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Altered connections on the road to psychopathy

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Molecular Psychiatry (2009) 14, 946–953
& 2009 Nature Publishing Group All rights reserved 1359-4184/09 $32.00
www.nature.com/mp

ORIGINAL ARTICLE

Altered connections on the road to psychopathy

MC Craig1,2, M Catani1,2, Q Deeley1, R Latham1, E Daly1, R Kanaan3, M Picchioni3, PK McGuire3,
T Fahy4 and DGM Murphy1
1
Section of Brain Maturation, Institute of Psychiatry, De Crespigny Park, London, UK; 2Natbrainlab, Institute of Psychiatry,
De Crespigny Park, London, UK; 3Section of Neuroimaging, Institute of Psychiatry, De Crespigny Park, London, UK
and 4Department of Forensic Mental Health Science, Institute of Psychiatry, De Crespigny Park, London, UK

Psychopathy is strongly associated with serious criminal behaviour (for example, rape and
murder) and recidivism. However, the biological basis of psychopathy remains poorly under-
stood. Earlier studies suggested that dysfunction of the amygdala and/or orbitofrontal cortex
(OFC) may underpin psychopathy. Nobody, however, has ever studied the white matter
connections (such as the uncinate fasciculus (UF)) linking these structures in psychopaths.
Therefore, we used in vivo diffusion tensor magnetic resonance imaging (DT-MRI) tracto-
graphy to analyse the microstructural integrity of the UF in psychopaths (defined by a Psycho-
pathy Checklist Revised (PCL-R) score of X25) with convictions that included attempted
murder, manslaughter, multiple rape with strangulation and false imprisonment. We report
significantly reduced fractional anisotropy (FA) (P < 0.003), an indirect measure of micro-
structural integrity, in the UF of psychopaths compared with age- and IQ-matched controls. We
also found, within psychopaths, a correlation between measures of antisocial behaviour and
anatomical differences in the UF. To confirm that these findings were specific to the limbic
amygdala–OFC network, we also studied two ‘non-limbic’ control tracts connecting the
posterior visual and auditory areas to the amygdala and the OFC, and found no significant
between-group differences. Lastly, to determine that our findings in UF could not be totally
explained by non-specific confounds, we carried out a post hoc comparison with a psychiatric
control group with a past history of drug abuse and institutionalization. Our findings remained
significant. Taken together, these results suggest that abnormalities in a specific amygdala–
OFC limbic network underpin the neurobiological basis of psychopathy.
Molecular Psychiatry (2009) 14, 946–953; doi:10.1038/mp.2009.40; published online 9 June 2009
Keywords: psychopathy; limbic system; white matter connections; diffusion tensor imaging;
tractography

Introduction ‘acquired sociopathy’ after frontal lobe injury, the

orbitofrontal cortex (OFC) and other regions of the
Psychopathic personality disorder (psychopathy) is
prefrontal cortex (PFC) have been considered impor-
characterized by features of emotional detachment
tant for personality and social behaviour.6 For exam-
and antisocial traits,1 and is strongly associated with
ple, OFC is crucial to successful reversal learning
criminal behaviour and recidivism.2 It has been esti-
(in which previously rewarded stimuli are associated
mated, for example, that 15% of the prison popula-
with punishment) and reversal learning is signifi-
tion are psychopaths and they commit approximately
cantly impaired in adult psychopaths7 and in young
50% more criminal offences than non-psychopathic
people with psychopathic traits.8 It has also been
criminals.3
reported that violent personality-disordered offenders
The development of reliable and valid methods
have reduced PFC grey matter volume9 and glucose
for diagnosing psychopathy (for example, the Hare
metabolism,10 and impaired OFC (and limbic) activa-
Psychopathy Checklist Revised; PCL-R4) in conjunc-
tion during aversive conditioning.11 In contrast, other
tion with brain-imaging techniques is converging
researchers have argued that amygdala dysfunction is
towards the identification of neurobiological mecha-
central to the affective deficits and impaired moral
nisms that may underpin psychopathy. Since the
socialization of psychopathy.12 This latter view is
report of the case of Phineas Gage,5 who showed
supported by evidence that psychopaths show per-
formance deficits in tasks sensitive to amygdala
Correspondence: Dr MC Craig, Psychological Medicine, Institute damage,13,14 and have significantly reduced amygdala
of Psychiatry, PO50, 16 De Crespigny Park, Denmark Hill, London volume15 and decreased amygdala activation during
SE5 8AF, UK.
E-mail: m.craig@iop.kcl.ac.uk
verbal learning16 and decreased activity in brain
Received 7 August 2008; revised 25 February 2009; accepted 13 regions modulated by amygdala during facial fear
April 2009; published online 9 June 2009 processing.17

