The Psychopath Inside PDF: A Neuroscientist's Journey

THE PSYCHOPATH INSIDE NEUROSCIENTIST’S PERSONAL JOURNEY INTO THE DARK SIDE OF THE BRAIN JAMES...

THE PSYCHOPATH INSIDE NEUROSCIENTIST’S PERSONAL JOURNEY INTO THE DARK SIDE OF THE BRAIN JAMES FALLON “His surprising final diagnosis could broaden the way we see normality.” —Nature  Praise for The Psychopath Inside “The Psychopath Inside is a deeply compelling personal story of an eminent scientist’s discovery of his own psychopathy. Jim Fallon confesses the sins of his biology and in doing so receives the ab- solution of being human. I couldn’t put it down.” —PaulJ.Zak, PhD, author of The Moral Molecule: The Source ofLove and Prosperity “Just the word ‘psychopath’ is enough to grab anyone’s attention, and it has inspired numerous TV shows and films for many de- cades. In truth, I believe the word itself does little to wrap its arms around the infinite behavioral traits psychopaths possess, for good and bad. Fallon lets us inside his mind as he takes us on a deftly woven journey, breaking down every convention of psychopathic behavior.” —Simon Mirren, former executive producer of Criminal Minds “In a thought-provoking account of self-exploration, Fallon puts himself ‘under the microscope’ in an attempt to make sense of how his own biological and developmental history has shaped his life. His perspective on psychopathy pushes us to consider the import- ant roles of nature and nurture, and the fine line between adaptive and maladaptive personality traits.” —John F. Edens, PhD, Professor of Psychology, Director of Clinical Training, and Cornerstone Faculty Fellow, College of Liberal Arts, Texas A&M University “An intriguing look into the dark side of the brain. A must-read for anyone curious about why our brains think our darkest thoughts and how many of us go into states of psychosis without even realizing it. Dr. Fallon’s study of my own brain helped me come to terms with my strangest ideas and why I function the way I do. Few people understand the brain as well as Dr. Fallon and can write about it in such a fun and engaging way. A fascinating read. —EFli Roth, writer, director, and producer  ABOUT THE AUTHOR Anderson, Daniel © Irvine UC James Fallon is an award-winning research neuroscientist at the University of California, Irvine, where he has taught neuroscience to medical students, graduate students, and clinicians in psychia- try and neurology for thirty-five years and has been named teacher of the year numerous times. His start-up company, NeuroRepair, was voted top new biotech firm of the year by a national associa- tion of its peers and has engineered major breakthroughs in stem- cell research. He has been married to his wife for forty-six years and has three children and five grandchildren.  THE PSYCHOPATH INSIDE A NEUROSCIENTIST’S PERSONAL JOURNEY INTO THE DARK SIDE OF THE BRAIN JAMES FALLON PORTFOLIO / PENGUIN  ob Portfolio/Penguin An imprint of Penguin Random House LLC 375 Hudson Street New York, New York 10014 First published in the United States of America by Current 2013 This paperback edition published 2014 Copyright © 2013 by James Fallon Penguin supports copyright. Copyright fuels creativity, encourages diverse voices, promotes free speech, and creates a vibrant culture. Thank you for buying an authorized edition of this book and for complying with copyright laws by not reproducing, scanning, or distributing any part of it in any form without permission. You are supporting writers and allowing Penguin to continue to publish books for every reader. Most Portfolio books are available at a discount when purchased in quantity for sales promotions or corporate use. Special editions, which include personalized covers, excerpts, and corporate imprints, can be created when purchased in large quantities. For more information, please call (212) 572-2232 or e-mail [email protected]. Your local bookstore can also assist with discounted bulk purchases using the Penguin Random House corporate Business-to-Business program. For assistance in locating a participating retailer, e-mail [email protected]. Photographs by the author. ISBN: 9781591846000 (hardcover) ISBN: 9781101603925 (ebook) ISBN: 9781617230158 (paperback) Printed in the United States of America 9 10 8 Book design by Alissa Amell Penguin is committed to publishing works of quality and integrity. In that spirit, we are proud to offer this book to our readers; however, the story, the experiences, and the words are the author’s alone. To my parents, Jennie and fohn Henry, who recognized my true nature very early on, and nurtured it anyway  CONTENTS PROLOGUE 1 CHAPTER 1 What Is a Psychopath? 9 CHAPTER 2 Evil Brewing 21 CHAPTER 3 The Brain of a Killer 42 CHAPTER 4 Bloodlines 65 CHAPTER 5 A Third Leg to Stand On 90 viii CONTENTS CHAPTER 6 Going Public 107 CHAPTER 7 Love and Other Abstractions 130 CHAPTER 8 A Party in My Brain 169 CHAPTER 9 Can You Change a Psychopath? 187 CHAPTER 10 Why Do Psychopaths Exist? 213 ACKNOWLEDGMENTS) 229 BIBLIOGRAPHY 23] INDEX 237  THE PSYCHOPATH INSIDE  PROLOGUE ne October day in 2005, as the last vestiges of an Indian J. moved across Southern California, I was inputting some last-minute changes into a paper I was planning to submit to the Obio State Journal of Criminal Law. I had titled it “Neu- roanatomical Background to Understanding the Brain of a Young Psychopath” and based it on a long series of analyses I had performed, on and off for a decade, of individual brain scans of psychopathic murderers. These are some of the baddest dudes you can imagine—they’d done some heinous things over the years, things that would make you cringe if I didn’t have to ad- here to confidentiality agreements and could tell you about them. But their pasts weren’t the only things that separated them from the rest of us. As a neuroscientist well into the fourth decade of my career, I’d looked at a lot of brain scans over the years, and these had been different. The brains belonging to these killers shared a rare and alarming pattern of low brain function in certain parts of the frontal and temporal lobes—areas commonly associ- ated with self-control and empathy. This makes sense for those 2 THE PSYCHOPATH INSIDE with a history of inhuman violence, since the reduction of activity in these regions suggests a lack of a normal sense of moral reason- ing and of the ability to inhibit their impulses. I explained this pattern in my paper, submitted it for publication, and turned my attention to the next project. At the same time I’d been studying the murderers’ scans, my lab had been conducting a separate study exploring which genes, if any, are linked to Alzheimer’s disease. As part of our research, my colleagues and I had run genetic tests and taken brain scans of several Alzheimer’s patients as well as several members of my fam- ily, who were serving as the normal control group. On this same October day, I sat down to analyze my family’s scans and noticed that the last scan in the pile was strikingly odd. In fact it looked exactly like the most abnormal of the scans I had just been writing about, suggesting that the poor individual it belonged to was a psychopath—or at least shared an uncomfort- able amount of traits with one. Not suspicious of any of my family members, I naturally assumed that their scans had somehow been mixed with the other pile on the table. I generally have a lot of research going on at one time, and even though I try to keep my work organized it was entirely possible for things to get misplaced. Unfortunately, since we were trying to keep the scans anonymous, we'd coded them to hide the names of the individuals they be- longed to. To be sure I hadn’t made a mistake, I asked our lab technician to break the blind code. When I found out who the scan belonged to, I had to believe there was a mistake. In a fit of pique, I asked the technician to  Prologue 3 check the scanner and all the notes from the other imaging and database technicians. But there had been no mistake. ‘The scan was mine. Imagine with me for a moment. It’s a bright, warm Saturday morning and you decide to take a stroll through the park near your home. After a brisk walk, you sit down on a bench in the shade of an oak tree next to a nice- enough-looking chap. You say hi, and he says hi, and then he says what a nice day it is and how good it is to be alive. As you talk to him for the next fifteen minutes, you form an opinion of him as he forms an opinion of you. There is much you can glean from someone in this brief window of time. You might learn what he does for a living, whether he is married or has children, or what he likes to do in his spare time. He can appear to be intelligent, charming, open, funny, and a generally pleasant conversationalist who can tell an interesting little story. But depending on who this person is, the second fifteen min- utes can be dramatically more telling. For instance, if he is in the early stages of Alzheimer’s disease, he might repeat the same exact interesting little story, with the same exact facial and body move- ments and punch line as before. If he is schizophrenic, he might start to shift in his seat or lean in a little too close as he talks to you. You might start to feel uncomfortable and will get up and leave, glancing back to make sure he isn’t following you. If I were the man sitting next to you on the bench, you would probably find me a generally interesting person. If you asked me d THE PSYCHOPATH INSIDE what line of work I’m in, I’d say that I am a brain researcher, and if you pressed further I’d say I am a professor in the Department of Psychiatry and Human Behavior and affiliated with the De- partment of Anatomy and Neurobiology in the School of Medi- cine at the University of California, Irvine. I’d tell you how I’ve spent my career teaching medical students and residents and grad- uate students about the brain. If you seemed interested, I would then tell you about my research with adult stem cells and animal models of Parkinson’s disease and chronic stroke, and that the basic research from my lab has led to the creation of three biotech companies, one of which has been netting profits consistently for the past twenty-five years, and another that just won a national award from its peer biotech companies. If you still seemed interested, I might mention that I am also involved in organizations and think tanks that focus on the arts, architecture, music, education, and medical research, or that I have served as an adviser to the U.S. Department of Defense on what war does to the brain. If you asked further, I might mention the T’V shows and films I’ve acted in or that I thoroughly enjoyed my past jobs as a bartender, a laborer, a schoolteacher, and a car- penter, and still have my out-of-active-duty Teamsters’ card from my days as a truck driver. At some point you might start thinking to yourself that I’m a blowhard or even that Iam making this stuff up, especially if I also mentioned that when I was fourteen years old I was named Cath- olic Boy of the Year for the diocese of Albany, New York, or was a five-sport high school and college athlete. But although you  Prologue 5 might think I talk way too much or am something of a bullshitter, you would also find that when I talk with you, I look you in the eye and listen carefully to everything you say. In fact, you might be surprised at how interested I am in your life, your opinions, and how you view the world. If you agreed to meet me again, we might end up becoming friends. Over time, you might notice things about me that rub you the wrong way—I may occasionally be caught in a lie, or I might disappoint you from time to time by not showing