Melanie A. Chinchilla
Dennis E. Reidy
David S. Kosson- 1Private Practice, San Francisco, CA, United States
- 2School of Public Health, Georgia State University, Center for Research on Interpersonal Violence, Georgia State University, Atlanta, GA, United States
- 3Department of Psychology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States
- 4Department of Psychology, College of Health Professions, Rosalind Franklin University of Medicine and Science Chicago Medical School, North Chicago, IL, United States
Although psychopathy has been widely studied within criminal justice contexts, its impact on society is rarely considered in public health contexts. Even so, evidence strongly implicates psychopathic traits in substantial costs (not just fiscal) to society. Individuals with psychopathic features commonly hurt those with whom they have relationships in important ways, including through abuse, manipulation, deception and, often, violence. We review the empirical evidence linking psychopathic traits to three recognized public health problems: substance misuse, sexual risk behavior, and violence. We argue that the evidence suggesting robust links between psychopathic traits and these known public health problems warrant the recognition of psychopathy as a public health concern in its own right. We argue that failing to consider psychopathy through a public health lens will slow research progress and the development of prevention strategies. Implications for public policy are considered.
1 Introduction
Although psychopathy has been widely studied within criminal justice contexts, its impact on society is rarely considered in public health contexts (1–3). Many individuals with psychopathic features seldom encounter the criminal justice system. Some appear able to operate successfully within the boundaries of conventional society for years in spite of behavior that adversely impacts the health of the people around them and of the social systems in which they live (4–6).
In contrast, violent acts, substance use, and sexual risk behavior are widely recognized public health threats that place individuals at heightened risk of injury, infection, or disease and that negatively impact the health of society. Psychopathic traits have often been linked to all three of these public health problems, and have been conceptualized as risk factors for these problems (e.g., 7, 8). Moreover, preliminary evidence suggests psychopathic traits may contribute to shared variance among public health threats (discussed below; see Section 1.3). We argue that the evidence for robust links between psychopathic traits and these public health threats suggests the possibility that psychopathy may account for some of the harms of these known public health concerns and is itself a significant threat to public health.
In addition, most contemporary approaches to preventing and treating these kinds of problems do not address psychopathy. However, recent research testing the effectiveness of intervention programs designed to impact youth with psychopathic traits provides preliminary evidence that these methods likely reduce the harm associated with psychopathic traits.
In short, we argue that psychopathic traits meet two important criteria for public health concerns: 1) they appear to have a substantial negative impact on the health of individuals and of society; and 2) preliminary evidence identifies promising avenues for effective prevention strategies. Consequently, increased effort is warranted to identify socio-behavioral risk and protective factors that are associated with the development of psychopathic traits, and to evaluate and implement prevention strategies that target these factors (9). Our intent is not to provide an exhaustive review of psychopathy and its relation to these particular outcomes, or health more broadly. Nor is it to critique these literatures, though we do attempt to rely on the most rigorous evidence available. Our purpose is to argue that psychopathy is a significant public health problem that warrants attention from public health and prevention researchers and practitioners and to illustrate the benefits to society likely to result from an increased public health response to psychopathy.
1.1 Psychopathy: definitions and prevalence
Psychopathy refers to a syndrome of personality pathology defined by a pattern of interpersonal, affective, and antisocial lifestyle characteristics including interpersonal manipulation, callous disregard for the rights of others, stimulation-seeking, poor anger control, impulsive, and persistent antisocial behaviors (10, 11). Psychopathic traits, like the features of most mental disorders exist on a continuum (12). People with high levels of these traits can be identified as people with psychopathy and have been identified in community samples in many different countries (e.g., 13).
Psychopathy is not the same thing as antisocial personality disorder (ASPD). Despite being described as synonymous with psychopathy in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 14), substantial research demonstrates these two syndromes are not equivalent (15, 16). Many individuals meet diagnostic criteria for ASPD but are not high in psychopathic traits, and a small minority of individuals with psychopathic traits do not meet diagnostic criteria for ASPD (17). Moreover, even among individuals with ASPD, those who also have psychopathic features exhibit more violent histories, poorer prognoses, and different kinds of emotion-processing and neurological anomalies than individuals with ASPD without psychopathic traits (15, 18–20). Herein, we focus our review and arguments on psychopathy. In several places, we distinguish findings pertaining to psychopathy from findings pertaining to ASPD (which is often comorbid with psychopathy). However, our arguments and conclusions pertain to preventing the public health harms associated with psychopathic traits because we believe scientific evidence suggests psychopathy is a public health problem.
Psychopathic traits can be assessed with a variety of different kinds of measures ranging from self-report measures (e.g., the Psychopathic Personality Inventory, the Triarchic Psychopathy Measure; 21, 22) to observational measures (23), to ratings by parents or teachers (24) and clinical measures (the Psychopathy Checklist measures; 25). Although the Psychopathy Checklist measures are widely considered the best validated measures of psychopathy (e.g., 26, 27; 28), all measures of psychopathy have limitations. In the sections that follow, we review studies that have employed a variety of different measures of psychopathy in a variety of different kinds of samples.
1.2 The public health impact of psychopathy
The adverse impact of psychopathy on public health is evident in its association with a myriad of risk behaviors and the widespread consequences of such behavior. To demonstrate this point, we review links between psychopathy and three classes of risk behaviors that receive attention in the field of public health: substance use, sexual risk behavior, and violence. We consider the social costs of these psychopathy correlates and their implications for considering psychopathy a public health concern. Although no direct evidence of causality has been identified for the vast majority of public health problems, psychopathic traits are commonly identified in childhood and adolescence, often prior to evidence of sexual behavior, substance use, or the age of criminal responsibility. The positive associations between psychopathic traits and these three kinds of problems have led researchers to posit psychopathic traits as risk factors for all three kinds of problems.
At the outset, we note that our chief focus is on the nature of bivariate relations between psychopathic traits and levels of substance use and misuse, sexual risk, and violent behaviors. The majority of the research we review reflects studies of male adults and adolescents (or samples that are primarily male) and includes studies with offender and community samples and a variety of different psychopathy measures. Most of the published studies were conducted with North American samples. Because psychopathy has been validated in youth, in women, and in populations from different countries and of different races and ethnicities, where possible, we note whether there is evidence that these relations generalize across age, biological sex, ethnicity/race, and/or country/culture.
1.2.1 Substance use
Substance use is widely recognized as one of the costlier social problems facing the United States, with costs that include communicable and noncommunicable diseases, substance use disorders, other mental disorders, criminal activity, and injuries related to substance use (29–31). Substance use is also associated with reductions in work productivity, increased costs related to social services, treatment, and hospitalization, and increased stress and financial costs to family members (e.g., 32–34). Consequently, substance misuse harms not only individuals who misuse substances but also their families, the companies that employ these individuals, and the community institutions that allocate human and financial resources to treat substance misuse. The robust links between substance misuse and relapse (e.g., 35) increase the magnitude of these costs. Moreover, overdoses and deaths related to drug use have grown dramatically over the past ten years (36) although they may now be declining (37).
Links between psychopathy and substance misuse have been replicated across multiple independent samples (e.g., 38–40). Psychopathy is associated with a greater number of symptoms of substance dependence (41–43) and has been linked to a variety of adverse health outcomes in substance use disorder samples. Youth with psychopathic traits are prone to earlier onset of substance use and use of drugs from a larger number of substance classes (44, 45). Although most of the evidence is based on cross-sectional studies, longitudinal associations between psychopathic traits and substance misuse have also been reported (e.g., 44, 46, 47). Links between psychopathic traits and substance misuse generalize across gender, race or ethnicity, and nationality. Even so, some gender differences have been reported (see Supplementary Material for additional detail), and the correlations between psychopathy and substance misuse criteria range from small to large in magnitude.
In addition to individual harms associated with substance use, there is evidence that negative peer influences on substance use can extend to the friends of someone who misuses substances and even their social connections and other peers (48). In this context, individuals with psychopathic traits are reported to be more effective than others at persuading peers to engage in a variety of deviant behaviors including substance use (49–52).
According to a National Drug Intelligence Center study (NDIC), illicit substance use in the United States costs over $282 billion in 2023 dollars (53; updated from 2007 dollars). This estimate includes lost productivity and health costs. Individuals with ASPD reportedly comprise approximately 20% of those with alcohol and drug use disorders (54, 55). The conservative estimate that one third of those with ASPD are high in psychopathic traits (56) suggests psychopathic traits are likely to cost at least 18 billion dollars related to illicit substance use each year.1
1.2.2 Sexual risk behavior
Sexual risk behavior has numerous consequences for the social, economic and physical well-being of individuals and populations (57). Participation in risky sexual behavior increases the likelihood of contracting several sexually transmitted infections (STIs) and diseases which themselves can lead to other life-threatening illnesses, including cancer and HIV (9). People who engage in sexual risk behaviors are also at heightened risk of transmitting STIs, especially those whose risk behaviors include sexual activity with a larger number of partners and sexual activity without using condoms. Sexually transmitted infections contribute in turn to long-term harm to the sexual and reproductive health of individuals and their partners and can predispose their children to lasting health complications which are associated with additional medical and hospitalization costs. One recent analysis estimates the total lifetime direct medical cost for new STIs in the U.S. in one year as approaching $20 billion annually (updated from 2018 dollars; 60).
Aside from these costs are the costs of unplanned pregnancies, especially among adolescents. Teen mothers are at heightened risk for complications including pre-term delivery, poor maternal weight gain, low infant birthweight, toxemia, neonatal mortality, and maternal mortality (61–63). In addition, girls with teen pregnancies have poorer educational and employment outcomes and lower socioeconomic status in adulthood (64–67). Moreover, the offspring of teen mothers face elevated risks for health complications (including low birth weight and infant mortality; 62) and heightened risk for some of the same adverse outcomes as their mothers, including adolescent pregnancies (67), lower. educational attainment, greater likelihood of unemployment, and poorer health as adults (61, 62, 64, 68). One analysis estimates the annual cost of teen pregnancy in the U.S. at approximately $13 billion dollars (updated from 2013 dollars; 69).
Substantial cross-sectional evidence links psychopathy to sexual risk behaviors in both men and women including hypersexuality, intercourse with a larger number of sexual partners, sexual affairs, and reduced use of condoms during sex (70–73). Among adolescents, psychopathic traits have been linked to earlier sexual debut, more unprotected sexual intercourse, and reduced willingness to modify risky behaviors (74–76). Psychopathic traits also predict future engagement in sexual risk behaviors (77; see also 78). Although these associations are quite variable in magnitude across sexual risk criteria and samples, similar links have been identified for studies conducted in North America and in other continents and for studies of psychopathy and gender (see Supplementary Material for additional detail). Psychopathy has also been linked to other unsafe behaviors, including sexual intercourse without condoms among HIV-positive males (79).2
Moreover, similar to theory and evidence reviewed above for the role of individuals with psychopathic traits in spreading substance use (e.g., 80), youth psychopathic traits appear to promote sexual risk behaviors among their peers, including early sexual debut, unprotected sexual behavior, and the use of sexual coercion, including engaging in sexual behavior with partners under the influence of alcohol or other substances that impair decision-making (71, 72, 78, 81–86). Psychopathic traits have also been linked with manipulative behaviors (including love bombing) designed to induce trust and promote romantic feelings, which may increase openness to sexual activity (e.g., 49, 88–90). All of these behaviors place individuals with psychopathic traits at heightened risk for both contracting and transmitting STIs to multiple peers, who may, in turn, transmit these infections to others (91–93).
