Elsevier

The Lancet Psychiatry

Volume 2, Issue 2, February 2015, Pages 153-160
The Lancet Psychiatry

Articles
Punishment and psychopathy: a case-control functional MRI investigation of reinforcement learning in violent antisocial personality disordered men

https://doi.org/10.1016/S2215-0366(14)00071-6Get rights and content

Summary

Background

Men with antisocial personality disorder show lifelong abnormalities in adaptive decision making guided by the weighing up of reward and punishment information. Among men with antisocial personality disorder, modification of the behaviour of those with additional diagnoses of psychopathy seems particularly resistant to punishment.

Methods

We did a case-control functional MRI (fMRI) study in 50 men, of whom 12 were violent offenders with antisocial personality disorder and psychopathy, 20 were violent offenders with antisocial personality disorder but not psychopathy, and 18 were healthy non-offenders. We used fMRI to measure brain activation associated with the representation of punishment or reward information during an event-related probabilistic response-reversal task, assessed with standard general linear-model-based analysis.

Findings

Offenders with antisocial personality disorder and psychopathy displayed discrete regions of increased activation in the posterior cingulate cortex and anterior insula in response to punished errors during the task reversal phase, and decreased activation to all correct rewarded responses in the superior temporal cortex. This finding was in contrast to results for offenders without psychopathy and healthy non-offenders.

Interpretation

Punishment prediction error signalling in offenders with antisocial personality disorder and psychopathy was highly atypical. This finding challenges the widely held view that such men are simply characterised by diminished neural sensitivity to punishment. Instead, this finding indicates altered organisation of the information-processing system responsible for reinforcement learning and appropriate decision making. This difference between violent offenders with antisocial personality disorder with and without psychopathy has implications for the causes of these disorders and for treatment approaches.

Funding

National Forensic Mental Health Research and Development Programme, UK Ministry of Justice, Psychiatry Research Trust, NIHR Biomedical Research Centre.

Introduction

Most violent crimes are committed by a small number of men.1 They display a pattern of antisocial and aggressive behaviour that begins in childhood and remains stable throughout the lifespan. They meet diagnostic criteria for conduct disorder in childhood and for antisocial personality disorder in adulthood. Lifelong patterns of poor decision making, impulsivity, and risk-taking behaviours characterise such men, and persist despite repeated punishments enacted by parents, teachers, and the criminal justice system.

Within this population, a subgroup presents with antisocial personality disorder and psychopathy, defined by the psychopathy checklist-revised (PCL-R)2 as including callousness, lack of empathy, an interpersonal style involving grandiosity and manipulation of others, and persistent reactive and instrumental aggression. Such individuals show reduced tonic skin conductance and cortisol concentrations, and have difficulty recognising fear and sadness in the faces of others.3 By contrast, men who have antisocial personality disorder without psychopathy are characterised by emotional lability, mood and anxiety disorders, and reactive aggression.4 Although the two phenotypes emerge early in life, those who develop antisocial personality disorder with psychopathy begin offending at an earlier age, engage in a broader range and higher frequency of offending behaviours,4 and respond less well to treatment in childhood5 and adulthood6 than those without psychopathy. The two groups show distinct differences in brain structure7 and functional responses to empathy-eliciting scenarios8 and emotional stimuli when engaged in goal-directed behaviour.9 Diagnostic classification systems, however, do not distinguish between antisocial personality disorder with and without psychopathy. Rehabilitation programmes typically exclude offenders with psychopathy.