up at an event you invite me to. But despite my mild narcissism and regular bouts of selfishness, we’d probably have fun together. Because, at the end of the day, I am basically a regular guy. Except for one thing. I’m a borderline psychopath. I agreed to write this story, a true if not wholly complete story, in part to share with my family, friends, and colleagues the biological and psychological background of my family. By necessity, this ex- position is based on comprehensive scientific data from brain im- aging, genetics, and psychiatry, but also emerges from brutally honest and sometimes disturbing admissions and discussions about myself and my past. (I hope my family doesn’t disown me once they’re done reading.) My aim here is not simply to tell a story or to espouse some new scientific findings. I hope that by telling my story, I will illuminate the conversation surrounding a subject that has received a lot of attention in our culture despite a general lack of understanding and consensus: psychopathy. Beyond the basic science and personal story, I hope that the 6 THE PSYCHOPATH INSIDE research I’ve done and the theories I’ve put forth about the way our brains, genes, and early environment determine how likely we are to be psychopaths might be useful, not only to individual read- ers, but also within the larger realms of parenting and criminal law. As strange as it sounds, the science discussed in the following pages could even help us achieve world peace. I’ve hypothesized that in areas with chronic violence, from Gaza to East L.A., the concentration of genes associated with psychopathy might be in- creasing as women mate with bad boys for protection and aggres- sive genes spread, increasing the violence and repeating the loop. Over generations, we end up with warrior societies. It’s a specu- lative idea but one that’s important to consider and study further. I’m a committed scientist—a neuroscientist who studies the anatomy and function of the brain—and this fact has shaped the way I view behavior, motivation, and morality for my entire adult life. In my mind, we are machines, albeit machines we don’t un- derstand all that well, and I have believed for decades that we have very little control over what we do and who we are. To me, nature (genetics) determines about 80 percent of our personality and be- havior, and nurture (how and in what environment we are raised) only 20 percent. This is the way I have always thought about the brain and behavior. But this understanding took a stinging, and rather embarrassing, blow starting about 2005, and I continue to rec- oncile my past belief with my present reality. I have come to understand—even more than I did before—that humans are, by nature, complicated creatures. And to reduce our actions, mo-  Prologue 4 tivations, desires, and needs to absolutes is doing each of us a disservice. We are not simply good or evil, right or wrong, kind or vindictive, benign or dangerous. We are not simply the prod- uct of biology, either, and science can only tell us part of the story. Which brings me back to the story at hand.  | CHAPTER 1 | What Is a Psychopath? “VAT hat is a psychopath?” After viewing my brain scan—which, being a scien- tist, I considered more of a professional curiosity than a personal cause for alarm—I started asking my psychiatrist colleagues this question to see if I fit the bill. I asked some of the most preemi- nent researchers in the field, and yet I couldn’t seem to get a satisfactory answer. Several dismissed the question, saying psy- chopaths didn’t exist at all and that asking them to define psycho- path was like asking them to define a nervous breakdown. It’s a phrase people throw around, but it doesn’t bear any scientific or professional meaning. (The same goes for vegetable, which is a somewhat arbitrary culinary term, not a biological one.) When I asked my friend Fabio Macciardi, a UCI colleague and a noted psychiatrist, he said, “There is no psychiatric diagnosis of psycho- path.” After some pressing he explained, “The closest thing we have in the manual is a personality disorder, antisocial personal- ity disorder. But that is not always the animal you’re looking for, either.” The manual Fabio was referring to is the Diagnostic and Sta- 10 THE PSYCHOPATH INSIDE tistical Manual ofMental Disorders, most commonly referred to as the DSM. For psychiatrists and psychologists, this is the Bible— the book that outlines, defines, and classifies all disorders of the mind as agreed upon by the American Psychiatric Association and provides a standard of diagnosis that professionals are expected to follow. The DSM classifies a wide range of disorders from an- orexia to schizophrenia, but psychopathy is not one of them. The definition for antisocial personality disorder, which Macciardi pointed to, is described as “a pervasive pattern of disregard for and violation of the rights of others that has been occurring in the person since the age of 15 years, as indicated by three (or more) of seven criteria, namely: a failure to conform to social norms; irre- sponsibility; deceitfulness; indifference to the welfare of others; recklessness; a failure to plan ahead; and irritability and aggres- siveness.” Outside of the DSM, many doctors and researchers have their own definitions of what makes a psychopath. The problem is, every definition is different and none are cut-and-dried. If one considers conventional medical standards of diagnosis, it’s actually no wonder there is so much controversy surrounding psychopathy. For conditions like obesity, diabetes, and high blood pressure, it’s easy to figure out whether a patient is afflicted, since the symptoms of these diseases are well-known and easy to test for. Do you have low levels of insulin, inhibiting your body’s abil- ity to metabolize sugar? You have diabetes. The same cannot be said for diseases of the mind. For one thing, psychiatric diseases are not considered dis- eases at all. Diseases are based on knowledge of the cause (or  What Is a Psychopath? 11 etiology) of a particular disorder and the effects (or pathophysi- ology) they have on the body. Unlike for many true diseases of other organ systems, we don’t have this luxury with diseases of the mind since so little is known of the underlying pathological biological mechanisms at work. Despite advances in our under- standing of how the brain works, the organ is still largely a mys- tery to us. Therefore, most psychiatric problems are called disorders or syndromes. Psychopathy stands on the lowest rung of this disease-disorder ladder, since no one agrees on what de- fines it—or if it exists at all—and so there is no professional agreement as to the underlying causes. Trying to identify or de- fine psychopathy with just a checklist of traits and no cause is like using a field taxonomy guide. If it flies and eats and makes noises it could be a bird, but it could also be a bat or an insect; you hav- en’t nailed down what the thing really is. Although there are no set methods to test for psychiatric dis- orders like psychopathy, we can determine some facets of a pa- tient’s mental state by studying his brain with imaging techniques like PET (positron emission tomography) and fMRI (functional magnetic resonance imaging) scanning, as well as genetics, behav- ioral and psychometric testing, and other pieces of information gathered from a full medical and psychiatric workup. Taken to- gether, these tests can reveal symptoms that might indicate a psy- chiatric disorder. Since psychiatric disorders are often characterized by more than one symptom, a patient will be diag- nosed based on the number and severity of various symptoms. For most disorders, a diagnosis is also classified on a sliding scale— 2 THE PSYCHOPATH INSIDE more often called a spectrum—that indicates whether the patient's case is mild, moderate, or severe. The most common spectrum associated with such disorders is the autism spectrum. At the low end are delayed language learning and narrow interests, and at the high end are strongly repetitive behaviors and an inability to com- municate. Despite the debate about whether psychopathy is a real dis- order and, if so, what defines it, there are some accepted parame- ters within the medical community. The most famous and widely used test is the PCL-R (Psychopathy Checklist, Revised), also known as the Psychopath Test or Hare’s Checklist, named for the Canadian psychiatrist Robert Hare, who developed it. The PCL-R consists of twenty items, each of which is scored 0, 1, or 2, desig- nating whether the psychopathic trait is not present (0 points), partially present (1 point), or definitely present (2 points). A person with a “perfect” score of 40 is a full-blown, categorical psychopath on this scale. Thirty is the normal cutoff for a diagnosis, although sometimes 25 is used. The test is scored by a person trained in giving the scale, usually during a session in which the clinician interviews the subject, sometimes supplemented with legal and medical records and third-person references. An evaluation can also be made by someone who knows the subject well, without his being present. The traits can be sorted into four different categories, or “factors.” The interpersonal factor includes the traits of superfi- ciality, grandiosity, and deceitfulness. The affective factor in- cludes lack of remorse, lack of empathy, and refusal to accept  What Is a Psychopath? 13 responsibility for one’s actions. The behavioral factor includes impulsivity, lack of goals, and unreliability. And the antisocial fac- tor includes hotheadedness, a history of juvenile delinquency, and a criminal record. Antisocial personality disorder is related to psy- chopathy but is much more common and is a measure of outward disruptive behavior rather than an underlying personality prob- lem. Psychopathy scores are actually a better predictor of criminal recidivism, severity, and premeditation. Psychopathy is not something one can just casually assess, although there are versions of the test that can be self-administered and are not “officially” diagnostic. A typical statement on a self- administered checklist might be, “I can be shrewd, crafty, sly, and clever—if needed, I can also be deceptive, unscrupulous, under- handed, manipulative, and dishonest.” Two other sample state- ments would be, “At times, I feel a strong need for novel, thrilling, and exciting stimulation; I get bored easily. This might result in me taking chances and doing things that are risky. Carrying tasks through ‘to the bitter end’ or staying in the same job for a longer time can feel very difficult for me,” and “Significant amounts of the money I have made, I have made by intentionally exploiting or manipulating others. With ‘classic’ forms of work, I often feel a lack of motivation, a problem with my self-discipline, or an in- ability to complete my responsibilities.” To illustrate the degrees represented on the PCL-R, I like to point to pop culture, which is full of portrayals—some accurate, some less so—of psychopaths. The most extreme and ridiculous examples can be found in horror films featuring foul-toothed 14 THE PSYCHOPATH INSIDE characters with one foggy eyeball who exude danger and imme- diately evoke chills. Think Freddy Krueger or the family in The Texas Chain Saw Massacre. Even Patrick Bateman, Christian Bale’s self-loving, unhinged character in the film adaptation of American Psycho, is not representative of a true psychopath, as he is too vio- lent to be realistic. These are caricatures—even the most violent criminals are rarely so obviously insane. Some reasonable characterizations include Tommy DeVito, played by Joe Pesci in Goodfellas, and Frank Booth, played by Den- nis Hopper in Blue Velvet. Both of these are relatively normal- looking guys—guys you might pass on the street and not think twice about. But they are deeply disturbed individuals who ulti- mately cannot control their innate aggressiveness and show little regret or sympathy for their violent actions. Tommy and Frank would score high on the PCL-R. Tommy in particular expresses the interpersonal aspects of glibness, charm, and manipulation. He’s entertaining, and he can go in and out of character. In the “Do I amuse your” exchange, he has the other guy pinned—there’s no right answer. Psychopaths can put people into untenable posi- tions. There’s also a scene in which Tommy shoots a guy in the foot, then curses him out for making a big deal of it and goes back to playing cards. After a murder, psychopaths often say they feel like someone else did it, or the victim precipitated the pulling of the trigger. They feel detached, impelled to action by forces out of their control. Tommy calls the foot-shooting incident an “ac- cident.” Not all psychopaths are impulsive or physically violent, but some are, as in the cases of Tommy and Frank.  