Although it is difficult to estimate the costs of sexual risk behavior attributable to individuals with psychopathic traits, recent estimates suggest that the costs of STIs (e.g., lifetime costs of the STIs in one year estimated at $19 billion) and teen pregnancies in the United States ($13 billion annually) are substantial (see Supplementary Materials for details). A substantial proportion of youth without psychopathic traits also engage in sexual risk behavior, and estimates of the proportion of youth with psychopathic traits in the community vary widely (e.g., 94, 95; see Supplementary Materials). At the same time, studies of antisocial youth suggest one quarter to one half of these youth who report engaging in sexual risk behaviors appear to be characterized by at least moderate levels of psychopathic traits. Consequently, available estimates suggest the annual costs of sexual risk behavior by youth with high levels of psychopathy in the U.S. likely exceed $1 billion dollars. (This estimate does not include sexual risk behaviors committed by adults with psychopathic traits).
1.2.3 Psychopathy and violence
Violence is a major contributor to premature death, disability, and injury and has long been recognized as a serious threat to public health (3, 96, 97). Over 150,000 people are hospitalized, and over 20,000 die each year as a result of violence in the U.S. alone (98–100). But the health consequences of violence also include increased risk for several psychological disorders among victims and survivors, including anxiety and depression, post-traumatic stress, and suicide (96, 101, 102). Those victimized by violence are also at heightened risk for poorer behavioral health, including participation in substance abuse and sexual risk behaviors that, in turn, place some individuals at heightened risk for STIs, unwanted pregnancies, overdoses, and death.
Moreover, violence victimization often exacerbates existing physical health problems, including cancer, cardiovascular disease, chronic pain, diabetes, gastrointestinal disorders, hypertension, pelvic inflammatory disease, and seizures (103). Further, youth who are victims or witnesses of violence are more likely to develop a range of interpersonal and social problems, including difficulties with emotion regulation, peer relationships, school adjustment, and pro-social behaviors (104–109). These kinds of physical and psychiatric problems are associated with increased costs to individuals and, through demands on healthcare, social services, and correctional institutions, increased costs to society. Such youth also more often endorse attitudes condoning violence (106, 110), increasing the likelihood of later acts of violence (106, 110).
Youth and adults with psychopathic traits are responsible for a disproportionate share of violence (1, 3, 6, 111, 112) and are therefore responsible for an outsized share of the adverse health and economic consequences. For example, Coid and Yang (1) reported that individuals with psychopathy comprised 0.7 percent of the general population of Great Britain but accounted for 17.5 percent of the violent incidents over a 5-year period. This finding suggests that developing effective violence prevention with fewer than 1 percent of the population could reduce collective levels of violence substantially. Psychopathic traits also correlate with severity of victim injury, number of different types of victims, and with perpetrating violence both inside and outside the home (1, 113–117). A study of over 500 U.S. community individuals aged 18 to 40 revealed a significant relation between psychopathic traits and perpetration of violence (11). Moreover, evidence suggests links between psychopathic traits and violent behavior generalize across gender, race or ethnicity, and nationality, although some gender differences and ethnicity differences have been reported, and these effects range from small to large in magnitude (see Supplementary Material for additional detail).
Although most studies are cross-sectional, psychopathic traits also predict the commission of violence prospectively. Within a large sample of civil psychiatric patients, Skeem and Mulvey (118) found psychopathy scores predicted future violence, with 50% of psychopathic patients committing a violent act during a one-year follow-up period compared to 22% of non-psychopathic patients. Similarly, among incarcerated individuals followed for several years, men with psychopathic traits were more likely than other men to be charged with new violent crimes (119–122).
There are few comprehensive estimates of the costs of violent crime in the U.S. However, two recent estimates place the annual costs in the hundreds of billions. Anderson (123, 124) updated his own earlier estimates for the annual costs of rape, robbery, and assault to $346.6 billion (updated from 2020 dollars) and provided estimates for murders that permit a rough estimate of the annual cost of murders in the U.S. at $480.3 billion (see Supplementary Materials for details). Others have estimated that violence-related health care, lost work days, and reduced productivity cost the global economy billions of U.S. dollars per year (96, 125). One recent estimate for the annual costs of medical treatment and lost productivity due to homicide and nonfatal assaults was approximately $437 billion in the U.S. (100).
Taken together, these estimates suggest violent crime costs Americans upwards of $800 billion per year. The proportion of violent crime due to people with psychopathy can be estimated using the same formula previously used by Kiehl and Hoffman (126) to estimate the proportion of crime due to psychopathy. They argued that 20% of the crime reflected people with psychopathy. Given the substantial evidence that individuals with psychopathic traits account for a disproportionate share of the violent crime, it appears conservative to rely on the same figure in estimating the proportion of violent crime attributable to psychopathy. If individuals high in psychopathy account for only 20% of the costs of violent crime, then the costs of violence associated with psychopathy in the U.S. appear to exceed $150 billion annually (see Supplementary Materials for additional detail).
This figure likely underestimates the costs of violence by individuals with psychopathy. Even studies with methods designed to estimate the costs for those who do not report crimes (e.g., 123) do not commonly capture the harms to the intimate partners, children, and other family members and friends of those with psychopathic traits who witness the abuse of others (127).
1.2.4 Additional costs to the health of society
There is also evidence that the negative impact of psychopathy extends to include harm to the overall health of societies in additional ways. We note here two examples.
First, beyond the harm to individuals through violence at their workplaces, people with psychopathic traits harm workplaces and organizations themselves (128). It is difficult to quantify the financial and reputational harm done to larger systems such as companies (through workplace-related lawsuits, corporate theft, and fraud) or to public institutions (through corruption and abuse of government programs). However, there is evidence psychopathic traits predict not only abusive individual interactions with individual supervisees, but also reduced job satisfaction among coworkers (129, 130), reductions in productive work behavior (131–133), and damage to corporate climates (130, 134).
Second, in addition to the harm to those in relationships with people with psychopathy, it appears likely (but not yet certain) that there is harm to children who depend on those relationships. First, the links between psychopathic traits and sexual infidelity and a larger number of live-in and marital relationships can help to explain the associations between psychopathic traits and reduced marital satisfaction and divorce (135). The links between psychopathy and emotional, physical, and sexual abuse appear likely to also contribute to unstable marriages, but abusive behavior is also expected to have a large negative impact on partners’ health. Damage to a child’s parent (i.e., a parent without psychopathy) is harmful to that child because traumatic experiences reduce people’s effectiveness (e.g., 136, 137). It has been argued that parents with psychopathic features also negatively impact their children’s development (138, 139). Although there are few direct studies, in one sample, psychopathic traits in fathers were associated with poor parenting and with greater behavior problems in children (140). In addition, one longitudinal study demonstrated psychopathic traits in fathers were associated with psychopathic traits in their offspring (141) although these could reflect genetic mechanisms (142). Such links suggest there are likely to be additional negative public health impacts for those exposed to parental figures with psychopathic traits during childhood. However, such repercussions are difficult to quantify.
It is sometimes argued that evidence for genetic factors makes environmental factors (including interventions) unimportant. The evidence that genetic factors contribute to the development of psychopathic traits does not rule out the utility of intervention efforts in reducing the levels of psychopathic traits that emerge over time. As in other areas of psychopathology, most behavior genetic studies of psychopathy find consistent evidence of nonshared environmental effects but not of shared environmental effects (142, 143). In addition, there is evidence that environmental factors can interact with genetic factors. For example, some research has found that parenting practices by an adoptive mother buffered against the heritable risk for callous-unemotional (CU) features (144, 145). These findings demonstrate there is substantial room for environmental impacts in genetic models.
1.3 Pleiotropic effects of psychopathy on public health
Although substance misuse, sexual risk behavior, and violence represent distinct public health problems, there is evidence suggesting they may be related. Notably, increased sexual risk behaviors and increased violence have been observed in individuals with substance misuse (e.g., 146–148). Similarly, violence and substance use have been identified as challenges faced by individuals with sexual risk behaviors (149–151), and substance misuse and sexual risk have been identified as challenges among individuals who commit violence (e.g., 152–154). Moreover, although most intervention programs are designed to address a single problematic behavior, some intervention programs have been designed to impact some combination of these public health problems (e.g., see 155–158). These relations suggest the possibility that some external factor could be related to all three of these public health problems.
In recent years, a few studies have reported important relations among psychopathic traits, sexual risk behavior, and substance use. Thornton and colleagues (77) reported that substance use appears to partly account for the relations between psychopathic traits in adolescence and risky sexual behavior. There is also preliminary evidence that psychopathy in adults contributes to the shared variance between violence and substance misuse. Examining a large sample of incarcerated male detainees, Vincent et al. (159) reported that psychopathic traits accounted for a significant proportion of the variance shared between indices of violent behavior and dependence symptoms for several classes of substances. These findings suggest the possibility that psychopathic traits may also confer heightened risk for several other kinds of risky or harmful activities.3 In this context, it is plausible that people with psychopathic traits may contribute further to the harms to which their offspring, siblings, parents, friends, romantic partners, colleagues, and organizations are exposed. Because most studies examine costs related to only one outcome at a time, the true cost burden of psychopathy is likely greater than even current estimates suggest. Studies are needed to provide more comprehensive estimates of the cost burden of psychopathy.
2 Psychopathy and interventions for addressing these public health problems
Many intervention programs have been designed to combat substance misuse, sexual risk behaviors, and violence. Recognition of these as public health problems has contributed to substantial investments in preventing and treating these kinds of harmful public health behaviors. In this section, we focus on two specific issues.
First, it appears that most interventions designed to ameliorate substance misuse not explicitly include procedures for addressing people with psychopathic traits. Reviews of treatments for substance use disorders that we identified did not mention psychopathy explicitly (e.g., 161–166). Several reviews have suggested comorbid psychopathology increases the difficulty of treating substance misuse (167, 168), and several have emphasized poorer outcomes for those with a comorbid personality disorder (156, 169, 170).
Similarly, most interventions designed to promote sexual health or reduce sexual risk behaviors do not address psychopathy (e.g., 149, 171–174). We were unable to identify reviews of sexual risk behavior that addressed personality disorders in general. However, some reviews and some individual studies have identified links between specific personality disorders or related traits (e.g., impulsivity) and sexual risk behavior (e.g., 175–177).
Many reviews of violence interventions do not address psychopathy or personality disorders as relevant factors (e.g., 178–184). Reviews that include personality disorders have emphasized that comorbid personality disorders are associated with lower rates of program success, including reduced motivation and greater dropout (e.g., 185–187). However, only a small proportion appear to include studies that address psychopathy explicitly (e.g., 188–190).
There is also little attention to people with psychopathic traits in the empirical literatures focusing on substance misuse and sexual risk behaviors. Notably, most review papers focused on impacting substance misuse and sexual risk behaviors do not explicitly address psychopathy (e.g., 191–198). (In the area of violence, some reviews do explicitly address psychopathy, e.g., 199). Even so, because people with psychopathic traits are more likely than others to misuse alcohol and other psychoactive substances, to engage in sexual risk behaviors, and to inflict violence on others, interventions that reduce psychopathy appear to represent an efficient way to reduce multiple public health problems. From this perspective, interventions that reduce the prevalence of psychopathic traits (or reduce the costs associated with psychopathic traits) may also reduce the costs associated with these recognized public health problems.
Second, the few studies that have evaluated the impact of psychopathic traits on the effectiveness of interventions for some of these public health problems have reported that these traits are associated with reduced effectiveness of programs designed to reduce unhealthy behaviors, including violence (200, 201; see also 202). Among forensic samples, the negative impacts of psychopathic traits on treatment compliance and working alliance appear more robust than the negative impact of ASPD on treatment outcomes (e.g., 203; cf., 204). Studies often (but not always) indicate the core affective and interpersonal components of psychopathy (those which differentiate psychopathy from ASPD; 205) are most predictive of treatment non-compliance and smaller gains in treatment (59, 201, 206, 207; cf. 200).4 Findings that psychopathic traits moderate the effectiveness of interventions designed to mitigate these costs indicate that such interventions are more effective for individuals without these traits than for those with them.
