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Psychopaths in Old Age: Mellow After All?

In the IDA course "Dynamics of Individual Differences", students write a blog post on a topic of their interest that is related to an aspect that differs between individuals and changes across the lifespan. Enjoy reading the blog post of Esmee!

Social predators who charm, manipulate, and ruthlessly plow their way through life, leaving a broad trail of broken hearts, shattered expectations, and empty wallets” (Hare, 1993, p. xi) are not typical terms you would use to describe your grandmother or your elderly neighbor down the street. However, they do narrowly describe psychopaths and the disastrous effect that they are capable of. While many people watch with disbelief real life Hannibal Lecter practices in documentaries, not every psychopath can be condemned as a violent criminal. Although the crude prevalence in the general population is estimated at 1.0%, the negative impacts on the person in question, the relatives, and society should not be underestimated (Holzer & Vaughn, 2017). This, in combination with the ever-growing aging of society, raises the question what psychopathy looks like in old age? Is that older neighbor living down the street still as psychopathic as she was in her youth? And if so, in the perspective of physical and mental health care, how should we deal with psychopathic older adults when they become more impaired due to age and are more in need of care?

Defining psychopathy

To be able to give a well-considered answer to these questions, we must first ask ourselves when someone can be labeled as a psychopath. What Monohan (2006) hailed as perhaps the most relevant forensic construct of the early 20th century has its roots in Cleckley’s (1941) work “The Mask of Sanity” in which 16 personality traits sketched the idea of a prototypical psychopath. Moving forward to the current criteria of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-V) three of the seven listed symptoms must be present for a diagnosis of antisocial personality disorder (ASPD). This mainly concerns concrete and behavioral characteristics of aggressive and impulsive behavior, but also the violation of the rights of others (Lynam & Vachon, 2012). However, psychopathy itself is not recognized as a disorder, but it can be added as a specifier to ASPD. This means that not everyone with ASPD can be considered a psychopath, but every psychopath does suffer from ASPD. This psychopath is characterized by a specific combination of personality traits in which disinhibition, meanness and boldness are central (Patrick et al., 2009) which results in low emotional affect, lack of guilt, shame, and empathy, as well as a deceptive interpersonal style (Hare, 2003).

Perhaps unsurprisingly, psychopathy is strongly associated with substance abuse, risky sexual behavior, instrumental violence, intimate partner violence, and criminal behavior, making it a costly disorder for both the diagnosed person and society (DeLisi, 2009). Given these outcomes, it is therefore not unimportant to ask the question how this disorder behaves across a person’s life course and which possible treatment options may be effective. Traditionally, personality disorders can by definition be regarded as a chronic disorder in which stability is seen as a defining feature (Hopwood & Bleidorn, 2018). In line with this reasoning, ASPD affects the diagnosed persons throughout life, with the stability of the disorder ensuring that these persons remain the same as they age. Coming back to the older neighbor who lives down the street, once a psychopath always a psychopath.

Decreasing antisocial behavior with age

Does this imply that there really is no hope for psychopaths? – Not necessarily. A reduction in psychopathic symptoms as people reach middle age has been observed in both research and mental health practice, often citing decreasing antisocial behavior in later life as an explanation (Black, 2015; Holzer & Vaughn, 2017; Sadock et al., 2016). Criminality has been found lower among people of 40 and older, whereby in addition a difference can be made between antisocial behavior into adolescence-limited and life-course persistently diagnosed individuals. (Moffitt, 2018). Since the majority belong to the first group, it is expected that those individuals naturally settle into a more conforming lifestyle as they adapt more to their fellow citizens in order to successfully meet the demands of life (Black, 2015). More interestingly is that the other group also shows decreases in antisocial behavior in later life, which suggests that indeed psychopathic older people may become a bit more mellow and may not be as hopeless as thought after all (Black, 2015).