What Is a Psychopath? 15 My favorite example comes from the 1986 film Manhunter, starring Brian Cox and William Petersen. Cox plays Hannibal Lecter, a cannibalistic serial killer who was later reprised more famously by Anthony Hopkins in the films The Silence ofthe Lambs and Hannibal. Lecter is characterized by his lack of empathy, his glib and charming manipulation of people, and his utter lack of remorse for his horrid and perverse behaviors. In short, he is what many would consider a classic psychopath and would probably have scored high on Hare’s Checklist. Real-life psychopaths who resemble Lecter account for the more sensational and extreme cases—think Jeffrey Dahmer, Ted Bundy, or the Son of Sam. But according to Hare, there is an entire other category of psychopaths out there—those who don’t score as high on the PCL-R but who still exhibit strong signs of classic psychopathic traits. These are people like the hero of Manhunter, the FBI pro- filer Will Graham, played by Petersen. Graham recognizes that he has the same urges and lack of interpersonal empathy as Lecter. Although he is not a murderer, he is, in fact, a psychopath, or at least a near-psychopath, what I like to call Psychopath Lite. He might score a 15 or 23 on the PCL-R, just under the 30-point score cutoff for full psychopathy, but other than that, you might think him completely normal. When my wife, Diane, and I saw the film in 1986, she pointed to Will and said, “That is you.” (At the time, it threw me off a bit, but I decided she was referring to how nice and deep a guy Will was.) Full-blown, categorical psychopaths—those who score 30 or more—make up only about 1 percent of females and 3 percent of 16 THE PSYCHOPATH INSIDE males who have taken the test. But despite—or perhaps because of—its broad classification system, Hare’s scale has been hotly contested, as usually happens in a new field of medicine or science. Every scientific meeting, every casual conversation in hallways and bars among colleagues in widely divergent fields, inevitably leads to an argument over the nature of the condition. One critique is that the scale doesn’t take into consideration class and ethnicity. What’s normative behavior in a crime-ridden lower-class neighborhood in downtown L.A. is different from that in an upper-class neighborhood in Minnesota. There are also de- bates about how well it predicts violence. Marta Wallinius and collaborators at the Swedish universities of Lund, Gothenburg, and Uppsala showed in 2012 that the antisocial facet (hotheaded- ness, etc.) predicts violent behavior particularly well, but the in- terpersonal aspect (superficiality, etc.) doesn’t predict it at all. The criminal justice system is especially interested in such findings. Despite the controversy over whether psychopaths exist, psy- chiatrists generally agree that one of the defining characteristics of those we refer to as psychopaths is the lack of interpersonal empathy, what one might call a flat emotional playing field. Psy- chopaths may not hate, but they also may not love the way most of us would prefer to love and be loved. Psychopaths are usually manipulative, are champion liars, and can be quite glib and dis- armingly charming. They don’t fear consequences the way most people do, and while they may react to the stress of being caught in a lie or violent act like anyone would, some remain cool as cu- cumbers. Even the most dangerous can appear jovial, carefree, and  What Is a Psychopath? ae social at times, but sooner or later they will display a telling dis- tance, a quiet coldheartedness and disregard for others. They are often impulsive, yet lack guilt and remorse, meaning they may invite you to join in on their reckless, even dangerous fun, and then shrug their shoulders if someone gets hurt. In identifying a psychopath, the Hare Checklist is a good start, but it’s not perfect. Rather than adding up twenty traits, each with a value of 0, 1, or 2, Iwould score them each from 0 to 5, and use a mathematical model to give each trait a different weight. Even better, each person would have an individualized profile rather than a single numerical score or a categorical yes- or-no diagnosis. You can’t judge health or obesity on height and weight alone. Are you exercising? What are you eating and drink- ing? You can be overweight but in great shape. A doctor who knows you well would take all of that into account. It’s also difficult to summarize a collection of behaviors as one disorder. There’s a lot of overlap between conditions, such as his- trionic, narcissistic, and antisocial personality disorders. And ev- eryone is a little bit psychopathic and has a little bit of ADHD and so on. Psychiatry is moving away from categorical thinking—the latest diagnostic manual talks about “dimensions” to disorders— but it’s hard when doctors don’t want to learn new methods, in- surance companies need to rely on specific diagnoses, and everyone likes closure and clearly defined labels. I see psychopathy like oth- ers see art; I can’t define it, but I know it when I see it. One question people often ask is if there is a difference be- tween a sociopath and a psychopath. Barring the fact that many 18 THE PSYCHOPATH INSIDE psychologists deny the existence of either, in a clinical setting the difference is purely semantic. Robert Hare has pointed out that sociologists are more likely to focus on the environmental or so- cially modifiable facets of the disorder, so prefer the term sociop- athy, whereas psychologists and psychiatrists prefer to include the genetic, cognitive, and emotional factors as well as the social fac- tors when making a diagnosis, and therefore would opt for psychop- athy. Since I am a brain scientist and am interested in the genetic and neurological causes of this personality disorder, I will use the term psychopath for the purposes of this book. And I will use it to describe people with some combination of those four facets of the Hare Checklist: interpersonal, affective, behavioral, and antisocial traits. I have been interested in the brain ever since I saw the movie Charly when I was a junior in college in 1968. Itis a story about an intellectually handicapped man who has the will to change his life and to learn how to learn. And learn he does, temporarily becom- ing a genius after undergoing a new neurosurgical procedure, the same procedure done to his alter ego, a laboratory mouse. This prescient film on the biological and chemical basis of behavior provided a clear career direction for me. Throughout my career, I have studied many facets of the brain. Whereas most researchers tend to specialize in a relatively narrow field of study, my interests have covered all manner of territory—from stem cells to sleep deprivation. I started studying psychopathy in the 1990s, when I was asked  What Is a Psychopath? 19 by my colleagues in the Department of Psychiatry and Human Behavior at the University of California, Irvine, to analyze PET scans of particularly violent murderers, including serial killers, who had just been convicted in court, and were subsequently start- ing the penalty phase of their trials. It is during this stage of the legal process that a murderer typically agrees to undergo a brain scan, often in the hope that a finding of brain damage will lead to a more lenient sentence. As I’ve already mentioned, we know very little about psy- chopathy, but without scanning technology, we’d probably know even less. It’s easy for a psychopath to feign caring and remorse when his brain tells a different story. This is the work I’d been doing that October day in 2005, when I discovered my odd brain scan indicating reduced activity in areas responsible for empathy and ethics. You might assume, given my closeness to the subject, that I’d be scared or worried or upset. But I wasn’t because I knew better. I was a happily married man with three kids whom I loved dearly. I had never been violent or manipulative or committed a danger- ous crime. I wasn’t some Hannibal Lecter type—an esteemed brain scientist studying the minds of unsuspecting patients in an attempt to understand how I might be better able to control them for my benefit. Heck, I was a research scientist—I didn’t even have patients! But my brain scan did tell me something I hadn’t fully under- stood before. I had just submitted a paper outlining the research I had done into the minds of psychopaths. I had laid out a theory 20 THE PSYCHOPATH INSIDE describing the neuroanatomical basis of psychopathy and identi- fied a pattern that I myself matched. So how could I reconcile my brain with the findings I’d just reported? Was I really an exception to my own rule? If I wasn’t a psychopath, what was I? And if we couldn’t rely on studies of our own brains, the very organ respon- sible for every thought and action we have, how could we ever understand who we truly are?  