More recently, the dichotomy between researchers
postulating whether OFC or amygdala dysfunction is
central to psychopathy18 has narrowed, and it has
been suggested instead that the social and emotional
deficits of psychopaths may reflect an interaction
between OFC and amygdala dysfunction.19,20 Analy-
sis of the functional and anatomical links between
these structures offers the potential to move beyond
theories of regional dysfunction towards a more
coherent understanding of the possible brain net-
works underlying psychopathy. However, to date,
nobody has studied the white matter tracts linking
these brain regions. The OFC and the amygdala are
interconnected by fibres belonging to the uncinate
fasciculus (UF), whose volume and integrity can be
analysed in vivo using diffusion tensor magnetic
resonance imaging (DT-MRI) tractography. This is a
non-invasive neuroimaging technique that can be
used to reconstruct three-dimensional trajectories of
white matter tracts within the living brain,21 and to
probe the microstructural integrity of white matter in
a wide range of neuropsychiatric conditions.22
We therefore used in vivo DT-MRI to dissect and
measure the volume and the microstructural integrity
of the UF.21 For each hemisphere, we dissected the
fibres of the UF and counted the number of stream-
lines (SLs) as a surrogate of the tract volume. We also
measured the mean fractional anisotropy (FA)—
which is an indirect measure of white matter spatial
organization and integrity.23 We compared the psy-
chopaths (that is, PCL-R score X2524) with age- and
IQ-matched controls. We recruited psychopaths from
three specialist forensic inpatient units. All were
repeat violent offenders with index offences that
included attempted murder, manslaughter, multiple
rape with strangulation and false imprisonment.
Methods
Patients
We studied 18 normal intelligence right-handed adult
male volunteers: nine with high PCL-R scores (mean
28.4, range 25–34), aged 34±12 years, with full-scale
IQ (FSIQ) 94±7, and nine healthy male controls aged
37±9 years, with FSIQ 91±6. All patients (that is, in
both groups) were unmedicated and screened by
formal psychiatric semi-structured interview using
the ICD-10 research criteria,25 and a review of case
notes was carried out to exclude any co-morbid
psychiatric illness or neurological/extra-cerebral dis-
orders that might affect brain function.
Most psychopaths had a past history of alcohol
and/or substance misuse (polysubstance misuse
(n = 3), combined polysubstance and alcohol misuse
(n = 3) and alcohol misuse (n = 1)), but none fulfilled
the criteria for a substance misuse or dependence
disorder within 6 months before scanning, with the
exception of one patient who fulfilled the criteria for
harmful use of cocaine. Psychopaths were recruited
from three specialist forensic inpatient units over a
period of 6 years from a group of 34 patients with high
Altered connections on the road to psychopathy
MC Craig et al
947
PCL-R scores (that is, X25). Sixteen patients initially
agreed to participate and nine were suitable for
magnetic resonance imaging (MRI). Healthy controls
were recruited from the general population through
the Institute of Psychiatry, Kings College London, and
the absence of psychopathy was confirmed using
the Hare Psychopathy Checklist: Screening Version
(PCL-SV).26
Ethical approval was obtained from the Ethical
Committee of the South London and Maudsley Trust
and Institute of Psychiatry, and St Georges Healthcare
Trust. After complete description of the study to the
patients, written informed consent was obtained.
Neuroimaging and data analysis
Magnetic resonance imaging of the brain was carried
out on GE Signa 1.5 Tesla LX MRI system (General
Electric, Milwaukee, WI, USA) at the Maudsley
Hospital, London.
DT-MRI acquisition. Data were acquired with
40 mT m 1 gradients, using an acquisition sequence
fully optimized for DT-MRI of white matter, providing
isotropic resolution (2.5  2.5  2.5 mm) and coverage
of the whole head. The acquisition was gated to the
cardiac cycle using a peripheral gating device placed
on the patients’ forefinger. After the correction for
image distortions introduced by the application of the
diffusion encoding gradients, the diffusion tensor was
determined in each voxel following the method of
Basser et al.27 The operator (Michael C. Craig) carried
out all dissections blind to the diagnosis. Anatomical
consistency with classical descriptions of the tracts of
interest was confirmed by using neuroanatomy text
books and tractography atlases.
Tract reconstructions. The trajectories of the UF,
inferior longitudinal fasciculus (ILF) and inferior
fronto-occipital fasciculus (IFOF) were each recon-
structed using an approach that involved dissecting
out two regions of interest (ROIs)28 (Figure 1).
The ILF is a ventral associative bundle with long
and short fibres connecting the occipital and temporal
lobes.3,28 The long fibres are medial to the short fibres
and connect occipital visual areas to the amygdala
and hippocampus. The first (temporal) ROI used to
dissect the ILF was defined around the white matter
of the anterior temporal lobe, usually on five axial
slices. The second (occipital) ROI was defined around
the white matter of the occipital lobe, usually on
13–15 slices.
The UF is a ventral anterior associative bundle
that connects the anterior temporal lobe (including
amygdala and hippocampus) with the medial and
lateral OFC. The first (temporal) ROI was defined
in the anterior temporal lobe (MNI, 15 to 19), as
described for the ILF. The second (external/extreme
capsule) ROI was defined around the white matter of
the anterior floor of the external/extreme capsule.
The IFOF is a ventral associative bundle that
connects the ventral occipital lobe and the OFC. In
Molecular Psychiatry
 Altered connections on the road to psychopathy
MC Craig et al