3 Decreasing the burden associated with psychopathy
Although psychopathy has sometimes been considered untreatable (56, 208, 209), recent research has provided evidence of the value of two different kinds of methods for reducing the harms associated with psychopathy. First, methods are available that appear to aid in reducing the development of psychopathic traits. Second, methods are available for reducing the harms caused by people who have developed psychopathic traits. A range of possible prevention strategies for reducing these impacts of psychopathic traits are summarized in Table 1.
Table 1. Prevention Strategies.
3.1 Factors that help to reduce the severity of psychopathic traits
Studies suggest that factors which promote the security of parent-child attachment and which promote constructive parenting can help to reduce the development of psychopathic traits over time. As early as 2003, Frick et al. reported that families characterized by lower levels of “negative parenting” demonstrated greater declines in psychopathic traits over a four-year follow-up period. More recent studies indicate individual differences in parenting quality are prospectively predictive of changes in the levels of psychopathic traits children display. Many of these studies have focused only on the affective component of psychopathy (often referring to the affective traits as callous unemotional or CU traits)(218); even so, they demonstrate that greater parental involvement and positive reinforcement, and less parental harshness are predictive of lower levels of specific psychopathic traits in children years later 219).
3.2 Opportunities for prevention
Recent studies also provide preliminary evidence for effective intervention in clinical samples of youth with psychopathic traits. Several researchers had earlier reported evidence that youth with conduct problems and CU traits are responsive to nurturance and rewards but are less responsive to punishments than other youth with conduct problems (208, 220). Consistent with this perspective, Caldwell et al. (212) reported that incarcerated youth offenders with psychopathic features showed significant gains after periods of intensive treatment in a setting where contingencies were designed to reward prosocial behavior. In this program, a behavioral point system ensured participants were rewarded each day for good behavior displayed the previous day. Youth high in psychopathic traits who spent a greater proportion of their time at this treatment center were less likely to violently reoffend than those who resided primarily in conventional youth prisons (212). In addition, Caldwell and colleagues (222), provided evidence that such treatments may reduce levels of psychopathic traits (at least as measured by adolescents’ self-reports). Even so, apart from replications with independent samples of youth at the same institution, it does not appear this approach has been examined in an independent sample. Of course, these interventions reflect a response to psychopathy after it has manifested and engendered problems, a tertiary prevention approach. However, identifying the effective elements in these interventions may yield fruitful starting points for adapting them to primary and secondary prevention strategies.
There is some evidence that early interventions may help to inhibit the development of psychopathic traits. McDonald and colleagues (223) demonstrated that a program designed to improve the parent-child relationship, increase prosocial behavior, and reduce problem behaviors led to reductions in parent-reported psychopathic traits compared with a control condition in which parents could seek out support or referrals, and these differences were maintained during a follow-up period. More recently, Kimonis et al. (211) reported that participation in an enhanced form of parent-child interaction therapy (Parent-Child Interaction Therapy adapted for CU traits) led to reductions in the affective features of psychopathy among preschoolers (mean age 4.5); this finding has been replicated in independent samples (210, 224). Collectively, this evidence suggests that some kinds of early interventions may help to prevent the development of some of the problematic behaviors (e.g., violence, substance use, sexual risk behavior) that are associated with high levels of psychopathic traits (see also 225). These findings also suggest that further investments in developing interventions targeting parent behavior early in childhood are likely to be helpful for reducing the costly and destructive behavior associated with psychopathy. Further, given the evidence that some early environmental risk factors are reliably associated with increases in the likelihood of psychopathic traits, interventions that reduce these risk factors may help to prevent the development of psychopathic traits. At the same time, it remains important to examine the robustness of these findings in independent samples and with investigators other than those who developed the intervention programs.
These examples are provided only to demonstrate the gains that have been made towards effective intervention to reduce the development of psychopathic traits and the costs associated with psychopathic traits. They are not intended to serve as the proposed solutions to psychopathy and its harmful effects. Our goal is not to lay out what a public health prevention approach to psychopathy would look like in specificity here. Rather, we are proposing that shifting our perspective from a primarily criminal justice orientation to an integrated public health perspective will offer important opportunities, methods, and resources to abate this societal issue.
4 Limitations
Because the focus of this review was direct relations between psychopathic traits and well-recognized public health concerns, we did not investigate the possibility that other important variables moderate the strength or direction of the relations that emerged from our review. Although the links between psychopathic traits and substance misuse, sexual risk behaviors, and violent behaviors have been replicated across different kinds of measures of psychopathy and in different kinds of samples (e.g., forensic vs. community settings, samples in different countries, samples that differ in gender or ethnicity or race; e.g., 70, 73, 226–228; see Supplementary Materials), there is also is evidence that some of the relations between psychopathy and these harmful behaviors are impacted by other factors (e.g., 229–231). It remains possible that unexamined factors may moderate the strength of these relations. Further, every measure of psychopathy has limitations.5 In addition, most measures of psychopathic traits include items that tap into behaviors associated with some of the public health problems reviewed here (e.g., stimulation seeking associated with use of psychoactive substances; promiscuity including sexual relationships with multiple partners, and reactive or proactive violence). Most studies we reviewed did not control for predictor-criterion overlap in assessing the relations reported (112); consequently, the magnitude of the relations may be smaller than they appear. Moreover, some of the direct effects we discussed were relatively small in size (e.g., 229, 232, 233). Nevertheless, the aggregate burden of psychopathy on population health is substantial and necessitates applying a public health approach to prevent it.
5 Summary and conclusions
Psychopathy places a substantial burden on societal institutions. Psychopathic traits adversely impact not only individuals with high levels of psychopathic traits themselves but also their families, friends, co-workers, victims, and the organizations in which they function. Less severe, on average, but still substantial are the impacts of individuals with moderate levels of psychopathic traits in the same relationship contexts (e.g., 234). Psychopathy presents a unique challenge for mental health practitioners, medical providers, and law enforcement personnel. Psychopathic traits are associated not only with high levels of risky behaviors, but with reductions in the effectiveness of some treatments (e.g., 59, 201, 206).
The current analysis suggests the public health burden of psychopathy is substantial. However, preliminary evidence suggests the potential to lessen or prevent this burden: 1) by reducing levels of psychopathic traits among children at risk for developing psychopathy, and 2) by reducing the costs of violence among adolescents and adults with psychopathic traits. Adaptation and effectiveness tests of programs based in part on these interventions as primary prevention and additional secondary prevention strategies may be the next step to increasing the use of methods that can reduce the development of psychopathic traits. Our intention is not to advocate for a particular intervention or set of interventions. Our goal is to promote the perception of psychopathy under a public health lens in order to stimulate broadly research and the development of effective prevention strategies.
Psychopathic traits have been linked with individual harm in a variety of different kinds of personal relationships and professional relationships (e.g., 5, 129, 235 Preston et al. (236). In the absence of effective policies for managing deception, organizations are at risk for disruption and victimization. To protect their stockholders, organizations may benefit from developing policies to be able to manage both staff members and clients who practice deception and manipulation. Yet few organizations or institutions have developed policies to address situations in which individuals misrepresent their goals and their behavior.
As research continues to demonstrate the value of identifying those with psychopathic traits, public health experts and stakeholders may at some point wish to consider the merits of screening for psychopathic traits in specific contexts. Ethical considerations regarding when and how to engage in such screening practices are critical. It is important that any assessments of psychopathic traits in youth are conducted for the benefit of those youth and their families and that screening is not used to deny opportunities to youth. For example, it may be possible to direct additional resources towards some youth (e.g., child management strategies emphasizing positive reinforcement rather than punishment) without using labels that link the resources to psychopathy (237). In addition, resources are needed to educate people about how to protect themselves from people with such features in these contexts. Education about psychopathy should help to reduce the costs of psychopathy. In sum, greater recognition of the harmful impact of psychopathy on society as a whole and application of a public health approach will accelerate the development and dissemination of prevention strategies and policies that help systems and individuals function more effectively.
In writing this manuscript, we have presented a selection of evidence to demonstrate why psychopathy should be a public health priority. It was not our intention to be exhaustive in reviewing these literatures. For example, beyond the impacts on individuals with psychopathic traits and those who interact with them in close relationships, psychopathy may additionally impact public health through financial (e.g., Ponzi Schemes), corporate (ENRON), or political malfeasance (acts contributing to genocide; 4, 134). Further, the mental and physical health of employees may be adversely affected by supervisors with psychopathic traits who create hostile work environments (131). However, the true nature and burden of psychopathy will remain unknown as long as we continue to address the issue as though it is solely a criminal justice problem. We propose that psychopathy is a public health problem influencing the health and well-being of individuals across the social ecology.
Data availability statement
The raw data corroborating statements made in the text of this article can be found at https://www.osf.io/8rdbu and https://www.osf.io/845n9.
Ethics statement
The studies involving humans were approved by the Institutional Review Board, Rosalind Franklin University of Medicine and Science. The studies were conducted in accordance with the local legislation and institutional requirements.
Author contributions
MC: Writing – original draft, Conceptualization, Methodology. DR: Methodology, Supervision, Writing – review & editing. DK: Methodology, Writing – review & editing, Supervision, Conceptualization, Formal analysis, Writing – original draft.
Funding
TThe author(s) declared that financial support was received for this work and/or its publication. Some of the research reported here was supported in part by Grant MH57714 from the National Institute of Mental Health and by a pilot grant from the School of Graduate and Postdoctoral Studies, Rosalind Franklin University of Medicine and Science to David S. Kosson. to David S. Kosson. No financial support was received for the publication of this article.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2025.1657080/full#supplementary-material
Footnotes
- ^ These estimates do not include all substance misuse-related costs. Notably, they do not include costs stemming from the misuse of alcohol; substantial evidence links psychopathic traits to more severe symptoms of alcohol dependence (e.g., 41, 43, 47). In addition, some psychopathic traits are associated with less successful completion of treatment for substance misuse (58, 59) which is likely to increase costs.
- ^ Some of these correlates are reported to be different in cisgender male than in cisgender female individuals (87).
- ^ In contrast, a similar study reported that alcohol misuse was not associated with the link between ASPD and intimate partner violence (160).
- ^ Preliminary evidence suggests that psychopathic traits also reduce the effectiveness of interventions designed to deter corruption, another threat to public health (221).
- ^ One of the chief limitations of self-report measures of psychopathy is that self-report measures of the affective and interpersonal features of psychopathy correlate only very modestly with clinical indices of these traits (e.g., 26). The PCL measures tend to be more difficult to use, requiring substantial training and time and reviews of collateral material (often institutional files).
References
1. Coid J and Yang M. The impact of psychopathy on violence among the household population of Great Britain. Soc Psychiatry Psychiatr Epidemiol. (2011) 46:473–80. doi: 10.1007/s00127-010-0212-4
2. Reidy DE and Bogen KW. “Public health considerations in psychopathy,”. In: Vitale JE, editor. The complexity of psychopathy. Springer Nature Switzerland AG, Cham (Switzerland (2022). p. 611–35. doi: 10.1007/978-3-030-83156-1_22
3. Reidy DE, Kearns MC, DeGue S, Lilienfeld SO, Massetti G, and Kiehl KA. Why psychopathy matters: Implications for public health and violence prevention. Aggression Violent Behav. (2015) 24:214–25. doi: 10.1016/j.avb.2015.05.018
4. Babiak P, Neumann CS, and Hare RD. Corporate psychopathy: Talking the walk. Behav Sci Law. (2010) 28:174–93. doi: 10.1002/bsl.925
5. Forth A, Sezlik S, Lee S, Ritchie M, Logan J, and Ellingwood H. Toxic relationships: The Experiences and Effects of Psychopathy in Romantic Relationships. Int J Offender Ther Comp Criminology. (2022) 66:1627–58. doi: 10.1177/0306624X211049187
6. Reidy DE, Lilienfeld SO, Berke DS, Gentile B, and Zeichner A. Psychopathy traits and violent assault among men with and without history of arrest. J Interpersonal Violence. (2019) 34:2438–57. doi: 10.1177/0886260516660972
7. Robertson EL, Walker TM, and Frick PJ. Intimate partner violence perpetration and psychopathy: A comprehensive review. Eur Psychol. (2020) 25:134–45. doi: 10.1027/1016-9040/a000397
8. Soulet E, Garcia M, Rouchy E, Delannoy D, Cochez F, Pham T, et al. Psychopathie et risque de récidive sexuelle: Analyse critique de la littérature scientifique [Psychopathy and risk of sexual recidivism: Critical analysis of the scientific literature. Annales Médico-Psychologiques. (2018) 176:928–35. doi: 10.1016/j.amp.2018.09.006
9. World Health Organization. Global health sector strategy on sexually transmitted infections 2016–2021: toward ending STIs (No. WHO/RHR/16.09) (2016). World Health Organization. Available online at: https://www.who.int/publications/i/item/WHO-RHR-16.09 (Accessed November 25, 2023).