CHAPTER 2 Evil Brewing he media and pop culture have done a great job over the years 4]Sepa pictures of psychopathic children or disturbed kids who grow up to be violent killers. Just consider every time there’s a school shooting; afterward, the friends, family, classmates, and teachers of the individual responsible seem to notice all of the warning signs that should have predicted what was to come. When parents see signs of abnormal or antisocial behavior in their kids, they immediately call the doctor, hoping therapy or prescription meds will head off any danger at the pass. That’s one reason why I originally gave little thought to my brain scan. I had had a happy childhood, and it wasn’t until I started reflecting on certain episodes in the context of my research and personal discovery that I started to see indications that I was not like the other boys. I was born in Poughkeepsie, New York, at 7:07 a.m. on Oc- tober 18, 1947, weighing seven pounds and seven ounces. Although I’m not a superstitious person, my lucky number by default has always been seven. The pregnancy was not a difficult one, but was angst-filled for my parents, who had already experienced four mis- 22 THE PSYCHOPATH INSIDE carriages leading up to my uneventful birth. According to what my parents, aunts and uncles, and grandparents have told me, I was a happy baby and toddler, but not so happy that I didn’t drive my older brother, Jack, crazy with my crying. According to my mother and several other family members, I was an “adorable happy baby” with no behavioral problems, although I developed severe, untreated asthma in my second year of life, a malady that follows me to this day. The difficulty breath- ing for days at a time would lead to some of my earliest and most lasting memories. I recently asked my mother to describe my personality until I hit puberty, and if my behavior changed or was strange in any way during this time. For adjectives, she said that throughout this period I was “adorable, lovable, straightforward, mischievous, inquisitive, capable, cheerful, insightful, likable, friendly, a prankster,” and added, “a pain in the ass, take your pick.” Over the years my family members told me similar things about my childhood self. They told me I was a beautiful toddler, and that my grandfather even once entered me into a national toddler beauty contest. My father carried me everywhere we went together, and this bonding continued even into my preadolescent years when he would take me to bars with him to play pool and darts and shuffleboard games, and sit at the bar and talk to the owners. We would go on fishing trips together, including over- night stays in the Adirondacks. He started taking me to the Thoroughbred and harness tracks at Saratoga Springs starting in 1950, when I was three, and I have made it a point to go to the  Evil Brewing 23 track in Saratoga every August since for sixty-three straight years, and to go trout fishing whenever possible. I was also close to my mother, and learned how to cook and sew and iron from her at a very early age. My family moved from Poughkeepsie in 1951, when I was four, and I started kindergarten the next year at St. Patrick’s School in Cohoes, New York. A Catholic primary school taught by nuns, it provided a happy time without incident. Well, there was one incident. While practicing to make my First Communion in first grade, I started joking around and my teacher put me into a trash basket, butt down, for fifteen minutes. Some of my class- mates looked at me, feet up in the air, with fear in their eyes, while a couple of goofball guys held back laughs. I distinctly remember thinking the scene was funny, so I made some goofball faces back at my classmates, earning an additional fifteen minutes of hard time. I believe it was at that moment when I began my career as class clown, and it’s a disposition I still can’t shake. When I was fifty-eight, I got kicked out of a sensitivity class along with a well- known TV network newswoman with whom I was flirting and giggling while a serious touchy-feely session was going on with thirty other people. I swear she was one of the girls in my St. Pat- rick’s first-grade class who got me into hot water with the nuns. A few years later we moved from Cohoes to nearby, upscale Loudonville, where I attended fourth through sixth grades at Loudonville School. These three years at the end of my primary schooling were uniformly bright and wonderful. I remember many of the individual days from those years, and I flourished 24 THE PSYCHOPATH INSIDE academically and socially. My teachers were particularly talented, and one, Miss Winnie Smith, has to be one of the greatest pri- mary schoolteachers of all time. She was well liked by most of us, but treated me with particular attention, and encouraged me to act in school plays, to play musical instruments, to draw, and to partake in all social activities, which I did with such enjoyment that I can remember dozens of even the most mundane events throughout that fifth-grade year with her at the helm. During my later primary school years I occasionally worked in my father and uncle’s pharmacy in Troy. My early interests in the natural world, animals, gardening, the outdoors—fueled by a native aptitude for science, math, and engineering—provided me with a comfortable interaction with the pharmacists. Iknew from a young age that I wanted to be a scientist. Iwas fascinated by what makes us who we are and why we are here. All the medical talk and sensory banquet one experiences working in the back rooms of a large pharmacy were incredible preparation for the future. It all fascinated me from the beginning, and I would continue work- ing in the pharmacy in junior high school and high school. I was interested in all of the drugs, and the chemistry of the basic in- gredients of the apothecary. Then I discovered the brown bottles of potassium nitrate, or saltpeter. After a few questions to the young pharmacists, I discovered that this compound was a key ingredient in gunpowder, probably something I didn’t need to know. The pharmacy was well stocked with basic chemicals, and I quickly located the other ingredients: charcoal, sulfur, and an accelerant, magnesium oxide. This began a long love affair with  Buvil Brewing 25 explosives and all things that go boom. I started making my own fireworks and then graduated, with the help of a particularly dar- ing friend, to making larger and larger pipe bombs, which we detonated on a regular basis for years. About the same time, two other friends with a penchant for starting fires and shooting guns invited me along on their adventures, which often ended in grand field fires that threatened to burn down their own houses. With two of these friends we would also try to act tough, but we were just mischievous boys, hardly malevolent, although if we tried get- ting away with that stuff today, we'd be in jail every week. Some of my friends were also into shooting animals with guns—nailing birds or pegging cows in the ass—but that never interested me. We were hellions on nights sanctioned for mayhem, such as Halloween, my favorite holiday. We pulled off every prank imag- inable but never hurt anyone, and at the end of the night, loaded down by bags chockablock full of candy, we would drop them off at the convent for charity, or maybe just to keep the nuns sweet the next time they had a reason for disciplining us. We were not bad kids, just pranksters. For me, the innate drive to tease and torment people may have a dark side, but the way it would ulti- mately express itself after the joke was over usually had a light side. My penchant for such shenanigans may have been learned. My father and uncle were both pranksters, with my uncle Arnold, my father’s pharmacy partner, and my maternal great-uncle Char- lie being the masters. But in all cases their practical jokes ended on a positive note. My father and uncle would pretend to their poorer customers that they were price-gouging them, when in 26 THE PSYCHOPATH INSIDE reality they were slashing their prices by up to 90 percent. If some- one came in wanting to buy a cane that cost ten dollars, they'd give him a sly look instead of naming the real price and say, “That'll be two dollars.” Iwould watch them do this time and time again, and the pranks, although they made these customers a bit crazy, were really done to ensure that the less-fortunate clientele could maintain their dignity without going broke. As grade school became junior high and high school, I tran- sitioned to Shaker High School, a public school in nearby Colonie. It was a new and experimental school and sported high-tech fea- tures such as computerization, even back in 1959. My years at Shaker were also uniformly terrific, and I was given every oppor- tunity to flourish academically, socially, and in the arts, music, and sports. This was a tremendous school with some gifted teachers, and I loved every year there. For my entire postpubescent life, I felt that I was a nice, reg- ular guy—kind, helpful, and fun to be around. Although I said some curious things now and again, I was accepted by most people and found that they wanted to hang out with me, and that many people wanted to be my playmate and often close friend. I seemed to get along with girls and women better than most guys, and my numerous long-standing close friendships, from my teenage years to the present, provided proof that I was not only a man’s man, but also one who could form close friendships with women. Physically, I was not intimidating—just short of six feet tall and weighing between 180 and 220 pounds throughout high school and college—nor aggressive. I did not fight with people,  Evil Brewing 27 and was one of the more calmly behaved of my siblings, who ranged from very introverted to very extroverted and who had a range of aggressive interactions with people throughout life. I have four brothers and a sister. Jack was born first, followed by me five years later. Four years after that came my brother Peter, fol- lowed three years later by Tom, then Mark two years later, and finally Carol the year after that. Pete was always a handful. He has ADHD and was climbing the walls and getting into mischief. Jack was more aggressive than I was and got into a lot of fights. Tom, Mark, Carol, and I were pretty calm. I wasn’t known as a fighter, but I’d go after a bully if Isaw him picking on someone. I’d step in and tell him to stop. If I needed to, I’d muscle him and lift him off the ground and tell him I was going to kill him. This happened a number of times, starting when I was around twelve. One time when I was nineteen or twenty, I saw my buddy provoking a fight in a bar and I pulled him away, but the other guy went after him. I thought that wasn’t fair, so I grabbed the guy by the scruff and yanked him outside. My friend wanted me to hold him while he hit him, but I thought that wasn’t fair, either, so I refused. While many of the males in my family are athletic and several just love to fight, I never developed a taste for pugilism, preferring to mentally pummel someone than to do so using bare knuckles. Even in high school I couldn’t get all psyched up for a wrestling match or football game, opting al- ways to get to my opponent by just rattling him and making him laugh by any means necessary. I loved sports in this way, never serious or violent, but just good, romping fun. 28 THE PSYCHOPATH INSIDE While in junior high, I developed obsessive compulsive dis- order (OCD), which manifested itself partially as an obsession with religion, in particular my mother’s Catholicism. No one in my family or inner circle ever pushed me into religion, and I kept this as much to myself as possible. Only one priest, and my mother, seemed to notice the emerging obsession. I began to sneak off to daily Mass, and would spend every waking moment on Saturdays preparing to confess my sins on Saturday night, so that I could continue to take the sacraments on a daily basis. Throughout my entire youth, including my six years in junior high and high school, I never missed Sunday Mass or all the holy days of obliga- tion. I lived in a secret world completely controlled by an internal mechanism of pointing out weaknesses in my character, and even in my perceptions. Always vigilant for purity and perfection, I began to make up sins that were quite bizarre. My priest tried to tell me in confession that what I was describing to him each week were not sins at all, and even though I knew they really weren’t sins, I would mutate them into destructive ideations so that they became “sins.” It’s not unusual for OCD sufferers to put a moral spin on their obsessions. One of my more bizarre drives was to pay as much attention to the left side of my personal space, extending outward to infinity, as to my right side. I would keep count of this internal space orientation, and at the end of each ten to twenty seconds of such internal dialogue, I would realize that I had spent one more second attending to one side than the other. That be- came a mortal sin. But then I would decide that thinking incor-  Evil Brewing 29 rectly like this would be another mortal sin on top of the first. At twelve years old, I could sit alone on a park bench, not moving, and commit forty mortal sins, each worthy of eternal damnation, in a one-hour period. This would continue for hours and days and dominated my inner life for two entire years. Generally I could hide the angst generated by this florid, obsessive-compulsive world, but it was eating me up, to be sure. At the same time, I was experiencing spontaneous moments of dread and doom lasting up to half an hour. These then became associated with an ongoing religious or, more correctly, spiritual crisis, that lasted for years. All of this occurred in the complete absence of any external pres- sure from family, friends, or church personnel. If anything, they tried to get me to chill out. Aside from my attention to symmetry, I also had to wash my hands repeatedly. And walking to the school bus, I would waver thirty feet in each direction picking up litter, leaving a swath of cleanliness behind me. Everything became a moral issue. I had to be perfect, and I had to have good intentions about everything. If I did something good but it wasn’t from the heart, I would start thinking that it was immoral. I knew it was crazy, but I couldn’t put an end to it. EventuallyIstopped telling people because they said it was insane. I couldn’t even imagine stealing or breaking rules. I refused to have sex as a teenager, even when I was dating Diane, the woman who would become my wife, because I saw it as immoral. After several years she finally said enough is enough. Years later, when I was in my sixties, my mother told me a story she remembers about my OCD. It was the summer of 1961. 