What is known and objective: Psychopathy is a personality disorder characterized by deficits in personality and behaviour. Personality deficits are marked by interpersonal and affective facets, including pathological lying, grandiose sense of self-worth, lack of remorse and callousness. Behavioural deficits are defined by lifestyle and antisocial deficits, including impulsivity, parasitic lifestyle and poor behavioural controls. The objective of this review is to provide clinicians with (i) an appreciation of the clinical features of psychopathy, (ii) an understanding of the structural and functional derangements and the genetic and environmental factors which serve as the basis for the development of psychopathy and (iii) a summary of published reports of pharmacological approaches to the management of this disorder.

Methods: A literature search of MEDLINE/PubMed (1966-present) was conducted using the MeSH search terms psychopathy and antisocial personality disorder alone and in combination with the subheading drug therapy. Additional databases included Web of Science (1945-present) and International Pharmaceutical Abstracts (1970-present) using the text words psychopath and antisocial personality were searched. A search of Amazon books using the search terms psychopathy and sociopathy was also performed. Bibliographies of relevant articles were searched for additional citations. All data sources in English were considered for inclusion. For background information, broad subject headings were searched for review articles first. Human and animal drug therapy articles were evaluated giving preference to those papers using a controlled trial methodology.

Results and discussion: Psychopathy is a personality disorder characterized by a lack of conscience, pathologic lying, manipulative behaviour and often superficial charm. The incidence of psychopathy in the general population is generally considered to be 0·6-4% with a higher proportion of males to females. Brain imaging studies of psychopaths suggest a smaller and less active amygdala and prefrontal cortex. There also appear to be physiological derangements in psychopathy, including alterations/dysregulation in neurotransmitter homeostasis (dopamine and serotonin), altered endocrine responses (testosterone and cortisol) and altered autonomic responses to emotional stimuli and stressors. Although both genetic and environmental factors likely contribute to the developmental basis of psychopathy, these factors are poorly understood at present. To date, limited studies with pharmacologic interventions in psychopathy are available and there are insufficient trials to determine efficacy.

What is new and conclusion: Psychopathy is a serious personality disorder with profound negative effects on individuals and society. To design rational therapeutic strategies for this disorder, additional research is needed to discover the specific pathological and pathophysiological basis of psychopathy and to further elucidate the genetic and environmental factors responsible for psychopathic development. There is emerging evidence of phenotypic variants in psychopathy, including successful and unsuccessful types. It is important for clinicians to be cognizant of the psychopathic personality.