10. Campbell MA, Porter S, and Santor D. Psychopathic traits in adolescent offenders: an evaluation of criminal history, clinical, and psychosocial correlates. Behav Sci Law. (2004) 22:23–47. doi: 10.1002/bsl.572
11. Neumann CS and Hare RD. Psychopathic traits in a large community sample: Links to violence, alcohol use, and intelligence. J Consulting Clin Psychol. (2008) 76:893–9. doi: 10.1037/0022-006X.76.5.893
12. Guay J, Ruscio J, Knight RA, and Hare RD. A taxometric analysis of the latent structure of psychopathy: evidence for dimensionality. J Abnormal Psychol. (2007) 116:701–16. doi: 10.1037/0021-843X.116.4.701
13. Sanz-García A, Gesteira C, Sanz J, and García-Vera MP. Prevalence of psychopathy in the general adult population: A systematic review and meta-analysis. Front Psychol. (2021) 12:3389/fpsyg.2021.661044. doi: 10.3389/fpsyg.2021.661044
14. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed.. Arlington (VA): American Psychiatric Publishing; (2013)
15. Kosson DS, Lorenz AR, and Newman JP. Effects of comorbid psychopathy on criminal offending and emotion processing in male offenders with antisocial personality disorder. J Abnormal Psychol. (2006) 115:798–806. doi: 10.1037/0021-843X.115.4.798
16. Werner KB, Few LR, and Bucholz KK. Epidemiology, comorbidity, and behavioral genetics of antisocial personality disorder and psychopathy. Psychiatr Ann. (2015) 45:195–9. doi: 10.3928/00485713-20150401-08
17. Kosson D. Unpublished data addressing the prevalence of antisocial personality disorder and Psychopathy Checklist-based psychopathy among county jail offenders. (2024). Available online at: https://www.osf.io/8rdbu (Accessed May 28, 2025).
18. Gregory S, Ffytche D, Simmons A, Kumari V, Howard M, Hodgins S, et al. The antisocial brain: psychopathy matters. Arch Gen Psychiatry. (2012) 69:962–72. doi: 10.1001/archgenpsychiatry.2012.222
19. Howard RC, Khalifa N, and Duggan C. Antisocial personality disorder comorbid with borderline pathology and psychopathy is associated with severe violence in a forensic sample. J Forensic Psychiatry Psychol. (2014) 25:658–72. doi: 10.1080/14789949.2014.943797
20. Baskin-Sommers AR, Baskin DR, Sommers IB, and Newman JP. The intersectionality of sex, race, and psychopathology in predicting violent crimes. Criminal Justice Behav. (2013) 40:1068–91. doi: 10.1177/0093854813485412
21. Miller JD and Lynam DR. An examination of the psychopathic personality inventory’s nomological network: A meta-analytic review. Pers Disorders: Theory Research Treat. (2012) 3:325–6. doi: 10.1037/a0024567
22. Patrick CJ and Drislane LE. Triarchic model of psychopathy: origins, operationalizations, and observed linkages with personality and general psychopathology. J Pers. (2015) 83:627–43. doi: 10.1111/jopy.12119
23. Hampton SL, Vitacco MJ, and Kosson DS. Construct validity of the three-factor model of the Interpersonal Measure of Psychopathy. Criminal Justice Behav. (2018) 45:1613–33. doi: 10.1177/0093854818786759
24. Matlasz TM, Frick PJ, and Clark JE. A comparison of parent, teacher, and youth ratings on the Inventory of Callous-Unemotional Traits. Assessment. (2023) 30:210–24. doi: 10.1177/10731911211047893
25. Hare RD. The hare psychopathy checklist-revised: technical manual. North Tonawanda, NY: Multi-Health Systems (2003).
26. Copestake S, Gray NS, and Snowden RJ. A comparison of a self-report measure of psychopathy with the Psychopathy Checklist-revised in a UK sample of offenders. J Forensic Psychiatry Psychol. (2011) 22:169–82. doi: 10.1080/14789949.2010.545134
27. Salekin RT, Neumann CS, Leistico AMR, DiCicco TM, and Duros RL. Psychopathy and comorbidity in a young offender sample: Taking a closer look at psychopathy’s potential importance over disruptive behavior disorders. J Abnormal Psychol. (2004) 113:416–27. doi: 10.1037/0021-843X.113.3.416
28. Salvador B, Arce R, Rodríguez-Díaz FJ, and Seijo D. Psychometric assessment of psychopathy: A meta-analytical review. Rev Latinoamericana Psicología. (2017) 49:36–47. doi: 10.1016/j.rlp.2015.09.015
29. GBD 2016 Alcohol and Drug Use Collaborators. The global burden of disease attributable to alcohol and drug use in 195 countries and territories 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Psychiatry. (2018) 5:987–1012. doi: 10.1016/S2215-0366(18)30337-7
30. Iqbal MN, Levin CJ, and Levin FR. Treatment for substance use disorder with co-occurring mental illness. Focus (American Psychiatr Publishing). (2019) 17:88–97. doi: 10.1176/appi.focus.20180042
31. U.S. Department of Health and Human Services, Office of the Surgeon General. Facing addiction in america: the surgeon general’s report on alcohol, drugs, and health (2016). Washington, DC. Available online at: https://www.hhs.gov/surgeongeneral/reports-and-publications/index.html (Accessed December 28, 2022).
32. Fardone E, Montoya ID, Schackman BR, and McCollister KE. Economic benefits of substance use disorder treatment: A systematic literature review of economic evaluation studies from 2003 to 2021. J Subst Use Addict Treat. (2023) 152:209084. doi: 10.1016/j.josat.2023.209084
33. Morgan JR, Murphy SM, Assoumou SA, and Linas BP. Estimating absenteeism related to nonalcohol substance use in a US national cohort of full-time employees. J Occup Environ Med. (2022) 64:899–904. doi: 10.1097/JOM.0000000000002612
34. Soellner R and Hofheinz C. Burden and satisfaction with social support in families with a history of problematic substance use or dementia - a comparison. BMC Psychol. (2024) 12:448. doi: 10.1186/s40359-024-01940-1
35. Rowell-Cunsolo TL, Liu J, Hu G, and Larson E. Length of hospitalization and hospital readmissions among patients with substance use disorders in New York City, NY USA. Drug Alcohol Depend. (2020) 212:107987. doi: 10.1016/j.drugalcdep.2020.107987
36. Fujita-Imazu S, Xie J, Dhungel B, Wang X, Wang Y, Nguyen P, et al. Evolving trends in drug overdose mortality in the USA from 2000 to 2020: an age-period-cohort analysis. EClinicalMedicine. (2023) 61:102079. doi: 10.1016/j.eclinm.2023.102079
37. Garnett MF and Miniño AM. Drug overdose deaths in the United States 2003–2023 (Nchs data brief no. 522). Natl Center Health Stat. (2024). doi: 10.15620/cdc/170565
38. Gudonis LC, Derefinko K, and Giancola PR. The treatment of substance misuse in psychopathic individuals: why heterogeneity matters. Subst Use Misuse. (2009) 44:1415–33. doi: 10.1080/10826080902961625
39. Hemphill JF, Hart SD, and Hare RD. Psychopathy and substance use. J Pers Disord. (1994) 8:169–80. doi: 10.1521/pedi.1994.8.3.169
40. Sellbom M, Donnelly KM, Rock RC, Phillips TR, and Ben-Porath YS. Examining gender as moderating the association between psychopathy and substance abuse. Psychology Crime Law. (2017) 23:376–90. doi: 10.1080/1068316X.2016.1258466
41. Brieman CL, McGarrigle WJ, Cope LM, Kiehl KA, and Kosson DS. Clarifying relationships between core features of psychopathy and substance (mis)use: A replication and extension in two large independent samples. J Pers Disord. (2024) 38:138–56. doi: 10.1521/pedi.2024.38.2.138
42. Smith SS and Newman JP. Alcohol and drug abuse-dependence disorders in psychopathic and nonpsychopathic criminal offenders. J Abnormal Psychol. (1990) 99:430–9. doi: 10.1037/0021-843X.99.4.430
43. Walsh Z, Allen LC, and Kosson DS. Beyond social deviance: Substance use disorders and the dimensions of psychopathy. J Pers Disord. (2007) 21:273–88. doi: 10.1521/pedi.2007.21.3.273
44. Baskin-Sommers AR, Waller R, Fish AM, and Hyde LW. Callous-unemotional traits trajectories interact with earlier conduct problems and executive control to predict violence and substance use among high-risk male adolescents. J Abnormal Child Psychol. (2015) 43:1529–41. doi: 10.1007/s10802-015-0041-8
45. Taylor J and Lang AR. Psychopathy and substance use disorders In: Patrick CJ ed. Handbook of Psychopathy. The Guilford Press (2006), 495–511.
46. Charalampous K, Stavrinides P, Georgiou S, and Giasemidou P. Is there a psychopathic element in adolescent drinking? A longitudinal study. Eur J Dev Psychol. (2019) 16:47–65. doi: 10.1080/17405629.2017.1334547
47. Waller R and Hicks BM. Trajectories of alcohol and marijuana use among primary versus secondary psychopathy variants within an adjudicated adolescent male sample. Pers Disorders: Theory Research Treat. (2019) 10:87–96. doi: 10.1037/per0000303
48. Fujimoto K and Valente TW. Social network influences on adolescent substance use: disentangling structural equivalence from cohesion. Soc Sci Med. (2012) 74:1952–60. doi: 10.1016/j.socscimed.2012.02.009
49. Brazil KJ, Dias CJ, and Forth AE. Successful and selective exploitation in psychopathy: Convincing others and gaining trust. Pers Individ Dif. (2021) 170. doi: 10.1016/j.paid.2020.110394
50. Curtis SR, Richards DK, and Jones DN. The association between psychopathy and influencing others to use substances. Subst Use Misuse. (2020) 55:1097–105. doi: 10.1080/10826084.2020.1729196
51. Kerr M, van Zalk M, and Stattin H. Psychopathic traits moderate peer influence on adolescent delinquency. J Child Psychol Psychiatry. (2011) 53:826–35. doi: 10.1111/j.1469-7610.2011.02492.x
52. Van Zalk MHW and Van Zalk N. Violent peer influence: The roles of self-esteem and psychopathic traits. Dev Psychopathol. (2015) 27:1077–88. doi: 10.1017/S0954579415000693
53. National Drug Intelligence Center. The economic impact of illicit drug use on American society (2011). Washington D.C: United States Department of Justice. Available online at: https://www.justice.gov/archive/ndic/pubs44/44731/44731p.pdf (Accessed November 10, 2016).