30 THE PSYCHOPATH INSIDE I was thirteen years old and had been very social all my life. But suddenly, with no apparent trigger, I closed off and crawled into my own little world. I had nothing to do, but the guy next door had a beat-up old boat sitting in his yard. I looked at that and said maybe if I fix it up I could use it to go fishing. I retreated to work on the boat every day, sometimes for up to fourteen hours. I didn’t talk to many people and I sank into a mood. My mother told me that one day she watched me work on the boat from the kitchen window and grew concerned. It was the first time I’d ever exhibited any antisocial behavior. “I was torn whether to tell your father, and to contact a psychiatrist we knew,” she said. By the time I started school in September and was forced into my routine, I went back to normal. My mother never told my father, and I never experienced another period of depression like that again. When I returned to school I became so active socially and athletically that anytime it would creep up, I’d have something to do. There wasn’t any time to get depressed. As I moved into my freshman year of high school, my piety was rewarded by my diocese naming me Catholic Boy of the Year at the yearly New York State conference of Catholic youth. For this honor, I got to spend some time with Governor Nelson Rockefeller, the Archbishop of New York Cardinal Spellman, and other officials of the Church and State. I met some other people about my age who had received the same honor. During the re- treat associated with the statewide conference with these students and priests, I realized for the first time that my fellow Catholic youth activists were interested in action items of the Church, real  Evil Brewing 31 practical matters, while I was just interested in a purely metaphys- ical world, a world of insanity. My four years of high school were filled with nonstop activi- ties. Every year I was on the football team, the wrestling team, and the track and field team. In the summer I swam competitively, and in the winter I skied competitively each year in slalom and giant slalom. Although I enjoyed victory as much as anyone else, I never got mad at opponents. The same could not be said of me in all competitive situations, however; when I played parlor games I proved to be perfectly obnoxious. I hated to lose, and after a while I ostracized any potential poker or Scrabble opponent in my circle of friends. Despite my poor parlor sportsmanship, I was generally a nice guy. I was a musician in the band every year, acted in school pro- ductions, served as president of the drama club, and was involved in the student government. I enjoyed a rich social life and was considered one of the cool, good-looking, athletic, smart types in a school of more than a thousand students. I had three very close friends and about thirty people I considered good friends, and I was on friendly terms with all my classmates and was accepted into the jocks, thespians, arts, and geek groups. I sincerely felt at ease with all of them and found their interests and activities compel- ling. I had an exhausting sense of humor and an openness and optimism that made people want to spend time with me. I was a bright kid, but not particularly focused, and to my parents’ dismay earned the distinction of “Class Clown” for my high school grad- uating class. 32 THE PSYCHOPATH INSIDE Recently I asked an old friend, Pat Quinn, whom I have known since the seventh grade and who later became a clinical psychologist, what she remembers of my personality and char- acter while we were in high school. She e-mailed, “You were tough on the football field, but empathetic and caring off the field. You were a bright competitive student who seldom missed an opportunity to be a prankster. You also had a more conser- vative, rigid side when it came to politics and religion. As teen- agers, it was not unusual to push the limits, particularly in the norms of the mid-sixties. But you were not a rule breaker and when it came to societal norms, you were clearly a black and white thinker. You could often be heard debating a popular sub- ject, but you had little patience for those who were not of your intellectual ability. You were a well-rounded adolescent who would never be considered to lack insight, empathy, or compas- sion for others.” At the same time, in the background of my mind, I knew there was a dark bogeyman lurking, drawing me into lonely and weird places. One series of brief, disorienting experiences in my junior year helped to change my attitude about my obvious bouts of OCD and bizarre religiosity. My father had me do drug deliveries for the pharmacy, and this involved hospitals, individual physicians, pa- tients, factories, and a variety of quirky shut-in customers. But that summer he had me take drug shipments to a home for the elderly filled with psychiatric patients. When I walked down those halls I witnessed behaviors that astonished me: elderly women stripping  Buvil Brewing 33 and urging me to jump into bed with them, people with echolalia who would repeat the same phrases over and over for hours on end, and others with schizophrenia, terminal dementia, and un- speakable behaviorial problems. After seeing that scene several times, I realized that any emotional problems I might have were a mere inconvenience compared to the burden these poor souls had to endure. Those visits, and ones to the girls’ criminal home, set me straight on what real problems were about. Seeing all the bi- zarre and terribly unhappy people there appropriately turned off any woe-is-me sensibilities. I began to appreciate the life my par- ents had blessed us with. I was so busy, and my external life was so positive, I thrived throughout those years. I graduated and immediately found a col- lege where I could continue to play football and ski against top collegiate alpine skiers in the Northeast and Canada. I entered Saint Michael’s College in Vermont at seventeen. My obsessions had abated as high school progressed, but during my college fresh- man year I started being afflicted by other odd disorders. One day, while talking to a classmate in the cafeteria, my hands began to shake uncontrollably for no apparent reason. I was diagnosed with benign familial tremor, a genetic disorder, and still experience those shakes from time to time. That same month, I drove back to New York to visit Diane, whom I’d been dating since high school. While driving with her that weekend I felt an unpleasant tingling in my feet that then spread up my legs to my torso. By the time this vibratory pressure 34 THE PSYCHOPATH INSIDE wave shot into my neck, I thought the top of my head would blow off. My heart started pounding so fast that Diane freaked out because she could see my pulse in my throat and my chest was heaving violently. We pulled over and she took the wheel, picked up her mother, and drove me to the hospital. By the time I got there my blood pressure was 240 over 165, and my pulse was 142 beats per minute, a combined cardiovascular event of dangerous magnitude. The doctors pumped me with an IV solution of Val- ium. Within fifteen minutes my blood pressure and heart rate began to normalize. That event would be the first of approximately 850 panic at- tacks I would experience over the ensuing years, mostly occurring in my twenties and early thirties, until I learned to manage them whenever I felt one coming on. But during the first five hundred panic attacks, I was certain that I was going to die within a minute or two. I would get these anytime, day or night, and it didn’t mat- ter if I was alone or in a crowd. It would just happen. It did not matter that I knew full well I would not die, having experienced these attacks before. The limbic system convinced the rest of my brain that I was about to kick the bucket. So although my OCD and episodes of dread had abated, my brain now charmed me with shaky hands and panic attacks. Nice. One positive spin on developing panic attacks is that I was so freaked out by the potential for a stroke or heart attack that I never took hard or hallucinogenic drugs throughout college and beyond. I stuck with alcohol, and an occasional joint in certain social sit- uations, but I do believe that, given my well-established addictions  Evil Brewing 35 to nicotine and alcohol, the fear of losing my mind and dying of a stroke permanently kept me otherwise drug-free. A year after the onset of the panic attacks, I was called to answer the draft for the Vietnam War. When I arranged for my physical, Iwas asked what conditions I had. The draft board could not have cared less about my OCD or panic attacks. But they were open to the problems my allergic asthma might present in a the- ater of war. So I was given an allergy scratch test on my forearm. Within ten minutes of the scratch application, I developed tunnel vision, with a dark blinding wash coming over my eyes. The next thing I knew, I was on the physician’s table getting an IV. I had gone into complete anaphylactic shock from the allergens. I never received a call to the draft, and this was clearly another case where one of my inconvenient maladies probably saved my life. In fact, every one of the weird cognitive, emotional, psychiatric, and physical challenges I’ve been blessed with had a net positive influence on my life and my attitude toward it. Darwin would be amused. My college years from 1965 through 1969 were probably as normal and intense and wasteful as most kids experienced in the late 1960s. I was interested in biology, skiing, and playing football. Many of my closest friends were musicians and nonscience majors, and that naturally went hand in hand with a certain level of East- ern mysticism, hallucinogens, and veritable bales of marijuana. Even snorting camphorated opiate rectal ointment was not off- limits to this confederacy, and our four-day weekend fight song, “Any Port in a Storm for a Buzz,” guided those heydays of mes- 3'6 THE PSYCHOPATH INSIDE merizing silliness. Just recently a former college classmate of mine, Henry (some names have been changed), reminded me of an episode that he was apparently sober enough to recall, in which