomic status play a role, Dutton offers a mixing dial analogy of psychopathic traits in The Wisdom of Psychopaths, that I find useful.

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Psychopathy is not as binary and clear cut as most would initially consider. For psychiatric diagnostic purposes there must exist a cut-off point that delineates the diagnosis of psychopathy, however all the constituent traits of psychopathy exist on a spectrum from low to high. If enough of them are high, then a diagnosis can be made however, which side of the law a psychopath falls on can be influenced by which specific traits are high.

There are several validated tools to assess psychopathy but to continue the discussion here I have chosen a commonly used one: the Psychopathic Personality Inventory (PPI)[v], which assesses the following eight factors:

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1.??????? Machiavellian egocentricity (ME) – The ruthless self-centred willingness to exploit others

2.??????? Social potency (SOP) – Ability to charm and influence others

3.??????? Coldheartedness (C) Lack of emotion, guilt, or regard for the feelings of others

4.??????? Carefree nonplanfulness (CN) – difficulty planning ahead or considering the consequences of one’s actions

5.??????? Fearlessness (F) – eagerness for risk-seeking behaviours and a lack of fear that should be experienced during high-threat encounters

6.??????? Blame externalisation (BE) – inability to take responsibility for one’s actions and tendency to blame others for adverse outcomes

7.??????? Impulsive nonconformity (IN) – disregard for social norms and culturally acceptable behaviours

8.??????? Stress immunity (STI) – A lack of typical marked reactions to traumatic or otherwise stressful events.

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On face value, they all might look like bad personality traits to have. However, under certain circumstances, it might be appreciated that some of them could come in very handy.

Let’s consider an agent of the intelligence services attempting to recruit a human intelligence source to gain critical information of international significance, perhaps about a terrorist organisation’s intent on conducting a mass-casualty attack. That agent, under those circumstances, would benefit greatly from a healthy dose of ME, SOP, C, and F.

Returning to Dutton’s mixing deck analogy, they would want those dials turned up towards maximum, with a low to normal level of CN, BE, and IN.

In my old role as a doctor with Special Operations, I seem to have benefited from, when appropriate, cranking up the dial on C, F, and STI when treating combat casualties and remaining functional in my role during the aftermath.

The normal 98-99% of society has all eight of these mixing deck dials set to a low-mid level, with the potential of turning up one or two of the dials under extreme circumstances (sometimes referred to as situational psychopathy).?

Having all the dials on their lowest settings can lead to overwhelming anxiety and pathological non-confrontation.

To have them all cranked to max is a recipe for disaster and is most consistent with the stereotypical Hannibal Lecter type psychopath.

One interesting perspective on psychopathy is that it may convey some evolutionary benefit, arguing that if it was all bad, then why haven’t these traits been bred out of the human race over the course of evolution? There’s certainly speculation that some psychopathic traits (particularly SOP and IN) offer an advantage to males in finding (many) mates and promulgating gene lines!

For anyone who has read my previous newsletters, you will know my love for the Yerkes-Dodson “inverted-U” Stress-Performance curve as a great tool to frame discussions relevant to military and first responder roles.

A similar inverted-U curve has been proposed as an empirical relationship between psychopathy level and functionality[vi].

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To quote the author responsible for this graph, sociologist John Ray, directly on the topic:

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“Both extremely high and extremely low levels of psychopathy may be maladaptive, with intermediate levels being most adaptive. The basis for saying that high levels of psychopathy are maladaptive is, of course, the trouble into which clinical psychopaths often get themselves. The basis for saying that low levels of psychopathy may also be maladaptive stems from the common observation of the role of anxiety in psychopathy: psychopaths do not seem to show any anxiety. The debilitating function of high levels of anxiety hardly needs to be stressed. In a normal, non-institutionalized population, therefore, their relative immunity from anxiety may give psychopaths an advantage.” (Ray, cited in Dutton, 2012, p.132)

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Furthering the discussion of criteria differentiating prosocial (functioning, or successful, psychopaths) from antisocial (criminal) psychopathic behaviour, Dutton offers the following equation:

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By applying this equation, we can see that a psychopath with the intelligence and self-control to make good decisions, and in the right context, can stay on the correct side of the law. They may even thrive!

A 2018 study looking at psychopathy and heroism in first responders found higher levels of psychopathic traits in first responders than the general population, as well as a correlation between these traits and heroic actions[vii].

Fascinatingly, although perhaps not altogether surprising, was the finding in the same study of a cohort of first responders who had both been recognised for their heroics as well as been disciplined for their negative behaviours. This suggests that the line between sheepdog and wolf may be blurred.

I witnessed this myself among Special Operations soldiers. One case that sticks in my mind was of a soldier who, while awaiting a disciplinary hearing for a spectacularly silly and illegal indiscretion, was first on scene at a vehicle accident. The vehicle was on fire and the driver of it was trapped by his arm, which had been badly lacerated and was bleeding from a major artery. Using MacGyver-like improvisation and speed, the disgraced soldier sourced water to extinguish the fire and then fashioned a makeshift arterial tourniquet to stop the life-threatening bleeding.