54. Goldstein RB, Compton WM, Pulay AJ, Ruan WJ, Pickering RP, Stinson FS, et al. Antisocial behavioral syndromes and DSM-IV drug use disorders in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Drug Alcohol Depend. (2007) 90:145–58. doi: 10.1016/j.drugalcdep.2007.02.023
55. Kessler RC, Crum RM, Warner LA, Nelson CB, Schulenberg J, and Anthony JC. Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey. Arch Gen Psychiatry. (1997) 54:313–21. doi: 10.1001/archpsyc.1997.01830160031005
56. Hare RD and Neumann CS. Psychopathy: Assessment and forensic implications. Can J Psychiatry. (2009) 54:791–802. doi: 10.1177/070674370905401202
57. Centers for Disease Control. Sexually transmitted infections: Prevalence, incidence, and cost estimates in the United States(2020). Available online at: https://www.cdc.gov/std/statistics/prevalence-incidence-cost-2020.htm (Accessed December 28, 2022).
58. Berger K, Rotermund P, Vieth ER, and Hohnhorst A. The prognostic value of the PCL-R in relation to the SUD treatment ending. Int J Law Psychiatry. (2012) 35:198–201. doi: 10.1016/j.ijlp.2012.02.008
59. Swogger MT, Conner KR, Caine ED, Trabold N, Parkhurst MN, Prothero LM, et al. A test of core psychopathic traits as a moderator of the efficacy of a brief motivational intervention for substance using offenders. J Consulting Clin Psychol. (2016) 84:248–58. doi: 10.1037/ccp0000065
60. Chesson HW, Spicknall IH, Bingham A, Brisson M, Eppink ST, Farnham PG, et al. The estimated direct lifetime medical costs of sexually transmitted infections acquired in the United States in 2018. Sexually Transmitted Dis. (2021) 48:215–21. doi: 10.1097/OLQ.0000000000001380
61. Basch CE. Teen pregnancy and the achievement gap among urban minority youth. J School Health. (2011) 81:614–8. doi: 10.1111/j.1746-1561.2011.00635.x
62. Chandra PC, Schiavello HJ, Ravi B, Weinstein AG, and Hook FB. Pregnancy outcomes in urban teenagers. Int J Gynecology Obstetrics. (2002) 79:117–22. doi: 10.1016/S0020-7292(02)00240-0
63. Jutte DP, Roos NP, Brownell MD, Briggs G, MacWilliam L, and Roos LL. The ripples of adolescent motherhood: social, educational, and medical outcomes for children of teen and prior teen mothers. Acad Pediatr. (2010) 10:293–301. doi: 10.1016/j.acap.2010.06.008
64. Assini-Meytin LC and Green KM. Long-term consequences of adolescent parenthood among African-American urban youth: A propensity score matching approach. J Adolesc Health. (2015) 56:529–35. doi: 10.1016/j.jadohealth.2015.01.005
65. Diaz CJ and Fiel JE. The effect(s) of teen pregnancy: Reconciling theory, methods, and findings. Demography. (2016) 53:85–116. doi: 10.1007/s13524-015-0446-6
66. Gorry D. Heterogeneous consequences of teenage childbearing. Demography. (2019) 56:2147–68. doi: 10.1007/s13524-019-00830-1
67. Meade CS, Kershaw TS, and Ickovics JR. The intergenerational cycle of teenage motherhood: an ecological approach. Health Psychol. (2008) 27:419–29. doi: 10.1037/0278-6133.27.4.419
68. Patel PH and Sen B. Teen motherhood and long-term health consequences. Maternal Child Health J. (2012) 16:1063–71. doi: 10.1007/s10995-011-0829-2
69. Power to Decide (formerly The National Campaign to Prevent Teen and Unplanned Pregnancy). Counting it up: key data (2013). Washington, DC. Available online at: https://powertodecide.org/what-we-do/information/resource-library/counting-it-key-data (Accessed October 12, 2023).
70. Chan HO and Beech A. Risky sexual behavior and psychopathy: Testing the relationship in a non-clinical sample of young adults in Hong Kong. Behav Sci (Basel Switzerland). (2024) 14:94. doi: 10.3390/bs14020094
71. Fulton JJ, Marcus DK, and Payne KT. Psychopathic personality traits and risky sexual behavior in college students. Pers Individ Dif. (2010) 49:29–33. doi: 10.1016/j.paid.2010.02.035
72. Kastner RM and Sellbom M. Hypersexuality in college students: The role of psychopathy. Pers Individ Dif. (2012) 53:644–9. doi: 10.1016/j.paid.2012.05.005
73. Reynolds BL, Maurer JM, Cook AM, Harenski C, and Kiehl KA. The relationship between psychopathic traits and risky sexual behavior in incarcerated adult male offenders. Pers Individ Dif. (2020) 156:109798. doi: 10.1016/j.paid.2019.109798
74. Malow RM, Devieux J, Rosenberg R, Nair M, McMahon R, Brown EJ, et al. Antisocial psychopathy and HIV risk among alcohol and other drug (AOD) abusing adolescent offenders. Am J Infect Dis. (2007) 3:230–38. doi: 10.3844/ajidsp.2007.230.239
75. Ručević S. Psychopathic personality traits and delinquent and risky sexual behaviors in Croatian sample of nonreferred boys and girls. Law Hum Behav. (2010) 34:379–91. doi: 10.1007/s10979-009-9196-6
76. Visser BA, Pozzebon JA, Bogaert AF, and Ashton MC. Psychopathy, sexual behavior, and esteem: It’s different for girls. Pers Individ Dif. (2010) 48:833–8. doi: 10.1016/j.paid.2010.02.008
77. Thornton LC, Frick PJ, Ray JV, Wall Myers TD, Steinberg L, and Cauffman E. Risky sex, drugs, sensation seeking, and callous unemotional traits in justice-involved male adolescents. J Clin Child Adolesc Psychol. (2019) 48:68–79. doi: 10.1080/15374416.2017.1399398
78. Gretton HM, McBride M, Hare RD, O'Shaughnessy R, and Kumka G. Psychopathy and recidivism in adolescent sex offenders. Criminal Justice Behav. (2001) 28:427–49. doi: 10.1177/009385480102800403
79. Benotsch EG, Rodríguez VM, Hood K, Lance SP, Green M, Martin AM, et al. Misleading sexual partners about HIV status among persons living with HIV/AIDS. J Community Health. (2012) 37:1049–57. doi: 10.1007/s10900-011-9529-5
80. Rowe DC and Rodgers JL. A social contagion model of adolescent sexual behavior: Explaining race differences. Soc Biol. (1994) 41:1–18. doi: 10.1080/19485565.1994.9988856
81. Anderson SL, Zheng Y, and McMahon RJ. Predicting risky sexual behavior: The unique and interactive roles of childhood conduct disorder symptoms and callous-unemotional traits. J Abnormal Child Psychol. (2017) 45:1147–56. doi: 10.1007/s10802-016-0221-1
82. Khan R, Brewer G, Kim S, and Centifanti LCM. Students, sex, and psychopathy: Borderline and psychopathy personality traits are differently related to women and men’s use of sexual coercion, partner poaching, and promiscuity. Pers Individ Dif. (2017) 107:72–7. doi: 10.1016/j.paid.2016.11.027
83. Knight RA and Guay JP. The role of psychopathy in sexual coercion against women: An update and expansion. In: Patrick CJ, editor. Handbook of psychopathy. Guilford Press, New York (2018). p. 662–81.
84. Kosson DS, Kelly JC, and White JW. Psychopathy-related traits predict self-reported sexual aggression among college men. J Interpersonal Violence. (1997) 12:241–54. doi: 10.1177/088626097012002006
85. Muñoz LC, Khan R, and Cordwell L. Sexually coercive tactics used by university students: A clear role for primary psychopathy. J Pers Disord. (2011) 25:28–40. doi: 10.1521/pedi.2011.25.1.28
86. Jonason PK, Li NP, and Buss DM. The costs and benefits of the Dark Triad: Implications for mate poaching and mate retention tactics. Pers Individ Dif. (2010) 48:373–8. doi: 10.1016/j.paid.2009.11.003
87. Hoffmann AM and Verona E. Psychopathic traits, gender, and motivations for sex: Putative paths to sexual coercion. Aggressive Behav. (2019) 45:527–36. doi: 10.1002/ab.21841
88. Arabi S. PTSD symptoms: Romantic relationships with individuals who have narcissistic and psychopathic traits. Harvard University Division of Continuing Education (2022). Available online at: https://dash.harvard.edu/server/api/core/bitstreams/338c3f91-40c1-4231-a2b9-2a917db6a94b/content (Accessed November 4, 2025).
89. Brazil KJ and Forth AE. Psychopathy and the induction of desire: Formulating and testing an evolutionary hypothesis. Evolutionary psychol Sci. (2020) 6:64–81. doi: 10.1007/s40806-019-00213-0
90. Jauk E, Neubauer AC, Mairunteregger T, Pemp S, Sieber KP, and Rauthmann JF. How alluring are dark personalities? The dark triad and attractiveness in speed dating. Eur J Pers. (2016) 30:125–38. doi: 10.1002/per.2040
91. Decker MR, Silverman JG, and Raj A. Dating violence and sexually transmitted disease/HIV testing and diagnosis among adolescent females. Pediatrics. (2005) 116:e272–6. doi: 10.1542/peds.2005-0194
92. Goesling B, Colman S, Trenholm C, Terzian M, and Moore K. Programs to reduce teen pregnancy, sexually transmitted infections, and associated sexual risk behaviors: a systematic review. J Adolesc Health. (2014) 54:499–507. doi: 10.1016/j.jadohealth.2013.12.004
93. Kaestle CE, Halpern CT, Miller WC, and Ford CA. Young age at first sexual intercourse and sexually transmitted infections in adolescents and young adults. Am J Epidemiol. (2005) 161:774–80. doi: 10.1093/aje/kwi095
94. Forth AE, Kosson DS, and Hare RD. The Hare psychopathy checklist: youth version, technical manual. New York: Multi-Health Systems, Inc (2003).
95. Kemp EC, Frick PJ, Matlasz TM, Clark JE, Robertson EL, Ray JV, et al. Developing cutoff scores for the Inventory of Callous-Unemotional Traits (ICU) in justice-involved and community samples. J Clin Child Adolesc Psychol. (2023) 52:519–32. doi: 10.1080/15374416.2021.1955371
96. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, and Lozano R. World report on violence and health. Geneva, Switzerland: World Health Organization (2002).
97. Mercy JA, Rosenberg ML, Powell KE, Broome CV, and Roper WL. Public health policy for preventing violence. Health Affairs. (1993) 12:7–29. doi: 10.1377/hlthaff.12.4.7
98. Florence C, Haegerich T, Simon T, Zhou C, and Luo F. Estimated lifetime medical and work-loss costs of emergency department–treated nonfatal injuries—United State. Morbidity Mortality Weekly Rep. (2015) 64:1078–82. doi: 10.15585/mmwr.mm6438a5
99. Florence C, Simon T, Haegerich T, Luo F, and Zhou C. Estimated lifetime medical and work-loss costs of fatal injuries—United State. Morbidity Mortality Weekly Rep. (2015) 64:1074–7. Available online at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6438a4.htm (Accessed October 12, 2023).
100. Centers for Disease Control and Prevention. Web-based injury statistics query and reporting system (WISQARS). Available online at: https://www.cdc.gov/injury/wisqars (Accessed November 25, 2023).