I booted a guy out of a convertible and whisked away his date. Even after college, I partied hard. In 1977, while I was a post- doctoral fellow at UC San Diego, I attended a major collegiate football game with a physician friend of mine. After the game, we headed to fraternity row, where a bunch of drunk college students in several houses thought it would be fun to move all their furni- ture outside. I encouraged them to pour alcohol on the furniture and light it on fire. In nearly all matters, I was both reckless and charming. When the police arrived, they didn’t seem too con- cerned. I offered a fireman a joint, and in return he let me play with the hose, so I started spraying people. Minutes later my friend and I ran down the street to attend a large party at another fraternity house. I went up to the third floor and looked down at the band on the patio, then saw an emergency fire hose and asked the guy next to me to hand it over. I stuck it out the window and told him to turn it on. I wiped out the band, full blast. Drums were flying everywhere. A bunch of huge guys, probably football players, came up, furious, and dragged me downstairs. On my way I saw the water from the hose seeping through the ceiling of the second floor. I was put in handcuffs, and then made the cops laugh enough while convincing them that we had never really harmed anyone physically that they released me. On the run from an an- gry crowd, my friend and I ended up getting booted out of another frat house, then run out of an inner-city dive, and pulled over  Evil Brewing By twice on the way home for suspected DUL. In all these cases I gave the police a story they enjoyed, and the two of us made it home at six a.m., just in time for him to do a twenty-four-hour ER stint and for me to start an experiment in the lab at eight a.m. I was well out of puberty but still acting like an adolescent. And hey, a few house break-ins and, yeah, car thefts for fun really didn’t mean that much back then. Boys will be boys. Most of my baby boomer friends and I feel sorry for the present Gen Y-ers who are banned from school and society for pranks we pulled on a daily basis. My early ability to make teachers and police laugh meant I never got in any real trouble. But the Animal House she- nanigans were clearly getting less and less controlled by the end of my adolescent years—clearly not the kind of high mark one reaches for when one has his heart and mind set on a career in the top echelon of the medical sciences. I was blowing it, but I was also having a great time. Teenagers do dumb things, especially when they’re around other teenagers and copious amounts of alcohol and drugs. I won’t pretend that the antics just described betray some demon within me, waiting for any opportunity to wreak havoc on the lives of everyone I knew. But considering how calm and good-natured I was as a child, the carefree and borderline destructive attitude I adopted in college was somewhat remarkable. At the same time I was getting myself into trouble at school, I was also adopting a laissez-faire attitude toward society at large. In the protected environs of a small Catholic school in Vermont, many of us were kept blissfully uncaring about social and political 38 THE PSYCHOPATH INSIDE events elsewhere. We paid some homage to the imperatives of those faraway social conflicts by swearing our opposition to the Vietnam War and offering a cursory nod to the grab bag of social ills and inequities many of us were poorly equipped to understand and too distracted with partying and schoolwork to do anything about. I had been a much more sensitive humanist in high school and for the first two years of college, but those sensibilities faded as I reached twenty. My loss of social awareness and empathy wasn’t due to the environment of the college itself. Saint Michael’s was founded on liberal French Enlightenment principles, which extended far be- yond the classroom. The priests on the faculty were both educa- tors and social activists and often disappeared overnight to take up the banner for whatever cause was most pressing—civil rights, Vietnam, and so on. Instead there seemed to be a crack opening and widening in my psyche, a vaguely defined door in my sensi- bilities that became obvious during my junior year. My behavior suggested that the change in my thinking and behavior was real, and perhaps permanent. And through that crack, on the other side of the door, was a grand hypomanic party that has never let up to this day. My sophomore year, I enrolled in a philosophy class taught by a priest who saw something in me, something he didn’t like, an emerging change of character. He wouldn’t start class until I showed up and sat down, and he went so far as to hold up class one day until one of my classmates ran back to the dorm and got me out of my bed. Classmates had told him about my supposed ESP.  Evil Brewing 39 I never believed in it, but I would tell people what they were think- ing or make predictions, probably just because I picked up on subtle physical clues, and it freaked them out. One time when I was younger, I was in my friend’s backyard and pretended to be someone sitting in heaven. Inamed a friend of his father’s and said I was driving my Jaguar XKE along Route 9E toward Lake Placid when I came around a curve and hit a tree in the road and died. Several days later that happened. My friend’s father heard my pre- diction and said I couldn’t hang out with his son anymore. People tell me I have a gift, but I say if you talk a lot you’re bound to be right sometimes. In college, a few friends also said I developed a way of looking through people. Some felt scared, although they knew I wouldn’t attack them. Still, it bothered them. I never tried to be a tough guy, but I was doing something that people were picking up on. The priest started calling me “evil” during class. I laughed it all off, especially since I had still not done anything I considered immoral or unethical. In my mind, my personality and character were very much intact. People said something in me was changing, something they said was rather unholy. I thought all their observations were a bunch of hooey. As I transitioned into the upperclassman years, I renewed my interest more and more in the biological and chemical sciences, and became an even stauncher believer in the notion that behavior is all about chemistry and electricity and probably genes, and that if one could manipulate these genetic processes, one could control the brain and the mind. The film Charly, based on the novel Flow- ers forAlgernon, came out in 1968, while I was a third-year biology 40 THE PSYCHOPATH INSIDE student. It highlighted the biochemical basis of behaviors and res- onated with me at a time when I was really receptive to it. My career as a mechanistic, reductionist, genes-control-all scientist had begun. The rest, a belief in free will and God, went missing that junior year. Around that time, I, the former Catholic Boy of the Year in my diocese of New York, left the Catholic Church. I approached one of my professors, Father Stapleton, and told him about my doubts and asked for a formal last confession. He laughed and said, “We don’t usually help people get out of the Church,” but he agreed. I was still well behaved, and studious of the Scripture. I’d thoroughly learned the lessons of Christ and Aquinas and Augus- tine. He said, “You don’t need the Church anymore, and in fact it’s making you crazy, with all the OCD stuff.” With that, a great dismal onus lifted, and I felt free and light. It was like a switch had flipped in my brain, one full of positive and aggressive energy, buoyed by self-confidence—maybe even overconfidence. My belief that we are born and not made also had a profound impact on my political views. Whereas prior to college I sub- scribed to a mix of my mother’s conservatism and my aunts’ lib- eralism (my father was neutral), I became increasingly fed up with views on both the left and the right that environmental forces are somehow responsible for shaping who we are. For the right, this manifested itself in support of the nuclear, heterosexual family; on the left, it was rooted in the belief that society should take care of its citizens. In 1969, I became a Libertarian. The possibilities available in a career in the neurosciences,  Evil Brewing 4] where one deals in hard science and facts, were intoxicating to me, and I would commit my life to the study of how the brain shapes who we are. Soft psychology, although of interest to me through- out high school and the early college years, seemed to offer few real insights into what makes us human. After some temporary academic flubs and fumbles in my senior year of college, I would first teach in an all-girls Catholic high school in Albany, and then enter the physiological psychology and psychophysics graduate program at Rensselaer Polytechnic Institute in Troy. After that, I entered a doctoral program in anatomy and physiology at the Uni- versity of Illinois College of Medicine in Chicago, studying, cu- riously enough in hindsight, the orbital cortex and temporal lobe and associated systems in the primate brain—areas I later saw damaged in killers’ brains. This positioned me on a bright-line trajectory to a neurochemistry and neuroanatomy postdoctoral stint at the University of California, San Diego, before landing me a tenure-track job at the University of California, Irvine, where I have been ensconced in the ensuing years, as a satisfactorily suc- cessful professor to this day. All had been beautiful and terrifically fulfilling and easy the whole way through from college onward. Smooth, at least, for thirty-five years.  CHAPTER 3 The Brain of a Killer first became interested in science when I was a child, thanks to my early experiences working on a farm, walking in the forest, and investigating life in ponds and streams in upstate New York. I was urged on in my interest of the world of bugs, frogs, and creepy crawlies by my parents and grandparents, and especially my aunt Flo, who was a nurse and graduate of Columbia University. Flo saw my interest in the natural world starting in the first years of grade school. I asked her once when she first had that insight, and she said that when I was nine months old she was bathing me in the kitchen sink, and when she drained the large porcelain basin, I had a wide- mouthed, gaping look of amazement as the water swirled down the drain. From that moment onward, she said, I was a scientist. When we moved from Cohoes to Loudonville in 1956, Aunt Flo gave me a microbiology text from her nursing school class at Columbia, at about the same time my father gave me an old, but high-quality, vintage 1930s Bausch & Lomb microscope. I was in the fourth grade. Oddly enough, at the same time that I developed a fascination with science and nature, I harbored my growing obsession with  The Brain of a Killer 43 religion and spirituality. I began to ponder the infinite and the hereafter. Whatever had put these worries into my head, the com- bination of awe and fear they inspired was both thrilling and ter- rifying and led to a lifelong quest to understand the fundamentals of the human mind, heart, and soul. For the first twenty years of my academic life I devoted all my work to the basic neurosciences, while also teaching medical stu- dents and graduate students about the structure and function of all the systems in the body in the gross anatomy and microanat- omy courses. In the 1990s, I started teaching more and more in UCI’s human neurosciences curriculum to medical students, graduate students, and residents in neurology and psychiatry, and this whetted my appetite for