Many decisions, including whether or not to engage in an antisocial act, involve the ability to assess consequences. Selecting an action is dependent on reinforcement learning, whereby possible rewards are weighed against possible punishments on the basis of past experience.10 Men with antisocial personality disorder show impairments in adaptive decision making, characterised by abnormal processing of reinforcement information.11, 12 Their behaviour seems to be driven more by potential rewards than potential punishments (reward dominance). Impaired learning about the consequences of actions might result in overly optimistic and inaccurate predictions of favourable outcomes, resulting in frustration, which could predispose to reactive aggression. Impaired self-control lowers the threshold for aggression in response to such frustration.13 In behavioural studies offenders with antisocial personality disorder and psychopathy have shown notable impairment in using reinforcement information when choosing between punished and rewarded objects in passive avoidance,14 extinction,15 and reversal learning tasks.11, 16, 17 The failure to use punishment information to signal inappropriate behaviour is thought to be the primary deficit in psychopathy, and emerges early in childhood.18

Reversal learning tasks examine the ability to adjust behaviour to changes in reinforcement contingency. Studies of healthy adults and adults with brain lesions have identified a neural network recruited during reversal learning.19 The dorsomedial prefrontal cortex, ventrolateral prefrontal cortex, and dorsolateral prefrontal cortex serve, respectively, to allocate attentional resources, assess conflicting responses, and initiate response modulation. The ventromedial prefrontal cortex, posterior cingulate cortex, and dorsal caudate track changes in reinforcement information, reducing activation in response to punishment, thus signalling behavioural error, change in reinforcement contingency (when reward is expected but punishment received), and the need to adapt behaviour.20, 21

Little is known about the neural systems serving reinforcement learning anomalies in offenders with antisocial personality disorder with and without psychopathy. Offline versions of probabilistic response reversal tasks are self-paced, which means that intervals between the stimulus presentation, response, and feedback vary across trials.11 A variant of this task has been developed for the functional MRI (fMRI) scanning environment that is designed specifically to minimise behavioural differences between antisocial individuals and normal controls. Importantly, the scanner version of the task provides reinforcement more often and more consistently than the offline task. This change lessens task difficulty and the likelihood of confounding introduced by large differences in performance, such as differential contamination by error events.22 The scanner version of the task has been used to assess adolescents with conduct disorder and callous unemotional traits,21 which are the childhood antecedents of antisocial personality disorder with psychopathy.5 Compared with healthy teenagers, adolescents who have conduct disorder with callous unemotional traits showed intact recruitment of the dorsomedial prefrontal cortex, dorsolateral prefrontal cortex, and inferior frontal cortices when changing their behaviour in response to punishment signals, but did not appropriately reduce activation of the ventromedial prefrontal cortex. This finding was interpreted as intact recruitment of regions involved in response change immediately after punishment, but impairment in regions that alter long-term value associated with responses, thereby increasing the likelihood of future incorrect responding.

We used the scanning environment probabilistic response reversal task to do an fMRI study of reinforcement processing and decision making in violent adult offenders with antisocial personality disorder with and without psychopathy. Focusing on responses to punished reversal errors relative to rewarded correct responses, we tested the hypothesis that violent offenders with antisocial personality disorder and psychopathy would show increased activation within the ventromedial prefrontal cortex, caudate, and posterior cingulate cortex to punished reversal errors, as identification of anomalous responding to reinforcement information within such individuals could be useful as a diagnostic biomarker.

Section snippets

Participants and study design

Between January, 2007, and January, 2011, we enrolled 50 men, aged 20–50 years, with reading age higher than 10 years as defined by the Schonell instrument. Eligible participants had no history of major mental disorders (bipolar 1, bipolar 2, major depression, or psychotic disorders), as defined by the structured clinical interview for Diagnostic and Statistical Manual of Mental Disorder, fourth edition (DSM-IV), axis I disorders (SCID I), or self-reported neurological disorders, head injury

Results

The three groups did not differ significantly except for education and PCL-R score (table 1). The offenders with antisocial personality disorder and psychopathy were significantly younger at first conviction than those without psychopathy. They also had higher numbers of convictions for violent crime, but this difference was not significant. Significantly more offenders had lifetime diagnoses of alcohol and cocaine dependence than non-offenders (appendix). Of note, though, the proportions of

Discussion

We investigated the neural basis of reversal learning in violent offenders with antisocial personality disorder with and without psychopathy. Offenders with antisocial personality disorder and psychopathy displayed abnormal responding to punishment signals within the posterior cingulate and insula, illustrated by significantly greater BOLD activation to punished reversal errors than to rewarded correct responses in both regions. These differences were not related to the number of antisocial

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