101. Coker AL, Smith PH, Bethea L, King MR, and McKeown RE. Physical health consequences of physical and psychological intimate partner violence. Arch Family Med. (2000) 9:451–7. doi: 10.1001/archfami.9.5.451
102. Walsh K, Keyes KM, Koenen KC, and Hasin D. Lifetime prevalence of gender-based violence in US women: Associations with mood/anxiety and substance use disorders. J Psychiatr Res. (2015) 62:7–13. doi: 10.101/10.1016/j.jpsychires.2015.01.002
103. Rivara F, Adhia A, Lyons V, Massey A, Mills B, Morgan E, et al. The effects of violence on health. Health Affairs. (2019) 38:1622–9. doi: 10.1377/hlthaff.2019.00480
104. Cyr C, Euser EM, Bakermans-Kranenburg MJ, and Van Ijzendoorn MH. Attachment security and disorganization in maltreating and high-risk families: a series of meta-analyses. Dev Psychopathol. (2010) 22:87–108. doi: 10.1017/S0954579409990289
105. Farrell AD and Sullivan TN. Impact of witnessing violence on growth curves for problem behaviors among early adolescents in urban and rural settings. J Community Psychol. (2004) 32:505–25. doi: 10.1002/jcop.20016
106. Guerra NG, Huesmann LR, and Spindler A. Community violence exposure, social cognition, and aggression among urban elementary school children. Child Dev. (2003) 74:1561–76. doi: 10.1111/1467-8624.00623
107. Scott KL, Wolfe DA, and Wekerle C. Maltreatment and trauma: Tracking the connections in adolescence. Child Adolesc Psychiatr Clinics. (2003) 12:211–30. doi: 10.1016/S1056-4993(02)00101-3
108. Wolfe DA, Scott K, Wekerle C, and Pittman AL. Child maltreatment: Risk of adjustment problems and dating violence in adolescence. J Am Acad Child Adolesc Psychiatry. (2001) 40:282–9. doi: 10.1097/00004583-200103000-00007
109. Wood SL and Sommers MS. Consequences of intimate partner violence on child witnesses: A systematic review of the literature. J Child Adolesc Psychiatr Nurs. (2011) 24:223–36. doi: 10.1111/j.1744-6171.2011.00302.x
110. Kim J, Lee B, and Farber NB. Where do they learn violence? The roles of three forms of violent socialization in childhood. Children Youth Serv Rev. (2019) 107:104494. doi: 10.1016/j.childyouth.2019.104494
111. Vaughn MG, Salas-Wright CP, DeLisi M, and Maynard BR. Violence and externalizing behavior among youth in the United States: Is there a severe 5%?. Youth Violence and Juvenile Justice.. (2014) 12:3–21. doi: 10.1177/1541204013478973
112. Blais J, Solodukhin E, and Forth AE. A meta-analysis exploring the relationship between psychopathy and instrumental versus reactive violence. Criminal Justice Behav. (2014) 41:797–821. doi: 10.1177/0093854813519629
113. Laurell J, Belfrage H, and Hellström Å. Facets on the Psychopathy Checklist: Screening Version and instrumental violence in forensic psychiatric patients. Criminal Behav Ment Health. (2010) 20:285–94. doi: 10.1002/cbm.779
114. Mach JL. Psychopathy, stake in conformity, and ethnicity: Differentiating perpetrators of intimate partner violence from other criminal offenders. Rosalind Franklin University of Medicine and Science, North Chicago (IL (2018).
115. Vitacco MJ, Caldwell MF, Van Rybroek GJ, and Gabel J. Psychopathy and behavioral correlates of victim injury in serious juvenile offenders. Aggressive Behav. (2007) 33:537–44. doi: 10.1002/ab.20211
116. Vincent G, Huss MT, Winters J, Thomas L, and Dutton D. “The psychopathic batterer: Subtyping perpetrators of domestic violence,”. In: Hervé H and Yuille JC, editors. The psychopath: Theory, research, and practice. Lawrence Erlbaum Associates, Mahwah, NJ (2007). p. 327–40.
117. Spidel A, Vincent G, Huss MT, Winters J, Thomas L, and Dutton D. The psychopathic batterer: subtyping perpetrators of domestic violence. The psychopath: theory, research, and practice. Lawrence Erlbaum Associates, Mahwah (NJ). (2007) p.327–340.
118. Skeem JL and Mulvey EP. Psychopathy and community violence among civil psychiatric patients: results from the MacArthur Violence Risk Assessment Study. J Consulting Clin Psychol. (2001) 69:358–74. doi: 10.1037/0022-006X.69.3.358
119. Grann M, Långström N, Tengström A, and Kullgren G. Psychopathy (PCL-R) predicts violent recidivism among criminal offenders with personality disorders in Sweden. Law Hum Behav. (1999) 23:205–17. doi: 10.1023/a:1022372902241
120. Hastings ME, Krishnan S, Tangney JP, and Stuewig J. Predictive and incremental validity of the Violence Risk Appraisal Guide scores with male and female jail inmates. psychol Assess. (2011) 23:174–83. doi: 10.1037/a0021290
121. Walsh Z. Psychopathy and criminal violence: the moderating effect of ethnicity. Law Hum Behav. (2013) 37:303–11. doi: 10.1037/lhb0000017
122. Asscher JJ, van Vugt ES, Stams GJ, Deković M, Eichelsheim VI, and Yousfi S. The relationship between juvenile psychopathic traits, delinquency and (violent) recidivism: a meta-analysis. J Child Psychol psychiatry Allied disciplines. (2011) 52:1134–43. doi: 10.1111/j.1469-7610.2011.02412.x
123. Anderson DA. The aggregate cost of crime in the United States. J Law Econ. (2021) 64:857–85. doi: 10.1086/715713
124. Anderson DA. The aggregate burden of crime. J Law Econ. (1999) 42:611. doi: 10.2139/ssrn.147911
125. Dahlberg LL. Public health and violence: moving forward in a global context. In: Felthous AR and Sass H, editors. The Cambridge handbook of violent behavior and aggression. 2nd ed.. Cambridge (UK): Cambridge University Press; 2012. p.671–686
126. Kiehl KA and Hoffman MB. The criminal psychopath: History, neuroscience, treatment, and economics. Jurimetrics. (2011) 51:355.
127. Huss MT and Langhinrichsen-Rohling J. Assessing the generalization of psychopathy in a clinical sample of domestic violence perpetrators. Law Hum Behav. (2006) 30:571–86. doi: 10.1007/s10979-006-9052-x
128. Babiak P and Hare RD. Snakes in suits: When psychopaths go to work. New York, NY: Regan Books/Harper Collins Publishers (2006).
129. Mathieu C and Babiak P. Corporate psychopathy and abusive supervision: Their influence on employees' job satisfaction and turnover intentions. Pers Individ Dif. (2016) 91:102–6. doi: 10.1016/j.paid.2015.12.002
130. Boddy CR, Ladyshewsky R, and Galvin P. Leaders without ethics in global business: Corporate psychopaths. J Public Affairs. (2010) 10:121–38. doi: 10.1002/pa.352
131. Boddy CR. Corporate psychopaths, conflict, employee affective well-being and counterproductive work behaviour. J Business Ethics. (2014) 121:107–21. doi: 10.1007/s10551-013-1688-0
132. D'Souza M and Oliveira D. Corporate psychopaths: Implications for organizational health and well-being. Eur J Public Health. (2020) 30. doi: 10.1093/eurpub/ckaa166.648
133. Scherer KT, Baysinger M, Zolynsky D, and LeBreton JM. Predicting counterproductive work behaviors with sub-clinical psychopathy: Beyond the Five Factor Model of personality. Pers Individ Dif. (2013) 55:300–5. doi: 10.1016/j.paid.2013.03.007
134. Boddy CR, Ladyshewsky RK, and Galvin P. The influence of corporate psychopaths on corporate social responsibility and organizational commitment to employees. J Business Ethics. (2010) 97:1–19. doi: 10.1007/s10551-010-0492-3
135. Weiss B, Lavner JA, and Miller JD. Self- and partner-reported psychopathic traits’ relations with couples’ communication, marital satisfaction trajectories, and divorce in a longitudinal sample. Pers Disorders: Theory Research Treat. (2018) 9:239–49. doi: 10.1037/per0000233
136. Conti L, Fantasia S, Violi M, Dell'Oste V, Pedrinelli V, and Carmassi C. Emotional dysregulation and post-traumatic stress symptoms: which interaction in adolescents and young adults? A systematic review. Brain Sci. (2023) 13:1730. doi: 10.3390/brainsci13121730
137. Baker JS, Greendale GA, Hood MM, Karlamangla AS, and Harlow SD. Self-reported history of physical intimate partner violence and longitudinal cognitive performance in midlife women. Women's Health (London England). (2024) 20:17455057241309782. doi: 10.1177/17455057241309782
139. Seto MC, Khattar NA, Lalumière ML, and Quinsey VL. Deception and sexual strategy in psychopathy. Pers Individ Dif. (1997) 22:301–7. doi: 10.1016/S0191-8869(96)00212-7
140. Uzieblo K, Boelaert A, and Bijttebier P. (2011). The influence of psychopathy in fathers on their parenting and attachment style and on behavioral problems in the child, in: Bergen Conference on the Treatment of Psychopathy, Bergen, Norway.