understanding the biological basis of the human mind, both normal and abnormal. As I became more and more knowledgeable about the human brain, as opposed to just animal brain neuroanatomy, I was being asked by more and more colleagues in psychiatry and in the behavioral and cognitive sciences to analyze brain scans of their patients in the clinical trials they were conducting for drug companies. I was developing a reputation for knowing about the entire brain and nervous sys- tem, and this lack of specialization fit my childhood dream of becoming a Renaissance man, like my hero, Leonardo da Vinci. So instead of becoming an expert in something, I was actually becoming an expert in nothing at all. One day in 1995, my colleague in psychiatry Anthony rang me up and said, “Hey, Jim, I’ve got a job for you. These lawyers I’m consulting have a guy who murdered some people, and we did 44 THE PSYCHOPATH INSIDE a scan to see if there was something wrong with his brain. Could you take a look and tell us what you see?” I said sure and reviewed his PET scan. A PET (positron emission tomography) scan is a tool used in radiology to determine the functioning of the body, specifically small areas the size of a grain of sand in tissues and organs. It is particularly useful in looking into organs, such as the brain, that are encased in bone. The PET scan is considered a functional rather than merely structural scan because it measures the func- tioning of the brain. Radioactive molecules that interact with the brain in specific ways are injected before the scan. They can be sugars, to measure the brain’s metabolism, or drugs that link to the receptors for various neurotransmitters, to measure the dis- tribution of those receptors. In this scan the doctors used an isotope of fluorine, F-18, bound to a type of glucose taken up by active brain cells. It re- mains in the cells and emits positrons, a form of radiation, for about an hour. The glucose is injected into a vein in the subject’s arm, and then the subject is slid onto a gurney into the PET scan- ner until the head is surrounded by the detectors. The amount of time the “photograph” of the brain is taken depends on the half- life of the isotope. In the case of F-18 this exposure time is thirty minutes, so the image that is obtained is a snapshot of brain activ- ity that occurs in this thirty-minute period. During this time, the F-18 releases positrons that immediately collide with electrons, resulting in a release of energy detected in the coils surrounding the head in the PET scanner. The scanner’s computer software  The Brain of a Killer 45 locates the source of all of the collisions, and is then able to recon- struct a 3-D image of them in the entire brain. We assign colors to the density of collisions, indicating use of glucose, and thus brain activity. The darker the area, the harder that part of the brain is working. So I looked at the scan and saw, compared to a healthy brain, a decrease of activity in the orbital cortex and the area around the amygdala. In a healthy brain, this area prevents impulsivity (.e., it inhibits behavior), so when it is turned off, the person is impul- sive. I relayed this to my colleague. The sicko’s lawyers then told the judge that as a matter of biology, their client couldn’t control himself, and he received life without parole instead of the death penalty. Anthony spread the word and I got more calls like this, analyzing the brains of about fifteen psychopathic killers over the next decade—many of them famous. I can’t reveal any details for legal reasons, but it was clear from their actions that they were not just impulsive killers but real methodical psychos. Today people ask me why I didn’t drop everything and pursue research on psychopathy, but I had a lot of other things going on. Collaborations with my clinical colleagues grew in scope in the early 1990s, and then they began to dominate my research inter- ests by 2000, along with my studies of adult stem cells. Eventually this interest and involvement with human psychiatric studies led me to move my academic appointment to the Department of Psy- chiatry and Human Behavior. Based on these studies, starting in the early and mid-1990s, I started to give more and more scien- tific, and then public and lay, talks on personality, development, 46 THE PSYCHOPATH INSIDE schizophrenia, addictions, male-female brain differences, emo- tional memory, and consciousness. By 1998, I was giving a mix of talks about stem cells and psychiatric research, and in 2000, our lab made a breakthrough discovery regarding how adult stem cells mobilize to repair brain injuries. The study was sent from the National Institutes of Health to the U.S. Congress as the first evidence that adult stem cells, as opposed to just embryonic stem cells, could be mobilized in the damaged adult brain, perhaps to cure Parkinson’s disease, stroke, and other neurodegenerative dis- orders. The work surrounding this finding diverted much of my energy and focus for the better part of six years starting in 2001. Meanwhile, our lab received three large federal grants, one to study the nature of tobacco addiction and two to design comput- ing systems for medical imaging. I was also starting a biotech company, NeuroRepair. So for the entire time leading up to dis- covering my own abnormal brain scan and what it might mean, I rarely thought of psychopaths. In 2005, I was contacted by the psychiatrist Daniel Amen, who uses brain imaging to study psychiatric disorders such as ADHD, PTSD, and Alzheimer’s. From his expert testimony work over the years Amen had amassed about fifty brain scans of mur- derers, both psychopathic and impulsive, and he was curious whether I might find a pattern in them. I told him to send them over, but to take off the tags and mix them with other scans— those of healthy subjects, people with schizophrenia, and people with depression. I did the analysis in a blind process, something we always try  The Brain of a Killer 47 to do in science and especially where perceived patterns in data are so easily influenced by prior knowledge and bias toward the subject. When I considered all of the brains, the underlying brain circuitry patterns I saw fell into easily discernible groups—including two different types of killers. From the moment when the blind codes were all broken and I saw who was who in the groups, I became transfixed by what the information might portend. To better understand exactly what I saw in these scans and why it was so relevant, you first need to have a basic understanding of the human brain. The brain is organized in a bewildering num- ber of ways, even to a silverback neuroscientist. The researcher Floyd Bloom once called it an “electrified jelly,” which is certainly what it seems like to a first-year medical student. Neuroanatomists categorize themselves into “clumpers” and “splitters” based on how they like to organize the brain. Clumpers prefer to simplify the brain into as few sections as possible, while splitters divide the brain into thousands of pieces, all with their own Latin or Greek names. To make things even more confusing, splitters like to throw into the mix the name of the scientist who first described that brain area, so we end up with names like “Zuckerkandl’s fasciculus,” “the ventral tegmental relay zone of 99 66 Giolli,” and the “nucleus reticularis tegmenti pontis of Bechterew.” This is one of the reasons medical students are terrified of their first course in neuroscience. When these brain areas, their connections, chemistry, and circuitry, are considered together for any adaptive behavior, for example an infant expressing fear at the sight of a stranger, the  48 THE PSYCHOPATH INSIDE complexity of the brain’s wiring can start to get out of hand. For clinical sciences the representation of the relevant wiring of the brain can quickly send one packing to the nearest pub for a cold one. For example, here is a “simplified” version of the brain cir- cuitry involved in depression. Don’t let this figure put you off. Everyone, including neuroscientists, hates these kinds of figures of the brain, but the brain is extraordinarily complex, so we have to deal with these Jackson Pollock monstrosities from time to time. BA2d dorsal/midAC — Autonomnics/Petiphery| immune. _Motor/Lymphocytes _ er ae System — | Circadian system FIGURE 3A: Depression brain circuitry.  The Brain of a Killer 49 Most of us, however, fall somewhere in between these camps and organize the brain into a few hundred parts. I am a splitter, and I like having thousands of specific parts to study. But for the sake of simplicity, especially when teaching or writing a paper, I like to organize the brain into a 3x3x3 “Rubik’s Cube” pattern. This twenty-seven-part brain is as simple as I’m willing to go and still be able to sleep at night without violating Einstein’s first law of simplicity in science: “Everything should be made as simple as possible, but not simpler.” Everyone is familiar with the idea that we have a left brain and a right brain. But this conception is woefully lacking in some important ways. On the next page is a drawing of the side of the brain at the top left, a view of the top of the brain looking down from above, and a view of the medial portion of the brain that you would see if you sliced the brain down the middle. This medial piece between the left and right hemispheres is also called the limbic lobe, from the word /imbus, which means “edge” in Latin, and here refers to a full circle of ancient cortex related to emotion, attention, memory, switching between cognitive and emotional states, and even helping you to see if someone has taken one of your french fries when you weren't looking. 50 THE PSYCHOPATH INSIDE 3 eeMedial Left and right hemispheres (and medial limbic/emotional core) Medial-limbic lobe FIGURE 3B: Brain hemispheres. The next slicing of the Rubik’s Cube brain is from front, or anterior, to back, or posterior. The most posterior region of the cortex is dedicated to the visual sensory system, as well as “asso- ciation” cortices that have functions more complicated than sim- ple seeing or touching or hearing, but rather cognitive tasks such as spatial processing. The external world—up, down, left, right, close up, far away—is mapped onto the cortex in the upper part of the posterior area, called the superior parietal cortex. People with damage to this brain area on one side will ignore the other half of their sensory world. So they may only perceive the num- bers on the left side of a clock dial, but not the right side. Given a  The Brain of a Killer 51 blank circle, they will fill in the numbers on the dial from 1 to 12, but these will all be drawn on just one half of the clock. If the damage is done to the hemisphere that controls their nondomi- nant hand, let’s say the right superior parietal cortex for a right- hander (each hemisphere controls the opposite side of the body), then they will go the extra step in their “agnosia.” They will be able to move the opposite leg, and feel a pinch on that leg, but they may ask the doctor or nurse to remove the leg from the hospital bed because it is foreign and doesn’t belong to their body. Another function of this posterior area is the understanding and conceptual creation of language. In the dominant hemisphere (the left side if you’re right-handed), this language function en- ables us to master syntax and grammar, while in the nondominant hemisphere, this language function allows us to understand the song and rhythm of language, as well as humor. It appears that the dominant hemisphere function is more genetically determined, while the nondominant hemisphere function is more