A Review of ‘The Psychopath Inside’ by James Fallon

jacket cover The_Psychopath_InsideReproduction of Cover featuring an Anamorphic Illusion

I was sent a copy of ‘The Psychopath Inside: A Neuroscientist’s Personal Journey Into the Dark Side of the Brain ’ by James Fallon to review.

Warning: Spoilers

I thought this was a very good book which will repay close study particularly for those in the field of neuroscience and mental health. The book will also have a wider appeal because of the human story. I imagined that this would have been a very difficult book to write because Fallon chooses to associate himself with the label of ‘Psychopath’ quite openly. The term Psychopath is not quite the same as Antisocial Personality Disorder which is a diagnostic category in ICD-10 and DSM-V. In the book, Fallon focuses on Hare’s Psychopathy Checklist as a starting point for the discussion around the psychopath construct. The diagnostic categories cannot be used interchangeably with scores on the Hare’s Psychopathy Checklist – Revised for several reasons. Firstly clinical diagnoses result from clinical assessments which may include but are not limited to the results of psychometric assessment tools. Secondly the HPCR is specifically used in the forensic setting with convicted offenders.

Diagnoses are neutral terms which should carry no pejorative overtones in the clinical setting. However in wider society nuanced clinical diagnoses can often take on meanings beyond those for which they were intended. The term ‘psychopath’ has been used in the arts to describe characters who are considered ‘evil’. Such labels can become stigmatising depending on the context in which they are used and there is much work to be done in addressing this stigma.

Subsequently Fallon is linking himself with a label which wider society approaches with considerable caution. Fallon recognises this and in my mind this is something which requires a great deal of courage and potential sacrifice particularly when thinking about reputation. Fallon focuses on some of the stigma that he experiences. When ‘outing’ himself with this label some of his friends disassociate from him although others are more ‘understanding’. In associating with this label Fallon is doing a great service to others with this label in being able to give an elegant voice to the profound issues that are raised. The book works on a number of levels though and so the focus on this possible link and the potential for stigma are just one of the many issues raised. Fallon is not arguing that he meets the criterion for psychopathy but instead he suggests he has a biological predisposition to psychopathy.

James Fallon – Confessions of a Pro-Social Psychopath

Jim Fallon – Exploring the Mind of a Killer

What I found quite fascinating about the book is that James Fallon has taken on the mantle of writers such as Carl Jung, Sigmund Freud, Kay Redfield Jamieson and Oliver Sacks who write about their own inner experiences in health or illness. Such writings for the general public give the reader an intuitive experiential understanding of tricky theoretical issues and highlight the scientific curiosity and drive of the authors who allow the public to ‘analyse’ them. The human story however is the most important element enabling them to connect with the reader. In this sense, Fallon’s style is very personable. Fallon is perhaps unique in this regards as he also gives a voice to the growing numbers of neuroscientists who are increasingly giving us invaluable clinical insights in the research setting.

In terms of the scientific understanding that Fallon offers us, the book is rich in learning material. Even for experienced clinicians there is plenty to learn from this master of neuroscience. To start with he has undergone a genome analysis and again he openly shares his findings on neurotransmitter receptor genotypes. Fallon has a very deep grasp of neurotransmitters and their receptors and he is able to offer the reader a potential pharmacological explanation for his own behavioural tendencies. This is just one of the areas that are well worth revisiting as the lessons are subtle and would repay close study. He also expands on the concept of a ‘warrior gene’ while also warning against oversimplifying the concept. Fallon navigates his way through the complex issues by balancing popular appeal against the science while telling a story.

The central premise of the book is that Fallon identifies a pattern on his own brain images that he finds in people with a diagnosis of psychopathy. While Positron Emission Tomography scans are more helpful in the diagnosis of organic illnesses there is less of a role in functional illnesses. However Fallon moves us through an intriguing central hypothesis – one that if correct has the potential to reshape our understanding of many aspects of mental illness. The core hypothesis is that Fallon lacks an ability for hot cognition a term which he uses to describe cognition which uses emotions and that this has correlates on the PET images. On the other hand, he argues from his own experience and insights that he is able to compensate in his work through cold cognition which he attributes to Dorsolateral Prefrontal Cortex functioning.