948

Figure 1 Virtual dissection of the major association pathways connecting to the amygdala and orbitofrontal cortex
(OFC). A two-region-of-interest (ROI)-approach was used to carry out virtual dissection of the major association pathways
connecting the amygdala and OFC. An anterior ‘frontal’ ROI was defined around the anterior floor of the external capsule in
five consecutive axial slices (from MNI 6 to 14). A second ‘temporal’ ROI was defined around the white matter of the
anterior temporal lobe in five consecutive axial slices (from MNI 22 to 30). A third ‘occipital’ region was defined in the
white matter of the occipital lobe in 10 consecutive axial slices (shown here only from MNI 4 to 4). To dissect the uncinate
tract, all fibres passing through the ‘frontal’ and ‘temporal’ regions are shown in yellow. All fibres passing through the frontal
and occipital regions are shown in red and correspond to the interior fronto-occipital tract. Finally, all fibres passing through
the temporal and occipital regions are shown in green and correspond to the interior longitudinal tract. Dissections were
carried out for both hemispheres.

this occipital course, the IFOF runs parallel to the ILF.
On approaching the anterior temporal lobe, the fibres
of the IFOF gather together and enter the external
capsule dorsally to the fibres of the UF. The first ROI
was delineated around the occipital lobe on approxi-
mately 13–15 contiguous axial slices in the same
manner as the posterior ROI of the ILF. The second
region was defined around the external/extreme
capsule as described above.
All fibres passing through the temporal and occi-
pital region are shown in light grey and attributed to
the ILF. All the SLs passing through the temporal and
external/extreme capsule are considered to belong
to the UF and are shown in white. Finally, all SLs
passing through the occipital and external/extreme
capsule are considered to belong to the IFOF.
At the termination of tracking, the FA—a measure
that quantifies the directionality of diffusion on

Molecular Psychiatry
 Altered connections on the road to psychopathy
MC Craig et al