141. Auty KM, Farrington DP, and Coid JW. Intergenerational transmission of psychopathy and mediation via psychosocial risk factors. Br J Psychiatry. (2015) 206:26–31. doi: 10.1192/bjp.bp.114.151050
142. Viding E and McCrory EJ. Genetic and neurocognitive contributions to the development of psychopathy. Dev Psychopathol. (2012) 24:969–83. doi: 10.1017/S095457941200048X
143. Tuvblad C, Bezdjian S, Raine A, and Baker LA. The heritability of psychopathic personality in 14- to 15-year-old twins: A multirater, multimeasure approach. psychol Assess. (2014) 26:704–16. doi: 10.1037/a0036711
144. Hyde LW, Waller R, Trentacosta CJ, Shaw DS, Neiderhiser JM, Ganiban JM, et al. Heritable and nonheritable pathways to early callous-unemotional behaviors. Am J Psychiatry. (2016) 173:903–10. doi: 10.1176/appi.ajp.2016.15111381
145. Waller R, Trentacosta CJ, Shaw DS, Neiderhiser JM, Ganiban JM, Reiss D, et al. Heritable temperament pathways to early callous–unemotional behaviour. Br J Psychiatry. (2016) 209:475–82. doi: 10.1192/bjp.bp.116.181503
146. Armoon B, Griffiths MD, Mohammadi R, and Ahounbar E. Inconsistent condom use and its associations among individuals with substance use disorders: A systematic review and meta-analysis. Sexuality Res Soc Policy: A J NSRC. (2025), 20. doi: 10.1007/s13178-025-01134-3
147. Gómez-Núñez MI, Molla-Esparza C, Gandia Carbonell N, and Badenes Ribera L. Prevalence of intoxicating substance use before or during sex among young adults: A systematic review and meta-analysis. Arch Sexual Behav. (2023) 52:2503–26. doi: 10.1007/s10508-023-02572-z
148. Klostermann K, Kelley ML, Mignone T, Pusateri L, and Fals-Stewart W. Partner violence and substance abuse: Treatment interventions. Aggression Violent Behav. (2010) 15:162–6. doi: 10.1016/j.avb.2009.10.002
149. Avallone F, Engler K, Cox J, Hickson F, and Lebouché B. Interventions, barriers, and facilitators to address the sexual problems of gay, bisexual and other men who have sex with men living with HIV: A rapid scoping review. AIDS Behav. (2024) 28:450–72. doi: 10.1007/s10461-023-04237-3
150. Hong JS, Voisin DR, Cho S, and Espelage DL. Association among subtypes of bullying status and sexually-risky behaviors of urban african american adolescents in Chicago. J Immigrant Minority Health. (2016) 18:1007–16. doi: 10.1007/s10903-016-0375-5
151. Dunn M and Yannessa J. The relationship between sexual intercourse before the age of 13 and alcohol, tobacco, and other drug use among high school students. J Drug Educ. (2022) 51:3–9. doi: 10.1177/00472379221111548
152. Davis KC, Neilson EC, Wegner R, and Danube CL. The intersection of men's sexual violence perpetration and sexual risk behavior: A literature review. Aggression Violent Behav. (2018) 40:83–90. doi: 10.1016/j.avb.2018.04.001
153. Lawler S, Stapinski L, Teesson M, Prior K, Basto-Pereira M, Newton N, et al. Unpacking violent behavior in young adulthood: The relative importance of hazardous alcohol use. J Interpersonal Violence. (2022) 37:NP18935–NP18959. doi: 10.1177/08862605211044103
154. Stuart GL, Temple JR, Follansbee KW, Bucossi MM, Hellmuth JC, and Moore TM. The role of drug use in a conceptual model of intimate partner violence in men and women arrested for domestic violence. Psychol Addictive Behav. (2008) 22:12–24. doi: 10.1037/0893-164X.22.1.12
155. Barrett S, Muir C, Burns S, Adjei N, Forman J, Hackett S, et al. Interventions to reduce parental substance use, domestic violence and mental health problems, and their impacts upon children’s well-being: A systematic review of reviews and evidence mapping. Trauma Violence Abuse. (2024) 25:393–412. doi: 10.1177/15248380231153867
156. Köck P and Walter M. Personality disorder and substance use disorder—An update. Ment Health Prev. (2018) 12:82–9. doi: 10.1016/j.mhp.2018.10.003
157. McNeill-Johnson AD, Glenn J, Daniel NI, Menon M, Aboul-Enein BH, Kelly PJ, et al. A scoping review of sexual and reproductive health interventions with youth in U.S. juvenile facilities. J Adolesc Health. (2025) 76:798–806. doi: 10.1016/j.jadohealth.2024.12.012
158. Sousa M, Andrade J, de Castro Rodrigues A, Caridade S, and Cunha O. The effectiveness of intervention programs for perpetrators of intimate partner violence with substance abuse and/or mental disorders: A systematic review. Trauma Violence Abuse. (2024) 25:4188–203. doi: 10.1177/15248380241270063Spidel
159. Vincent SR, Graupman EE, McGarrigle W, and Kosson DS. Psychopathy traits explain variance shared between features of substance use disorders and violence. Criminal Behav Ment Health. (2024) 34:431–45. doi: 10.1002/cbm.2353
160. Brem MJ, Florimbio AR, Elmquist J, Shorey RC, and Stuart GL. Antisocial traits, distress tolerance, and alcohol problems as predictors of intimate partner violence in men arrested for domestic violence. Psychol Violence. (2018) 8:132–9. doi: 10.1037/vio0000088
161. Beaulieu M, Tremblay J, Baudry C, Pearson J, and Bertrand K. A systematic review and meta-analysis of the efficacy of the long-term treatment and support of substance use disorders. Soc Sci Med. (2021) 285:114289. doi: 10.1016/j.socscimed.2021.114289
162. Graves BD and Fendrich M. Community-based substance use treatment programs for reentering justice-involved adults: A scoping review. Drug Alcohol Depend Rep. (2024) 10:100221. doi: 10.1016/j.dadr.2024.100221
163. López G, Orchowski LM, Reddy MK, Nargiso J, and Johnson JE. A review of research-supported group treatments for drug use disorders. Subst Abuse treatment prevention Policy. (2021) 16:51. doi: 10.1186/s13011-021-00371-0
164. Reif S, George P, Braude L, Dougherty RH, Daniels AS, Ghose SS, et al. Residential treatment for individuals with substance use disorders: assessing the evidence. Psychiatr Serv (Washington D.C.). (2014) 65:301–12. doi: 10.1176/appi.ps.201300242
165. Simoneau H, Kamgang E, Tremblay J, Bertrand K, Brochu S, and Fleury MJ. Efficacy of extensive intervention models for substance use disorders: A systematic review. Drug Alcohol Rev. (2018) 37:S246–62. doi: 10.1111/dar.12590
166. Tran K and McGill S. Treatment programs for substance use disorder. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health (2021).
167. Basu D, Sarkar S, and Mattoo SK. Psychiatric comorbidity in patients with substance use disorders attending an addiction treatment center in India over 11 years: Case for a specialized "dual diagnosis clinic. J Dual Diagnosis. (2013) 9:23–9. doi: 10.1080/15504263.2012.749557
168. Perry AE, Martyn-St James M, Burns L, Hewitt C, Glanville JM, Aboaja A, et al. Interventions for drug-using offenders with co-occurring mental health problems. Cochrane Database Systematic Rev. (2019) 10. doi: 10.1002/14651858.CD010901.pub3
169. Hasin D and Kilcoyne B. Comorbidity of psychiatric and substance use disorders in the United States: current issues and findings from the NESARC. Curr Opin Psychiatry. (2012) 25:165–71. doi: 10.1097/YCO.0b013e3283523dcc
170. Trull TJ, Solhan MB, Brown WC, Tomko RL, Schaefer L, McLaughlin KD, et al. Substance use disorders and personality disorders. In: Sher KJ, editor. The Oxford handbook of substance use and substance use disorders. Oxford, England, UK: Oxford University Press (2016). p. 116–48.
171. Aguilar-Quesada A, Sierra-Yagüe A, González-Cano-Caballero M, Zafra-Egea JA, and Lima-Serrano M. Effectiveness of digital interventions to reduce school-age adolescent sexual risks: A systematic review. J Nurs Scholarship. (2025) 57:342–53. doi: 10.1111/jnu.13015
172. McCuistian C, Peteet B, Burlew K, and Jacquez F. Sexual health interventions for racial/ethnic minorities using community-based participatory research: A systematic review. Health Educ Behav. (2023) 50:107–20. doi: 10.1177/10901981211008378
173. Wand H, Reddy T, Moodley J, Naidoo S, and Ramjee G. Review of impact of risk reduction sessions on sexual behaviors in HIV prevention trials: Insights from Africa. Arch Sexual Behav. (2025) 54:805–15. doi: 10.1007/s10508-024-03052-8
174. Zapata JP, Rapoport A, Wescott A, Gandhi S, Bergstrom TC, Avila AA, et al. Single-session interventions to enhance hiv outcomes among adolescents and young adults: A systematic scoping review and implications for integrating HIV and mental health services. AIDS Behav. (2025), 29. doi: 10.1007/s10461-025-04834-4
175. Frías Á., Palma C, Farriols N, and González L. Sexuality-related issues in borderline personality disorder: A comprehensive review. Pers Ment Health. (2016) 10:216–31. doi: 10.1002/pmh.1330
176. Mangassarian S, Sumner L, and O'Callaghan E. Sexual impulsivity in women diagnosed with borderline personality disorder: A review of the literature. Sexual Addict Compulsivity. (2015) 22:195–206. doi: 10.1080/10720162.2015.1017781
177. Villalobos Gallegos L, Medina Mora ME, Benjet C, Ruiz Velasco S, Magis Rodriguez C, and Marín Navarrete R. Multidimensional patterns of sexual risk behavior and psychiatric disorders in men with substance use disorders. Arch Sexual Behav. (2019) 48:599–607. doi: 10.1007/s10508-018-1227-2
178. Backhaus S, Blackwell A, and Gardner F. The effectiveness of parenting interventions in reducing violence against children in humanitarian settings in low- and middle-income countries: A systematic review and meta-analysis. Child Abuse Negl. (2025) 162:1–15. doi: 10.1016/j.chiabu.2024.106850
179. Borduin CM. Multisystemic treatment of criminality and violence in adolescents. J Am Acad Child Adolesc Psychiatry. (1999) 38:242–9. doi: 10.1097/00004583-199903000-00009
180. de Moura JQ, Sarrat MM, Dupont MF, Romero JA, Murta SG, and Habigzang LF. Intervenções baseadas em evidências para a prevenção da violência no namoro: Revisão sistemática [Evidence-based interventions for the prevention of dating violence: Systematic review. Avances en Psicología Latinoamericana. (2025) 43:1–24. doi: 10.12804/revistas.urosario.edu.co/apl/a.12170
181. Karakurt G, Koc E, D'Silva R, Oğuztüzün Ç., Choudhary A, Goto T, et al. Systematic review on the treatment of emotional abuse victimization in women by an intimate partner. J Family Violence. (2025). doi: 10.1007/s10896-025-00891-4
182. Mora-Pelegrín M, Aranda M, and Montes-Berges B. Emotional skills and health assessment in interventions for intimate partner violence perpetrators: A systematic review of randomized controlled trials. PloS One. (2025) 20:Article e0328034. doi: 10.1371/journal.pone.0328034
183. Owens J, Aboul-Enein BH, Bernstein J, Dodge E, and Kelly PJ. Reducing violence against women and girls in the Arab league: A systematic review of preventive interventions. Trauma Violence Abuse. (2024) 25:2219–33. doi: 10.1177/15248380231207902
184. Papalia N, Spivak B, Daffern M, and Ogloff JRP. Are psychological treatments for adults with histories of violent offending associated with change in dynamic risk factors? A meta-analysis of intermediate treatment outcomes. Criminal Justice Behav. (2020) 47:1585–608. doi: 10.1177/0093854820956377
185. Cunha O, Pedrosa J, Silva Pereira B, Caridade S, de Castro Rodrigues A, and Braga T. Intervention program dropout among perpetrators of intimate partner violence: A meta-analysis of correlated variables. Trauma Violence Abuse. (2024) 25:2735–51. doi: 10.1177/15248380231224036
186. Mitchell JE and Wupperman P. Mindfulness treatments for domestic violence: A review. J Aggression Maltreatment Trauma. (2023), 32. doi: 10.1080/10926771.2022.2038752
187. Shaw J and Edelmann R. Personality disorder, treatment readiness and dropout from treatment in three community-based cognitive skills and violence reduction programmes. J Forensic Pract. (2017) 19:247–57. doi: 10.1108/JFP-05-2017-0017
188. Brown D, Larkin F, Sengupta S, Romero-Ureclay JL, Ross CC, Gupta N, et al. Clozapine: An effective treatment for seriously violent and psychopathic men with antisocial personality disorder in a UK high-security hospital. In: Warburton KD and Stahl SM, editors. Violence in psychiatry. Cambridge, England, UK: Cambridge University Press (2016). p. 187–201.