However, when looking critically at this extinction of antisocial behavior in old age it is important to realize that reduction in antisocial behavior itself may not necessarily change to such an extent, but that criminal ratings decrease simply because the risky behavior of these individuals becomes fatal for a large proportion of them (Krasnova et al., 2019). Besides this, what can we say about those psychopaths who are not convicted and still manage to participate in society at a later age? After all, not all older psychopaths are poorly functioning individuals who end up behind bars as criminals. Gradations of the disorder are important to assume, and more successful ones with psychopathic traits should not be ruled out. However, research on psychopathy in later life is mainly based on institutionalized populations that use crime and associated overt behavior as a measurable outcome (DeLisi, 2009). Therefore it could be relevant to look into presentation of psychopathy during later life instead of only focusing on crime and associated behavior as an outcome.

Presentations of psychopathy

Namely, it is believed that the underlying dynamics of psychopathic traits that specifically typify psychopathy are not reflected in the relationship between age and crime previously explained (Boudreaux et al., 2019; Krasnova et al., 2019). In other words, although the old neighbor who lives at the end of the street shows less antisocial criminal behavior as a result of aging, does this imply that she became less psychopathic? Or perhaps, did the manifestation of the disorder change? For example, instead of getting involved in physical fights, she now expresses her aggression trough nonviolent behavior which may not meet the particular criteria of ASPD in the DSM-V (Oltmanns & Balsis, 2010). Indeed, it has been found that older adults with ASPD mainly lie, threaten and show a lack of empathy, resulting in deceiving others, justifying their own behavior and not experiencing guilt. On the other hand, less aggressive behavior is shown and there is more focus on passive- aggressiveness and addictions, with complaints about depression and psychosomatic disorders increasing (Van Alphen et al., 2007; Van Alphen et al., 2012).

It is therefore not difficult to imagine that while these older adults may change in the underlying manifestation of the disorder, they still have a huge impact on those around them and society in general. To reinforce the previous assumptions about psychopaths not changing in the way we thought before, it may therefore also be important to look at the victim’s perspective, which manifests itself in relatives who have to deal with the harmful behavior of these older adults on a daily basis. The only research done to date has shown that close ones perceive all traits of older individuals with ASPD and psychopathy as high levels, with high levels of callousness, manipulativeness, and deceitfulness (Andersen et al., 2022). More strikingly, it was indicated that psychopathic individuals over the age of 50, instead of settled down, still engaged in anti-social behavior such as violence and substance abuse. Crime was also reported, but it was indicated that despite some facing charges and convictions, these older people were even more likely to “get away with” criminal behavior overall (Andersen et al., 2022). To add exact numbers to these findings, 93% of those surveyed who knew these older adults both before and after age 50 reported that the antisocial behavior of these individuals was just as bad or even worse as they got older (Andersen et al., 2022).

Clinical consequences

If findings show that most of those people stay psychopathic and may actually get worse after the age of 50 in multiple types of relationships (Andersen et al., 2022), this raises questions about interventions and health care regarding older adults, with the main question being: how to deal with these individuals later in life? Considering the presence of psychopathic traits in the elderly remains and given the increasing aging of the population, it is not inconceivable that clinicians will be confronted with these older people too (Penders et al., 2020). To emphasize the importance, older adults with ASPD diagnosis experience increased levels of psychopathological comorbidities, including substance use disorders, major depression, mania, and anxiety disorders. Medically related, liver and cardiovascular disease, arthritis and stomach ulcer are associated with increased risk in these older people, resulting in a reduced physical health-related quality of life (Holzer et al., 2022).

Given the severity of these outcomes, there is a clinical urgency for appropriate assessment and treatment tools for psychopaths in old age (Penders et al., 2020). However, research on personality disorders in older adults in general is modest and limited. With regards to psychopathy specifically, longitudinal data and age-appropriate diagnostic tools are scarce to non-existent. This, in combination with the deficiencies of aging, which manifests itself in physical, functional, cognitive and psychosocial impairments (Holzer et al., 2020), leads to a very complex puzzle that professionals must decipher in order to enable appropriate personalized care.