This action posed a dilemma for the unit, who proceeded to recognise and celebrate him for his heroics and then kick him out for his previous stupidity!

The case study above is a great example of the concept “that the hero and the psychopath may be twigs on the same genetic branch” [viii] owing particularly to their shared predisposition towards fearlessness that can be channelled toward socially adaptive or maladaptive outlets[ix]

Modern scientific methods have started to decipher the neuroscience underlying the psychopath’s capacity for fearlessness and emotional coldness.

Functional Magnetic Resonance Imaging (fMRI), being a scanning technique that allows the function of a brain to be seen realtime, has been informative in this area. Equally, the measurement of physiological markers, such as heartrate, sweating, and skin temperature, in response to stressful stimuli, have added to the discussion.

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Hot versus Cold empathy

One of the key areas of interest in psychopathy is empathy, being broadly defined as the ability to understand and share the feelings of others. Empathy is believed to have been fundamental to productive human social evolution by driving concern for others and a stimulus to help others in distress or pain[x].

One of the core diagnostic criteria for psychopathy is a lack of empathy. However, there exists debate in the scientific community as to whether psychopaths lack empathy or are capable of it but just experience it in a different way. At the extreme end of this debate is the suggestion that a psychopathic serial killer needs to feel empathy for the suffering of their victims to derive the perverse sense of pleasure out of the heinous acts that many of them have reported to have done i.

Empathy can be deconstructed into different facets, with one model involving four themes[xi]:

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·????? Understanding – understanding another person’s world

·????? Feeling – to feel what another person does

·????? Sharing – to share another person’s world

·????? Self-Other differentiating – differentiating between their own feelings and those of another

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The different categories of empathy underpinning understanding and feeling another person’s world and emotional state are commonly referred to cognitive versus affective, or cold versus hot, empathy. It is in this differentiation that fMRI has been informative in helping decipher the neural response of empathy in psychopaths as it differs to non-psychopaths (normal subjects).

Studies using fMRI have demonstrated that when shown imagery of others in pain normal subjects activate neural pathways associated with their own experience of pain, hence experiencing affective (hot) empathy, and serving as a strong drive to help the other person viii. Psychopaths don’t, instead activating neural pathways relating to the cognitive understanding that the other person is in pain (cognitive or cold empathy) without any mirroring emotional response of their own suffering viii.

Other studies have taken this knowledge a step further and shown an adaptive nature to this finding. When faced with an emotionally charged situation that requires action to be taken, a normal person will have activation of their emotional neural networks that stand to hinder their complex reasoning and task-related neural networks to get the job done i. The psychopath on the other hand, has little to no activation of their emotional neural networks under those circumstances (emotional coldness) and can focus all their cognitive bandwidth on the task at hand, improving the chances of task success i.

It can be appreciated that in my old role as a doctor treating combat casualties, the ability to disconnect the emotion of treating a mortally wounded friend on the battlefield from the complex task of trying to save them conveyed huge benefits in the moment.

After the fact, when the emotional regions of my brain came back online, I found myself able to retrospectively empathise and experience the emotion of the situations. In the moment however, I was nothing more than a tactical medical robot.

Studies looking at the differences in normal subjects versus psychopaths in physiological markers of arousal in response to shocking stimuli, often graphic imagery of human suffering and loud, startling and offensive noises, have shown mixed results. Most studies have demonstrated lower levels of physiological response to shocking stimuli in psychopaths (in keeping with their hallmark fearlessness) while an outlier group showed increased arousal[xii].

This outlier group of studies that show increased physiological arousal to shocking stimuli could be interpreted in two ways.

Firstly, it could be seen as disproving the hypothesis that psychopaths don’t get physiologically aroused by shocking stimuli.

A second school of thought proposes that the increased arousal seen under these circumstances is a positive affective response, as opposed to the negative response causing the same increases in normal subjects. This hypothesis has given rise to the Fear Enjoyment Hypothesis [xiii], which proposes that psychopaths become positively excited by shocking stimuli.

In my opinion this makes sense. We know from the Yerkes-Dodson Stress Performance curve that a certain amount of stress is required to prime people for optimal performance.

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If a psychopath was completely incapable of firing the normal physiological responses to shocking stimuli, then it could be argued that they couldn’t prime themselves for an optimal response in a realtime situation. If, on the other hand, the emotional centres of their brain did not respond (which might drive a negative affective response) and their interpretation of the situation was positive (excitement rather than fear), then that arousal could prime them for an emotionless and optimised response to it.

Add in a high level of training in the domains of the tasks required to act in the objectively shocking situation and you have the perfect storm for the prosocial psychopath to thrive.

Anyone aware of Christian Craighead’s incredible response to a 2019 terrorist attack in Kenya might see some relevance here.