molded by environment. That is, you will learn to mirror the accents and cadence and patois of speech from your family and friends, but your basic ability for grammar and syntax is more genetically de- termined. One tends to adopt the song and rhythm of speech around the time one reaches puberty, but the range and capabili- ties of individuals vary widely. In the case of Henry Kissinger and his younger brother, Walter, who fled Nazi Germany in 1938, when Henry was sixteen and his brother was fourteen, the elder brother kept his pronounced Frankish accent while Walter sounded very American. a2 THE PSYCHOPATH INSIDE In the Rubik’s Cube middle sector of the hemisphere, there are the somatic and motor areas that map the skin senses in the back half of this middle piece, and the map of the areas that con- trol the muscles of the body. Just in front of this motor cortex is the premotor cortex, which is involved in the planning of motor movements and in learning the rules of how we swing a golf club and play the piano. These two motor-related cortices form a strip on each hemisphere in size and placement like the support arms of a set of earphones. The anterior, or front, section is the prefrontal cortex and is responsible for the so-called executive functions of the brain, includ- ing knowing rules, making plans, and enabling short-term memory. This “scratch pad” memory lasts seconds or tens of seconds and helps us to remember phone numbers long enough to dial them and tells us, without looking, where we set our drink while we’re eating or playing poker. The prefrontal cortex is the brain region most important for the elaboration of personality and character, and the control of impulse, obsessions, and antisocial behavior. Besides being the locus of will, the prefrontal cortex is related to a myriad of functions we consider particularly well developed in primates, especially humans. These involve what has been called “memory of the future,” that is, projecting one’s mind into the fu- ture to imagine, or experience, really, how one will remember an act that has not yet taken place. This is akin to the pleasant sensation one has when playing a game of chess and knowing that after just five moves one will cream his opponent. This knowledge of the imagined future resides in a circuit centered in the prefrontal cortex.  The Brain of a Killer 53 I suspect that humans’ ability to do this relies, in part, on a mutation in the gene for catechol-O-methyltransferase, or COMT. This enzyme is responsible for breaking down dopamine in the frontal lobe after it has been released. There are two possi- ble versions of the mutation, which, taken together, are referred to as the valine-methionine polymorphism. The methionine ver- sion of the gene leads to the production of a COMT enzyme that has a lower melting point, while the valine version codes for a COMT with a higher melting point. All this means is that, in those with the methionine version, COMT inactivates faster at normal brain temperature, allowing dopamine to hang around synapses triggering neuronal function for a longer period of time, since there is no enzyme to break down the neurotransmitter. The steady supply of dopamine enhances frontal lobe activity, includ- ing its capacities to brainstorm and premeditate. Thanks to this and other neurotransmitter-related mutations millions of years ago, early humans could plan further ahead and anticipate future events like war and famine. And because they could anticipate these events, they did things like invent weapons and learn to farm. Likewise, memory of the future allows us to appreciate a sense of time and helps explain our belief in religion, the afterlife, and eternity. The next way we can slice the brain’s hemispheres is into upper, middle, and lower thirds, more correctly referred to as the dorsal, intermediate, and ventral streams. The upper, or dorsal, stream lies right under where you wear a ten-gallon hat. This “stream,” so called by Leslie Ungerleider of 54 THE PSYCHOPATH INSIDE the National Institute of Mental Health, is primarily concerned with processing “where” things are in your external environment, as well as their movements. The lower, or ventral, stream pro- cesses “what” things are in your external world, especially in the visual system. The intermediate stream codes for “when” things happen, but is also involved intimately with language and the mir- ror neuron system (explained in chapter 7). The dorsal part of the prefrontal cortex and its interconnect- ing subcortical areas are associated with “cold cognition,” emo- tionless processing of thoughts, perceptions, short-term or executive memories, plans, and rule-making. This involves both generating these thoughts and also inhibiting other thoughts, de- pending on established rules for success and failure in the appro- priate context. Life is full of rules and contingencies, whether in Scrabble or golf or business, and the dorsal prefrontal cortex tells you when it’s okay to act on your urges—when you should place a tile or hit a ball or buy a stock—and when you shouldn’t. The lower, or ventral, part of the prefrontal cortex, largely made up of the orbital cortex and ventromedial prefrontal cortex, is involved in similar functions, but more those enabling and disenabling “hot cognition”—emotional memory and socially, ethically, and mor- ally programmed behaviors. Someone with a highly functioning dorsal prefrontal system would have superior planning and exec- utive functions, whereas someone with a highly functioning ven- tral prefrontal system would have superior control over impulsive and inappropriate interpersonal and social behaviors. Likewise, lower functioning in these systems leads to not only a lack of  The Brain of a Killer 55 comprehension of these high-order behaviors, but an inability to control them under socially inappropriate circumstances. Connecting with others involves both cold (rational) cogni- tion, where one person understands what others might be think- ing and what an appropriate response might be, and hot (emotional) cognition, where one can experience empathy with another’s feel- ings and attitudes—that is, actually “feel” them much like the other person would experience them. Someone with damage to the hot system, let’s say in the orbital cortex, might not be able to predict others’ thoughts but will have the most trouble sharing his feelings. A dichotomy may exist between empathy, a fundamental connection with the pain of others and arising very early in life, and “theory of mind,” a more elaborated medial prefrontal system that allows us to consider others’ thoughts and beliefs, even if they’re different from our own. People with autism lack theory of mind but not empathy, while people with psychopathy lack empa- thy but not theory of mind. Without empathy you can still have sympathy, though—the ability to retrieve emotional memories, including those that can predict what painful event is probably about to befall another person, and the will to help that person. These brain circuits mature at different times during devel- opment, and although there are major maturational events that take place in the terrible twos, puberty, late adolescence, the twen- ties, and the mid-thirties, some are not completely integrated un- til one is in the sixties, which appears to be the typical average peak time of human insight, cognition, and understanding in many realms of life. 56 THE PSYCHOPATH INSIDE The central cube in the Rubik’s Cube brain consists of the subcortical structures that lie deep in the cortex, and these include the basal ganglia, the thalamus, and the brain stem. The basal ganglia are a region important for understanding how cognition and emotion interact to facilitate or turn off behavior. It is a yin- yang area in dynamic balance where dopamine and the endor- phins may have opposite effects on adjacent neurons, and where motivation, drive, hedonism, addictions, sensory-motor activity, and all sorts of fascinating behaviors get their oomph. There are millions of so-called loops of neuronal connections that pass through the basal ganglia, integrating cortical command information with other subcortical way stations such as the tha- lamic structures (called the thalamus, epithalamus, subthalamus, and hypothalamus), brain stem, and cerebellar circuits. Some of these loops are closed, or direct, feedback loops con- necting the same brain areas over and over, while others are open loops where the information is passed to adjacent brain channels for integrating, say, different modalities of perception, emotion, consciousness, attention, planning, and will. Within each loop there are parallel channels, one of which leads to motor action and is thus a “Do It” channel, and its part- ner, which keeps you from doing something, and is thus a “Don’t Do It” channel. These two converge on motor neurons that add up the “Do Its” (excitation) and the “Don’t Do Its” (inhibition) and determine whether you move. Since dopamine turns on the “Do It” channel, and simultaneously turns off the “Don’t Do It” chan- nel in the loops, dopamine is the key neurotransmitter that flips  The Brain of a Killer Be, the switch when you are lying on your couch watching the game and decide you want to go get a beer. People whose dopamine cells die do not have this ability to get up from the couch. These people have Parkinson’s disease. They have the will to get up (prefrontal cortex), and they have the plan (premotor cortex) and command signal (motor cortex) to get up and start walking, but they don’t have the dopamine to activate and déactivate these “Do It” and “Don't Do It” channels to get the movement started. There are millions of these closed and open loops in the brain connecting the cortex and subcortical areas, and in this way broad areas of the brain become involved in even the seemingly simplest of behaviors we take for granted. This is why when we look at a PET scan or {MRI scan or EEG, just a finger tap can activate many brain areas in both cortical and subcortical areas. As I looked at the scans of killers Amen sent, there were a few features I expected to see in the psychopaths. They would have decreased activity in the orbital cortex—the part of the prefrontal cortex just above the orbits, or eye sockets—and the nearby ven- tromedial prefrontal cortex. These are involved in inhibition, so- cial behavior, ethics, and morality. I expected psychopaths would also have damage to the front of the temporal lobe, including the amygdala, which processes emotions, leading to cold behavior. I'd seen these neural deficits in other scans of psychopathic killers, and they’d also been identified in more formal research by other labs. So I pointed to the scans I thought belonged to the psycho- pathic killers. When we looked up their code numbers, I’d nailed  58 THE PSYCHOPATH INSIDE it. When a neuroanatomist sees a pattern, he goes crazy. I could have been studying butterflies and I still would have gotten excited. Patterns are where we get our buzz. And that’s when I really became interested in psychopathy. Combining these scans with others of diagnosed psychopaths I'd collected over the years, I noticed a more intricate pattern. In psychopaths, I saw a loss of activity that extends from the orbital cortex into the ventromedial prefrontal cortex and into a part of the prefrontal cortex called the anterior cingulate. The loss then continues along the cingulate cortex to the back of the brain as a thin strip, then loops down into the lower part of the temporal lobe into the very tip of the temporal lobe and the amygdala. Orbital/ventromedial 4. prefrontal cortex a NS Amygdala/hippocampal cortex