This central hypothesis like many other aspects of the book is multi-layered. While Fallon argues that he is able to compensate with cold cognition, it is the difficulty with hot cognition that offer us a powerful insight into an aspect of our shared humanity. Fallon finds that several areas of his brain show markedly decreased areas of functioning with the PET imaging. These areas include the Orbitofrontal Cortex, Anterior Cingulate Cortex, Amygdala, Anterior Insular Cortex and Inferior Temporal Lobe. At first he finds these signature patterns in the scans of people who have been convicted of murder. Without the context set out in this book, I would have been quite sceptical at such a simple link. However Fallon goes on to share with us his own family history and he identifies several people who have been convicted of murder going back several generations. Even this though wouldn’t have been convincing.

Fallon convinces me by tackling the issue of nature versus nurture. Fallon argues that he would not meet the criteria for psychopathy and this he believes is due to his early upbringing. He suggests that were he to have had a traumatic upbringing then he may well have gone on to internalise antisocial values and turn out very differently. Fallon is therefore arguing for a susceptibility model for personality disorder. In this model a person lacks or has difficulties with emotional ‘hot’ cognition. With this susceptibility the person goes on to internalise values for managing relationships. Without an intuitive understanding of relationships, the person may carry on with a rather brittle set of values which are not easily adjusted by the usual mechanisms of feedback received during social interactions. If those values are damaging to relationships if applied automatically then this has the potential for harm to the person and those around them. This model may account for the tendency for personality disorders to ‘burn out’ if a person is able to learn enough about relationships to compensate for these automatic tendencies. Such a model may one day help to predict those with a predisposition to psychopathy and the key environment-dependent values that can be learnt to avoid this.

Another thread in the book is the discussion of ‘Theory of Mind’, empathy and sympathy. The scientific literature is replete with various definitions of ‘Theory of Mind’ and empathy and Fallon has a very specific definition for these constructs which helps him to find neurobiological links. Along the way Fallon references the work of Simon Baron Cohen and Rebecca Saxe. Again this section of the book will repay close study and there is an emerging literature on how empathy may link atypical forms of Autistic Spectrum Disorders with personality constructs.

Simon Baron Cohen on Zero Degrees of Empathy

Rebecca Saxe on how we read minds

Fallon also discusses obsessive-compulsive disorder, Bipolar Disorder and Panic Disorder in terms of his own experiences. I wasn’t clear on whether these were formally diagnosed although Fallon refers to treatment for panic attacks. It is not my place to comment on the possibility of these diagnosis as such diagnoses result from a clinical assessment. However Fallon’s mention of these diagnoses lead into a discussion of how his neurobiological model may offer explanatory insights.

While the uninitiated reader may hold in mind a stigmatised caricature of a psychopath, Fallon takes us through the nuances of the psychopathy construct to something more meaningful. In presenting himself if anything he reveals a fun loving person, who behaves responsibly and is clearly interested in the human condition. As this works on several levels the book can appeal to readers with little or no knowledge of clinical neuroscience all the way through to experienced clinicians. Fallon offers us a tabula plenus in the form of his own experiences and introspection to complement the broad range of biomedical and psychometric assessments he has undergone.

For those with an interest in neuroscience, who follow developments in brain imaging and genetics and who sometimes ask what is the point of it all, Fallon has an answer. Sigmund Freud wrote about the interpretation of dreams and opened up an entirely new discussion about the mind. He transformed Psychiatry and developed psychoanalysis based on his findings. Fallon has taken decades of studies with specific findings and fashioned them into an intuitive experiential model with the potential to start another such discussion. There are many possibilities for how this discussion can be taken forward including discussions of stigma, developing therapeutic approaches based on this model, and other works expanding on the concepts developed here.

Index: There are indices for the TAWOP site here and here Twitter: You can follow ‘The Amazing World of Psychiatry’ Twitter by clicking on this link. Podcast: You can listen to this post on Odiogo by clicking on this link (there may be a small delay between publishing of the blog article and the availability of the podcast). It is available for a limited period. TAWOP Channel: You can follow the TAWOP Channel on YouTube by clicking on this link. Responses: If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk. Disclaimer: The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog. Conflicts of Interest: For potential conflicts of interest please see the About section.

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