949
a scale from 0 (when diffusion is totally random) to 1 differences in FA and number of SL. Statistical
(when water molecules are able to diffuse along one analyses were corrected for multiple comparisons
direction only)—were sampled at regular (0.5 mm) using Bonferroni’s correction.
intervals along the tract (facilitated by the B-spline
continuous tensor-field approximation3) and the
Results
means computed. We terminated the fibre tracking
when the FA fell below an (arbitrary) threshold The psychopath group had a similar number of SLs
of 0.15. For each tract, the trajectory obtained was in the right and left UF compared with age- and
checked to ensure consistency with neuroanatomical IQ-matched controls, but a significantly reduced mean
atlases by reconstructing in three dimensions. FA in right UF (psychopaths 0.403±0.014, controls
0.435±0.023, P = 0.003). There were no differences in
Analyses of tracts. In our initial analysis, we the FA of the left UF (psychopaths 0.419±0.027;
compared the mean number of SL and FA of the UF controls 0.427±0.020, P = 0.448) (Table 1, Figure 2).
in psychopaths and controls. We hypothesized that There was no significant difference in the number
the mean number of SL and FA of the UF in the of SLs or FA of the left or right ILF and IFOF (Table 1,
psychopaths would be significantly less than in the Figure 2).
control group. Using a ‘two-factor’ model of psychopathy, we
To test the hypothesis that the FA changes were report a significant negative correlation between
specific to the UF, we carried out a secondary analysis ‘antisocial behaviour’ (factor 2) scores and total
of the volume and microstructural integrity of con- number of SL in the left UF (Pearson’s correla-
nections of two ‘non-limbic’ control tracts connecting tion = 0.880, P = 0.004) and right UF (Pearson’s
the posterior visual areas to the amygdala (through correlation = 0.884, P = 0.004). Using a ‘four-factor’
the ILF) and the OFC (through the IFOF). We hypo- model, we report a trend towards a negative
thesized that in these ‘non-limbic’ tracts, there would
be no significant between-group differences in the Table 1 Analysis of between-group differences in DTI
mean number of SL or FA. indices
We also investigated whether the anatomical differ-
ences in the UF of the psychopaths were associated Psychopaths Controls Differences
with variation in symptom severity. Early factor (s.d.) (s.d.) (P-value)
analyses of the PCL-R suggested that the two dimen-
sions reflect ‘emotional detachment’ (Factor 1) and UF (SL)
‘antisocial behavior’ (factor 2).29 We therefore corre- L 19.8 (16.2) 23.0 (9.0) 0.609
lated anatomical variation with these PCL-R factors R 37.1 (31.9) 28.6 (17.4) 0.490
within the psychopaths. More recent factor analy-
ILF (SL)
ses of the PCL-R have also suggested that 18 of the L 62.6 (38.8) 70.3 (43.6) 0.695
items are underpinned by four factors: Interpersonal R 48.9 (26.2) 49.3 (18.1) 0.975
(factor 1), Affective (factor 2), Lifestyle (factor 3) and
Antisocial (factor 4).30,31 We therefore correlated IFOF (SL)
anatomical variation with these PCL-R factors within L 77.2 (54.2) 67.9 (51.8) 0.714
the psychopaths using a ‘two-factor’ and a ‘four- R 62.4 (55.8) 59.1 (41.2) 0.887
factor’ model.
Finally, as noted above, the psychopaths had a UF (FA)
history of substance misuse and institutionalization, L 0.42 (0.03) 0.43 (0.02) 0.448
and this may have affected the significant difference R 0.40 (0.01) 0.44 (0.02) 0.003*
we found in the UF. Hence, we carried out a post hoc ILF (FA)
analysis comparing FA in the UF of psychopaths L 0.48 (0.02) 0.48 (0.02) 0.883
with that in 11 patients who had a past history of R 0.48 (0.02) 0.48 (0.03) 0.690
alcohol/substance misuse and institutionalized care
for psychotic mental illness. These patients did not IFOF (FA)
differ significantly in age (33±6 years), IQ (95±5) L 0.44 (0.02) 0.46 (0.02) 0.241
or handedness, and were screened to exclude the R 0.45 (0.02) 0.46 (0.03) 0.448
presence of an Axis II diagnosis (for example,
antisocial personality disorder) using the Schedule Abbreviations: FA, fractional anisotropy; IFOF, inferior
for Affective Disorders and Schizophrenia, Lifetime fronto-occipital fasciculus; ILF, inferior longitudinal fascicu-
version (SADS-L).32 lus; L, left; R, right; SL, streamlines; UF, uncinate fasciculus;
DTI, diffusion tensor imaging.
*P < 0.005.
Statistical analysis Psychopaths had similar number of SL in the right and left
Statistical comparisons of the data were carried out UF compared with controls, but a significantly reduced
using SPSS software (SPSS Inc., Chicago, IL, USA). mean FA in the right UF (P = 0.003). There were no
Student’s t-test (two-tailed) for independent samples differences in the FA of the left UF (P = 0.448) or in the
was used to investigate tract-specific mean group FA/SL of two ‘non-limbic’ control tracts: the ILF and IFOF.