189. Pinto e Silva T, Gouveia C, Santirso FA, Cunha O, and Caridade S. Effectiveness of motivational interviewing with justice-involved people: A systematic review and meta-analysis. Psychosocial Intervention. (2025) 34:89–102. doi: 10.5093/pi2025a8
190. McGuire J. A review of effective interventions for reducing aggression and violence. Philosophical Transactions of the Royal Society of London. Ser B Biol Sci. (2008) 363:2577–97. doi: 10.1098/rstb.2008.0035
191. Fazel S, Burghart M, Wolf A, Whiting D, and Yu R. Effectiveness of violence prevention interventions: Umbrella review of research in the general population. Trauma Violence Abuse. (2024) 25:1709–18. doi: 10.1177/15248380231195880
192. Gamelia E, Widjanarko B, and Shaluhiyah Z. Systematic review: Risk sexual behavior, sexually transmitted infections, and adolescent pregnancy prevention interventions. J Public Health Afr. (2023) 14:2672. doi: 10.4081/jphia.2023.2672
193. Lee AH and DiGiuseppe R. Anger and aggression treatments: A review of meta-analyses. Curr Opin Psychol. (2018) 19:65–74. doi: 10.1016/j.copsyc.2017.04.004
194. Loureiro F, Ferreira M, Sarreira-de-Oliveira P, and Antunes V. Interventions to promote a healthy sexuality among school adolescents: A scoping review. J Personalized Med. (2021) 11:1155. doi: 10.3390/jpm11111155
195. McGovern MP and Carroll KM. Evidence-based practices for substance use disorders. Psychiatr Clinics North America. (2003) 26:991–1010. doi: 10.1016/s0193-953x(03)00073-x
196. Pedlow CT and Carey MP. Developmentally appropriate sexual risk reduction interventions for adolescents: Rationale, review of interventions, and recommendations for research and practice. Ann Behav Med. (2004) 27:172–84. doi: 10.1207/s15324796abm2703_5
197. Sinclair DL, Chantry M, De Ruysscher C, Magerman J, Nicaise P, and Vanderplasschen W. Recovery-supportive interventions for people with substance use disorders: A scoping review. Front Psychiatry. (2024) 15:1352818. doi: 10.3389/fpsyt.2024.1352818
198. Wigham S, McGovern R, Kaner E, and Hackett SS. A review of recent innovation in psychosocial interventions for reducing, violence and aggression in adults using a horizon scanning approach. Aggression Violent Behav. (2022) 62:101685. doi: 10.1016/j.avb.2021.101685
199. Chow RTS, Yu R, Geddes JR, and Fazel S. Personality disorders, violence and antisocial behaviour: updated systematic review and meta-regression analysis. Br J Psychiatry. (2025) 227:481–91. doi: 10.1192/bjp.2024.226
200. O’Brien K and Daffern M. The impact of pre-treatment responsivity and treatment participation on violent recidivism in a violent offender sample. Psychology Crime Law. (2016) 22:777–97. doi: 10.1080/1068316X.2016.1181177
201. Reidy DE, Kearns MC, and DeGue S. Reducing psychopathic violence: A review of the treatment literature. Aggression Violent Behav. (2013) 18:527–38. doi: 10.1016/j.avb.2013.07.008
202. Eckhardt C, Holtzworth-Munroe A, Norlander B, Sibley A, and Cahill M. Readiness to change, partner violence subtypes, and treatment outcomes among men in treatment for partner assault. In: Murphy CM and Maiuro RD, editors. Motivational interviewing and stages of change in intimate partner violence. New York, NY, USA: Springer Publishing Company (2009). p. 89–131.
203. Taft CT, Murphy CM, Musser PH, and Remington NA. Personality, interpersonal, and motivational predictors of the working alliance in group cognitive-behavioral therapy for partner violent men. J Consulting Clin Psychol. (2004) 72:349–54. doi: 10.1037/0022-006X.72.2.349
204. Maldonado AI and Murphy CM. Readiness to change as a predictor of treatment engagement and outcome for partner violent men. J Interpersonal Violence. (2021) 36:3041–64. doi: 10.1177/0886260518770188
205. Harpur TJ, Hare RD, and Hakstian AR. Two-factor conceptualization of psychopathy: Construct validity and assessment implications. Psychol Assess. (1989) 1:6–17. doi: 10.1037/1040-3590.1.1.6
206. Olver ME, Lewis K, and Wong SC. Risk reduction treatment of high-risk psychopathic offenders: The relationship of psychopathy and treatment change to violent recidivism. Pers Disorders: Theory Research Treat. (2013) 4:160–7. doi: 10.1037/a0029769
207. Rock RC, Sellbom M, Ben-Porath YS, and Salekin RT. Concurrent and predictive validity of psychopathy in a batterers' intervention sample. Law Hum Behav. (2013) 37:145–54. doi: 10.1037/lhb0000006
208. Frick PJ. Extending the construct of psychopathy to youth: Implications for understanding, diagnosing, and treating antisocial children and adolescents. Can J Psychiatry. (2009) 54:803–12. doi: 10.1177/070674370905401203
209. Salekin R.t. Psychopathy and therapeutic pessimism: Clinical lore or clinical reality? Clin Psychol Rev. (2002) 22:79–112. doi: 10.1016/S0272-7358(01)00083-6
210. Fleming GE, Neo B, Briggs NE, Kaouar S, Frick PJ, and Kimonis ER. Parent training adapted to the needs of children with callous–unemotional traits: A randomized controlled trial. Behav Ther. (2022) 53:1265–81. doi: 10.1016/j.beth.2022.07.001
211. Kimonis ER, Fleming G, Briggs N, Brouwer-French L, Frick PJ, Hawes DJ, et al. Parent-child interaction therapy adapted for preschoolers with callous-unemotional traits: An open trial pilot study. J Clin Child Adolesc Psychol. (2019) 48:S347–61. doi: 10.1080/15374416.2018.1479966
212. Caldwell M, McCormick D, and Umstead D. Evidence of treatment progress and therapeutic outcomes among adolescents with psychopathic features. Criminal Justice Behav. (2007) 34:573–87. doi: 10.1177/0093854806297511
213. Ribeiro da Silva D, Rijo D, Brazão N, Paulo M, Miguel R, Castilho P, et al. The efficacy of the PSYCHOPATHY.COMP program in reducing psychopathic traits: A controlled trial with male detained youth. J Consulting Clin Psychol. (2021) 89:499–513. doi: 10.1037/ccp0000659
214. Ribeiro da Silva D, Rijo D, Salekin RT, Paulo M, Miguel R, and Gilbert P. Clinical change in psychopathic traits after the PSYCHOPATHY.COMP program: Preliminary findings of a controlled trial with male detained youth. J Exp Criminology. (2021) 17:397–421. doi: 10.1007/s11292-020-09418-x
215. Wilson N and Kilgour G. The High Risk Personality Programme - Revised: An evaluation report. Practice: New Z Corrections J. (2015) 3. Available online at: https://www.corrections.govt.nz/resources/research/journal/volume_3_issue_2_december_2015_evidence_based_practice/the_high_risk_personality_programme_revised_an_evaluation_report (Accessed October 13, 2025).
216. Wilson NJ and Tamatea A. Challenging the 'urban myth' of psychopathy untreatability: The High-Risk Personality Programme. Psychology Crime Law. (2013) 19:493–510. doi: 10.1080/1068316X.2013.758994
217. Tew J, Dixon L, Harkins L, and Bennett A. Investigating changes in anger and aggression in offenders with high levels of psychopathic traits attending the Chromis violence reduction programme. Criminal Behav Ment Health. (2012) 22:191–201. doi: 10.1002/cbm.1832
218. Frick PJ and White SF. Research review: The importance of callous-unemotional traits for developmental models of aggressive and antisocial behavior. J Child Psychol Psychiatry. (2008) 49:359–75. doi: 10.1111/j.1469-7610.2007.01862.x
219. Waller R, Gardner F, and Hyde LW. What are the associations between parenting, callous-unemotional traits, and antisocial behavior in youth? A systematic review of evidence. Clin Psychol Rev. (2013) 33:593–608. doi: 10.1016/j.cpr.2013.03.001
220. Kochanska G, Kim S, Boldt LJ, and Yoon JE. Children's callous-unemotional traits moderate links between their positive relationships with parents at preschool age and externalizing behavior problems at early school age. J Child Psychol Psychiatry. (2013) 54:1251–60. doi: 10.1111/jcpp.12084
221. Alawag G. Psychopathic personality weakens the efficacy of anti-bribery interventions. (2024). doi: 10.2139/ssrn.4952214
222. Caldwell M, McCormick D, Wolfe J, and Umstead D. Treatment-related changes in psychopathy features and behavior in adolescent offenders. Criminal Justice Behav. (2012) 39:144–55. doi: 10.1177/0093854811429542
223. McDonald R, Dodson MC, Rosenfield D, and Jouriles EN. Effects of a parenting intervention on features of psychopathy in children. J Abnormal Child Psychol. (2011) 39:1013–23. doi: 10.1007/s10802-011-9512-8
224. Fleming GE, Neo B, Kaouar S, and Kimonis ER. Treatment outcomes of children with primary versus secondary callous-unemotional traits. Res Child Adolesc Psychopathol. (2023) 51:1581–94. doi: 10.1007/s10802-023-01112-6
225. Fanti KA, Demetriou CA, Petridou M, Mavrommatis I, Sikki M, and Kimonis E. Correctly identifying and reacting to others’ sadness: Investigating three parent-child interventions for limited prosocial emotions. Eur J Dev Psychol. (2024) 21:258–74. doi: 10.1080/17405629.2024.2317384
226. Fekih-Romdhane F, Hsini A, Aouina AA, Ridha R, and Cheour M. Correlates of psychopathy in a Tunisian sample of incarcerated women. J Forensic Legal Med. (2021) 82:102232. doi: 10.1016/j.jflm.2021.102232
227. Gatner DT, Blanchard AJE, Douglas KS, Lilienfeld SO, and Edens JF. Psychopathy in a multiethnic world: Investigating multiple measures of psychopathy in Hispanic, African American, and Caucasian offenders. Assessment. (2018) 25:206–21. doi: 10.1177/1073191116639374
228. Vachon DD, Lynam DR, Loeber R, and Stouthamer-Loeber M. Generalizing the nomological network of psychopathy across populations differing on race and conviction status. J Abnormal Psychol. (2012) 121:263–9. doi: 10.1037/a0024683
229. DeMatteo D and Olver ME. Use of the Psychopathy Checklist-Revised in legal contexts: Validity, reliability, admissibility, and evidentiary issues. J Pers Assess. (2022) 104:234–51. doi: 10.1080/00223891.2021.1955693
230. van Bommel R, Uzieblo K, Bogaerts S, and Garofalo C. Psychopathic traits and deviant sexual interests: The moderating role of gender. Int J Forensic Ment Health. (2018) 17:256–71. doi: 10.1080/14999013.2018.1499684
231. Ishikawa SS, Raine A, Lencz T, Bihrle S, and Lacasse L. Autonomic stress reactivity and executive functions in successful and unsuccessful criminal psychopaths from the community. J Abnormal Psychol. (2001) 110:423–32. doi: 10.1037//0021-843x.110.3.423
232. Gillespie SM, Jones A, and Garofalo C. Psychopathy and dangerousness: An umbrella review and meta-analysis. Clin Psychol Rev. (2023) 100:102240. doi: 10.1016/j.cpr.2022.102240
233. De Brito SA, Forth AE, Baskin-Sommers AR, Brazil IA, Kimonis ER, Pardini D, et al. Psychopathy. Nat Rev Dis Primers. (2021) 7:49.
234. LeBreton JM, Binning JF, and Adorno AJ. “Subclinical psychopaths,”. In: Thomas JC, Segal DL, and Hersen M, editors. Comprehensive handbook of personality and psychopathology, Vol. 1: Personality and everyday functioning. John Wiley & Sons, New York (2006). p. 388–411.
235. Helfgott JB, Hickman MJ, Beck S, Atherly LT, Kosson DS, and Dorscher E. The relationship between personality traits and the effectiveness of guardian law enforcement training. J Forensic Psychol Res Pract. (2022) 23:1–29. doi: 10.1080/24732850.2022.2028392
236. Preston OC, Butterworth SE, Khazem LR, Houtsma C, Anestis MD, Green BA, et al. Exploring the relations of psychopathic and narcissistic personality traits to military experiences in National Guard personnel. Pers Individ Dif. (2020) 152:109554. doi: 10.1016/j.paid.2019.109554
Keywords: psychopathic, substance misuse, sexual risk, violence, public health
Citation: Chinchilla MA, Reidy DE and Kosson DS (2026) Psychopathy is a neglected public health problem. Front. Psychiatry 16:1657080. doi: 10.3389/fpsyt.2025.1657080
Received: 30 June 2025; Accepted: 12 November 2025; Revised: 05 November 2025;
Published: 07 January 2026.
Edited by:
Paweł Dębski, Medical University of Silesia, PolandReviewed by:
Krzysztof Nowakowski, Jesuit University Ignatianum in Krakow, PolandYiheng Lin, Shanghai Jiao Tong University, China
Alora McCarthy, Center for Justice Research and Policy, United States
Copyright © 2026 Chinchilla, Reidy and Kosson. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: David S. Kosson, ZGF2aWQua29zc29uQHJvc2FsaW5kZnJhbmtsaW4uZWR1