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For those readers unaware of what I’m talking about, Craighead was at the time a British 22 SAS operator in Kenya on a training assignment in 2019 when a terror cell launched a coordinated attack on civilians in a Nairobi shopping centre. Being in the area and with tactical equipment on hand, Craighead initiated a solo response and then coordinated the subsequent local law enforcement response. Reflecting on the incident Craighead is quoted as saying:

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“…it was the most remarkable day of my life. I’ve done close to a thousand door-kicking missions and there’s nothing that was ever like that day. Nothing. People talk about flow state …when you get dialled in and it’s on... I unlocked some sort of superpower on that day. When I crossed that threshold, I felt like I could see further, I could hear things, I could move faster, I was stronger, I had better mental agility, I really unlocked this flow state.”

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Now I’m not for a moment suggesting that Craighead is a psychopath, although if I was a gambling man I’d wager that he would meet the diagnostic criteria. What I interpret this quote to reflect is an underlying cold heartedness, fearlessness, and stress immunity, with a high level of training in close quarters battle, allowing him to see the situation as exciting, and firing a physiological response that put him in an optimal stress-performance zone to find flow (a match between skill and challenge) in the situation.

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Another interesting rabbit hole to go down in this discussion is the concept of courage.

If courage, as the great Nelson Mandela proposed, is “…not the absence of fear, but the triumph over it”, and if a psychopath doesn’t feel fear, then can a psychopath be courageous? That might be a discussion for another time!

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My hope in writing this (rather longwinded) newsletter is that it might reach a few people who are grappling with their own morality around experiences they have had. Especially those who may be feeling guilty for notfeeling guilty about certain experiences that they perceive a normal person should be affected by. More especially those who have the confusing outcome of a positive memory from what was an objectively profoundly negative situation.

In my personal experience, and in discussion with others who have had similar experiences, this can leave an individual feeling something less than human and can drive social isolation through the complete inability for the non-psychopath (98-99% of the population) to understand them.

My hope is that this newsletter might shed some light on the psychology behind what may have occurred and offer some insight into why different people react in different ways. My hope also is to add to the contemporary discussion around psychopaths and further the awareness that they aren’t all bad people.

In fact, the statistics suggest that a psychopath might be more likely to save your life than take it!

It is just a matter of which dials are turned up and which ones stay at a normal level.

If you want to hear more about my experiences in army Special Operations, I’ve written about them in my book The Combat Doctor (Australian Amazon link here)

As always, comments and questions are welcome. If you feel this newsletter might resonate with others in your community, please share it widely.

Until next time, stay safe, and don’t forget to have some fun!

Cheers,

Dr Dan Pronk

References?

[i] Dutton (2012) The wisdom of psychopaths, London, Penguin Random House.

[ii] Kiehl KA, Hoffman MB. The criminal psychopath: History, neuroscience, treatment, and economics. THE CRIMINAL PSYCHOPATH: HISTORY, NEUROSCIENCE, TREATMENT, AND ECONOMICS. Jurimetrics. 2011?

[iii] Anestis, J. C., Green, B. A., Arnau, R. C., & Anestis, M. D. (2019). Psychopathic Personality Traits in the Military: An Examination of the Levenson Self-Report Psychopathy Scales in a Novel Sample.?Assessment,?26(4), 670-683.

[iv] Australian Bureau of Statistics (Mar-quarter-2024),?Corrective Services, Australia , ABS Website, accessed 16 August 2024.

[v] Lilienfeld, Scott O.; Andrews, Brian P. (June 1996). "Development and Preliminary Validation of a Self-Report Measure of Psychopathic Personality Traits in Noncriminal Population".?Journal of Personality Assessment.?66?(3): 488–524.

[vi] Ray, J. J., & Ray, J. A. B. (1982). Some Apparent Advantages of Subclinical Psychopathy.?The Journal of Social Psychology,?117(1), 135–142.?

[vii] Patton CL, Smith SF, Lilienfeld SO. Psychopathy and heroism in first responders: Traits cut from the same cloth? Personal Disord. 2018 Jul;9(4):354-368.

[viii] Lykken, 1996, cited in Francis Smith et al, 2013

[ix] Francis Smith, S. et al. (2013). Are psychopaths and heroes twigs off the same branch? Evidence from college, community, and presidential samples. Journal of Research in Personality. 47 (5): 634-646.

[x] Decety J, Skelly LR, Kiehl KA. Brain response to empathy-eliciting scenarios involving pain in incarcerated individuals with psychopathy. JAMA Psychiatry. 2013 Jun;70(6):638-45.

[xi] Eklund, J.H., Meranius, M.S., 2021. Toward a consensus on the nature of empathy: a

review of reviews. Patient Educ. Couns. 104 (2), 300–307.

[xii] Wang P, Baker LA, Gao Y, Raine A, Lozano DI. Psychopathic traits and physiological responses to aversive stimuli in children aged 9-11 years. J Abnorm Child Psychol. 2012 Jul;40(5):759-69.

[xiii] Hosker-Field, A. M., Gauthier, N. Y., & Book, A. S. (2016). If not fear, then what? A preliminary examination of psychopathic traits and the Fear Enjoyment Hypothesis.?Personality and Individual Differences, 90,?278–282.