Molecular Psychiatry
 Altered connections on the road to psychopathy
MC Craig et al
950
Figure 2 Tract-specific measurements of fractional anisotropy (FA) in the psychopathy and control group. Psychopaths had
a significantly reduced mean FA in the right UF (P = 0.003). There were no differences in the FA of the left UF (P = 0.448) or in
the FA of two ‘non-limbic’ control tracts: the ILF and IFOF.
correlation between antisocial (factor 4) scores and
FA and total number of SL in the right UF (Pearson’s
correlation = 0.797, P = 0.058 and Pearson’s correla-
tion = 0.794, P = 0.059, respectively) and affective
(factor 3) scores and total number of SL in the left
UF (Pearson’s correlation = 0.792, P = 0.06) in
psychopaths (Table 2).
In our post hoc analysis, comparing psychopaths
with patients with an earlier history of substance
misuse and institutionalization, the psychopath group
had a significantly reduced mean FA in the right UF
(psychopaths 0.403±0.014, controls 0.437±0.016,
P < 0.000). In addition, the mean FA was reduced in
the left UF (psychopaths 0.419±0.027, controls
0.460±0.024, P = 0.002) and there was no significant
difference in the number of SLs or FA of the left
or right ILF and IFOF after correction for multiple
comparisons.
Discussion
In summary, we report significantly reduced FA in
the right UF of psychopaths compared with age- and
IQ-matched controls. Further, within psychopaths,
we report associations between measures of antisocial
behaviour and anatomical differences in the UF.
To confirm that these findings were specific to the
limbic amygdala–OFC network, we studied two ‘non-
limbic’ control tracts connecting the posterior visual
and auditory areas to the amygdala and the OFC,
and found no significant between-group differences.
Molecular Psychiatry
In addition, we examined (post hoc) whether our
findings could simply be explained by differences in
substance misuse and/or institutionalization.
Taken together, our findings suggest that abnormal
‘connectivity’ in the amygdala–OFC limbic network
may contribute to the neurobiological mechanisms
underpinning the impulsive, antisocial behaviour
and emotional detachment associated with psycho-
pathy. This hypothesis is supported by findings of an
association between UF dysfunction, impulsivity and
reactive aggression. For example, earlier studies have
reported (a) UF damage in many cases of Kluver–Bucy
syndrome (that is, a disconnection syndrome char-
acterized by aggressive behaviour, loss of normal
anger and fear responses, decreased inhibition and
other personality changes),33 (b) reduced UF FA in
children showing impulsive traits after early severe
socio-emotional deprivation34 and (c) reduced func-
tional connectivity between the amygdala and
OFC in impulsive aggressive borderline personality-
disordered patients.35 It could therefore be argued that
our findings are not specific to psychopathy per se;
but may underpin antisocial behaviour in general.
However, to date, there have been no studies that
have specifically analysed the UF in individuals with
antisocial personality disorder. Further, post-mortem
and DT-MRI studies that have analysed the UF in
schizophrenia, that is, another mental illness asso-
ciated with aggressive and violent behaviour,36 have
reported equivocal results.37–39 However, this is clearly
an important issue for future studies to address.
 Altered connections on the road to psychopathy
MC Craig et al

951
Table 2 Correlation between the ‘two factors’ and ‘four factors’ that underpin the PCL-R score and the microstructural integrity
of the uncinate fasciculus

Two-factor model F1 P-value F2 P-value Total P-value

UF (FA)
L 0.010 0.981 0.020 0.962 0.081 0.836
R 0.134 0.752 0.344 0.404 0.476 0.195

UF (SL)
L 0.608 0.110 0.880 0.004* 0.056 0.888
R 0.274 0.512 0.884 0.004* 0.318 0.404

Four-factor model f1 P-value f2 P-value f3 P-value f4 P-value

UF (FA)
L 0.152 0.774 0.200 0.704 0.085 0.872 0.570 0.237
R 0.368 0.473 0.433 0.392 0.628 0.182 0.797 0.058

UF (SL)
L 0.361 0.482 0.327 0.527 0.792 0.060 0.528 0.282
R 0.349 0.497 0.004 0.994 0.718 0.108 0.794 0.059

Abbreviations: FA, fractional anisotropy; L, left; R, right; SL, streamlines; UF, uncinate fasciculus.
Two-factor model: F1, factor 1‘emotional detachment’; F2, factor 2‘antisocial behavior’; *P < 0.005.
Four-factor model: f1, factor 1‘interpersonal’; f2, factor 2 ‘affective’; f3, factor 3‘lifestyle’; f4, factor 4‘antisocial’.
In a two-factor analysis, there was a significant negative correlation between factor 2 scores and total number of SL in the
left UF (P = 0.004) and right UF (P = 0.004) in psychopaths. In a four-factor analysis, there was a trend towards a negative
correlation between factor 4 (antisocial) scores and FA and the total number of SL in the right UF (P = 0.058, 0.059,
respectively) and factor 3 (affective) scores and the total number of SL in the left UF (P = 0.06) in psychopaths.