Future directions

A first step could be taken in moving away from the categorical diagnosis of psychopathy that we are doing now. After all, has the neighbor living down the street really become less psychopathic or are we simply unable to adequately diagnose her in old age? As described earlier, the presentation of the disorder does change with age (Mattar & Khan, 2017), but would we judge by the current DSM-V criteria that some symptoms may not be present. Therefore, a more dynamic approach when diagnosing psychopathy is needed that takes into account the heterogeneity of personality disorders over time. This gives the opportunity to describe older psychopaths more on an individual level, making changes easier to emphasize. In addition, it would help healthcare professionals to understand both strengths and weaknesses of older people with and without this disorder (Agronin & Maletta, 2000).

In addition, tools for recognizing and managing personality disorders in general for health professionals are already scarce (Van Alphen et al., 2015), leading to even fewer tools for dealing with psychopaths specifically. Given that the core of psychopaths has very strong cognitive deficits and unwillingness to participate is not uncommon (Penders et al., 2020), the question is whether direct interventions at patient level are advisable. A possible alternative you might find in behavioral counseling, where the patient’s behavior is treated in an indirect way by influencing relatives, caretakers and practitioners (Penders et al., 2020). For example, a specially developed model for professional care givers dealing with older adults with personality disorders could offer a solution, taking cognitive therapy as a starting point. This so-called Cognitive Model for Behavioral Interventions (Osterloh et al, 2018), takes into account the self-image of the patient and their image of others in combination with possible events which triggers the patients’ challenging behavior for caregivers. To explain further, it assumed that a certain event takes place as a result of which the core needs of the psychopath are not met and this confirms the image of themselves and/or others. This then provokes challenging behavior, which makes dealing with these elderly people very difficult (Osterloh et al, 2018). However, the idea of the above model is that replacing the event that initially provoked the behavior with employees who focus on the patient’s characteristic demands will reduce behavior problems. However, the feasibility of this model is not yet known (Penders et al, 2020), which raises the question about the effectiveness for older people with personality disorders in general and specific psychopathic individuals.

In conclusion, a comprehensive answer to the questions about the manifestation of psychopathy in old age that started this blog is not as straightforward as it may seem at first glance. Although the opinion in both the clinical and research field generally assumes a reduction in symptoms of psychopathy in old age, the opposite may be true. Does the manifestation of the symptoms change rather than an observable change in the degree of the disorder? Is it indeed the case that the psychopathy older neighbor living down the street shows less violent behavior than before, but lies and deceit all the more without any sense of remorse or empathy? – Based on previous explained findings, this is a resounding yes. Then throw this assumption into the balance in combination with the increased chance of both psychological and physical disorders in this specific group and you can imagine the impact on people around them in both family and professional setting. To emphasize, the aging of the population is an established fact and will only increase, creating an urgent need for adequate diagnostic tools and means of intervention.

If you are interested in reading the articles mentioned in this post, references and links are provided here:

van Alphen, S. P., Nijhuis, P. E., & Oei, T. I. (2007). Antisocial personality disorder in older adults. A qualitative study of Dutch forensic psychiatrists and forensic psychologists. International journal of geriatric psychiatry, 22(8), 813. 10.1002/gps.1758

Van Alphen, S. P. J., Bolwerk, N., Videler, A. C., Tummers, J. H. A., & Van Royen, R. JJ, Barendse, HPJ,… Rosowsky, E.(2012). Age-related aspects and clinical implications of diagnosis and treatment of personality disorders in older adults. Clinical Gerontologist, 25, 27-41.

van Alphen, S. V., Van Dijk, S. D. M., Videler, A. C., Rossi, G., Dierckx, E., Bouckaert, F., & Voshaar, R. C. (2015). Personality disorders in older adults: emerging research issues. Current psychiatry reports, 17(1), 1-7. 0538-9

Andersen, D. M., Veltman, E., & Sellbom, M. (2022). Surviving senior psychopathy: Informant reports of deceit and antisocial behavior in multiple types of relationships. International Journal of Offender Therapy and Comparative Criminology. https://doi. org/10.1177/0306624X211067089

Agronin, M. E., Maletta, G. (2000). Personality disorders in late life: understanding and overcoming the gap in research. Am J Geriatr Psychiatry, 8(1), 4-8.