Lesion studies also suggest that executive function
and impulse control may be lateralized to the right
hemisphere,40 and this might help explain why our
main findings were limited to the right UF. Further,
the right UF has been reported to play a pivotal role
in the recollection of affect-laden autobiographical
memory triggered by sensory stimuli (‘ecphory’).41
This relevance of this finding to our study is that
psychopaths have been reported to show poorer
memory for affect-laden material compared with
non-psychopathic offenders42 and healthy controls.43
Therefore, although highly speculative, reduced
microstructural integrity of the right UF could
contribute to deficits in the processing of emotional
autobiographical memory that may underpin psycho-
pathic traits such as shallow affect and lack of
empathy.
Finally, it could be argued that a past history of
institutionalization, alcohol and/or substance misuse
in most psychopaths is responsible for the anatomical
differences that we found. Although FA in the white
matter of patients with a past history of alcohol
misuse has been reported earlier, changes tend to be
diffuse and affect multiple tracts rather than being
localized to a single tract.44 Further, we carried out
a post hoc analysis comparing psychopaths with
patients who had a past history of alcohol/substance
misuse and institutionalized care. This post hoc
analysis confirmed our earlier findings in that the
psychopath group still had a significantly reduced
mean FA in the right UF.
Thus, in summary, earlier studies support our
findings of an association between reduced micro-
structural integrity of the UF and behavioural traits
that characterize psychopathy. However, it remains
unclear whether this is because of a primary patho-
logy in the UF white matter, or whether it is second-
ary to abnormalities in the amygdala and/or the
OFC. Further, the biological mechanisms underlying
reduced UF microstructural integrity also remain
unclear. One possible mechanism may include tract-
specific deficits in axonal maturation and/or myeli-
nation. This suggestion is based on the fact that FA
signal indirectly reflects the degree of myelination
and anatomical arrangement of axonal fibres,45 and
that the number of SL is an indirect index of tract
volume (which may also reduce in proportion with
axonal number and/or myelination).
Our study has a number of weaknesses. For
example, we only studied a relatively small number
of psychopaths, and so our findings need to be
replicated in a larger study. However, the difficulties
involved with recruiting and scanning our study
group cannot be over-emphasized. To control for
potential confounds as best as possible, we limited
our investigation to a group of psychopaths without
co-morbid mental illness, who were off medication
and not currently engaging in substance misuse.
Nonetheless, the psychopaths we recruited had
committed the most serious criminal offences defined
by Law (for example, rape, attempted murder, etc.)
with minimal guilt or remorse. As predicted, most

Molecular Psychiatry
 Altered connections on the road to psychopathy
MC Craig et al
952
individuals we identified in this group refused to
engage in medical research. In psychopaths who
fulfilled the criteria for entering the study, and who
agreed to aid our investigation, we then had to
negotiate complex security/safety issues. Hence, it is
extremely difficult to find/recruit very dangerous
psychopaths—especially those who do not have
co-morbid mental health problems and/or current
drug abuse. These factors contributed to the small
sample included in this study and are likely to
impede larger studies of this population. Lastly, it is
possible that early-onset, longstanding, abnormalities
in social interaction may themselves affect brain
development. Hence, future studies of neurobiologi-
cal differences in ‘at-risk’ populations of young indi-
viduals that may precede significant violent offending
behaviour are also required.
In conclusion, our findings may reconcile the dichot-
omy suggested by earlier regional-based theories of OFC
or amygdala dysfunction18 in psychopathy, and lend
support to a network-based model.19,20 Confirmation of
these findings by larger studies may have wider medico-
legal implications and may ultimately provide a focus
for the development of treatments for psychopathy.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgments
We thank Drs Gill Mezey, Dominic Beer, Amory
Clarke, Timothea Toulpoulou and John Dowsett for
their help in this study.
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