Black, D. W. (2015). The natural history of antisocial personality disorder. The Canadian Journal of Psychiatry, 60(7), 309-314.

Boudreaux, M. J., South, S. C., & Oltmanns, T. F. (2019). Symptom-level analysis of DSM– IV/DSM–5 personality pathology in later life: Hierarchical structure and predictive validity across self- and informant ratings. Journal of Abnormal Psychology, 128(5), 365-384. 10.1037/abn0000444.

Cleckley, H. (1941). The mask of sanity. Mosby

DeLisi M. (2009). Psychopathy is the unified theory of crime. Youth Violence and Juvenile Justice, 7(3), 256–273.

Hare, R. D. (1999). Without conscience: The disturbing world of the psychopaths among us. Guilford Press.

Hare, R. D. (2003). Hare Psychopathy Checklist–Revised (2nd Ed.) Multi-Health Systems.

Holzer, K. J., & Vaughn, M. G. (2017). Antisocial personality disorder in older adults: A critical review. Journal of geriatric psychiatry and neurology, 30(6), 291-302.

Holzer, K. J., Vaughn, M. G., Loux, T. M., Mancini, M. A., Fearn, N. E., & Wallace, C. L. (2022). Prevalence and correlates of antisocial personality disorder in older adults. Aging & Mental Health, 26(1), 169-178

Hopwood, C. J., & Bleidorn, W. (2018). Stability and change in personality and personality disorders. Current Opinion in Psychology, 21, 6-10.

Krasnova, A., Eaton, W. W., & Samuels, J. F. (2019). Antisocial personality and risks of cause-specific mortality: Results from the Epidemiologic Catchment Area study with 27 years of follow-up. Social Psychiatry and Psychiatric Epidemiology, 54(5), 617- 625.

Lynam, D. R., & Vachon, D. D. (2012). Antisocial personality disorder in DSM-5: Missteps and missed opportunities. Personality Disorders: Theory, Research, and Treatment, 3(4), 483.

Mattar, S., & Khan, F. (2017). Personality disorders in older adults: diagnosis and management. Progress in Neurology and Psychiatry, 21(2), 22-27.

Matthews, B., & Minton, J. (2018). Rethinking one of criminology’s ‘brute facts’: The age- crime curve and the crime drop in Scotland. European Journal of Criminology, 15(3), 296-320.

Moffitt, T. E. (2018). Male antisocial behaviour in adolescence and beyond. Nature human behaviour, 2(3), 177-186.

Monahan, J. (2006). Handbook of psychopathy. Guilford Press

Oltmanns, T. F., & Balsis, S. (2010). Assessment of personality disorders in older adults. Handbook of assessment in clinical gerontology, 101-122.

Osterloh, J. W., Videler, A. C., Rossi, G. M., & van Alphen, S. P. (2018). Cognitive model for behavioural interventions for personality disorders in older adults: a nursing approach. Tijdschrift Voor Gerontologie en Geriatrie, 49(5), 210-212. 10.1007/s12439-018-0256-6

Patrick, C. J., Fowles, D. C., & Krueger, R. F. (2009). Triarchic conceptualization of psychopathy: Developmental origins of disinhibition, boldness, and meanness. Development and psychopathology, 21(3), 913-938.

Penders, K. A., Peeters, I. G., Metsemakers, J. F., & Van Alphen, S. P. (2020). Personality disorders in older adults: A review of epidemiology, assessment, and treatment. Current Psychiatry Reports, 22(3), 1-14.

Sadock, B. J., & Sadock, V. A. (2008). Kaplan & Sadock’s concise textbook of clinical psychiatry. Lippincott Williams & Wilkins.

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