Brain self-regulation in criminal psychopaths

Psychopathic individuals are characterized by impaired affective processing, impulsivity, sensation-seeking, poor planning skills and heightened aggressiveness with poor self-regulation. Based on brain self-regulation studies using neurofeedback of Slow Cortical Potentials (SCPs) in disorders associated with a dysregulation of cortical activity thresholds and evidence of deficient cortical functioning in psychopathy, a neurobiological approach seems to be promising in the treatment of psychopathy. The results of our intensive brain regulation intervention demonstrate, that psychopathic offenders are able to gain control of their brain excitability over fronto-central brain areas. After SCP self-regulation training, we observed reduced aggression, impulsivity and behavioral approach tendencies, as well as improvements in behavioral-inhibition and increased cortical sensitivity for error-processing. This study demonstrates improvements on the neurophysiological, behavioral and subjective level in severe psychopathic offenders after SCP-neurofeedback training and could constitute a novel neurobiologically-based treatment for a seemingly change-resistant group of criminal psychopaths.

research overview see 3 ). Patients with severe epilepsy show no SCP self-regulation in the first training sessions comparable to the psychopathic group of this study.
Interestingly, the same pattern as in the ADHD-study of Strehl and colleagues 1 was found in our psychopathic sample, with difficulties to produce the correct polarities at the beginning of the training, especially in the transfer condition; however, our psychopathic patients learned to produce the correct polarities at the end of the training and could increase the SCPdifferentiation also in the transfer condition. In line with many SCP-studies in clinical samples e.g. 1,6,7 , we found smaller SCP differentiations in the transfer compared to the feedback condition.
Based on the results of a meta-analysis, including studies showing the superiority of neurofeedback training compared to non-treatment e.g. 8 or other treatments e.g. 9 , Arns and colleagues 10 concluded -with respect to ADHD-that neurofeedback can be considered as an efficacious and specific treatment regarding inattention, impulsivity and hyperactivity.

(B) Design of clinical-effect studies in psychopathic offenders
From a methodological point of view, a double blind controlled design is warranted to prove clinical effectivity. In such a design matched participants would have received (a) a psychological/behavioral treatment or (b) psychophysiological feedback based on another EEG parameter, like alpha activity; or sham SCP-feedback or feedback from electromyographical activity, as a control strategy. The aim of this study was to investigate the self-regulation abilities and related behavioral outcomes in highly psychopathic patients, have required at least an age-, psychopathy-and offence-matched control group, which is not available in the German forensic hospitals (note that our sample already consisted of offenders with high psychopathy scores and extreme crimes, exceeding markedly the proposed cut-off score for German 11 and European 12 psychopathic samples). The comparison between our highly psychopathic group with severe and multiple offences and a group consisting of participants with less severe offences or low scores on the PCL-R might have revealed specific differences, but cannot be regarded as a matched control group. In addition, blinding of therapists in self-regulation treatment is impossible, because patients and therapists are continuously informed of the achieved brain changes, which leads to conscious or subliminal perception of treatment progress and therefore uncontrolled placebo responses.
Placebo effects of SCP-training were excluded in most of the previous studies with healthy and psychopathological samples and different types of control procedures 2 . The physiological nature of the task, the extensive training time and the neurobiological measure limits the possibilities of placebo response, but certainly cannot exclude them completely.
Whether the modification of the cognitive and emotional behavior measured in this sample is sufficient for the compensation of the emotional and social deficits in psychopathy, is an empirical question and needs larger sample sizes -a significant limitation of the present study.
We split our sample at the median of the Total PCL-R score in to 'very high' and 'medium to high' psychopathy, but did not find any significant differences regarding the SCP-regulation performance, neither for the feedback (T(13)=.283, p=.782), nor for the transfer (T(13)=.247, p=.809) condition between the two groups. Besides the expected, highly significant correlation between the regulation performance in the two conditions (feedback, transfer) (R=.784, p=.001), correlational analysis revealed no significant relationships between the regulation performance and the PCL-R score, neither for feedback (R=-.369, p=.195), nor for transfer (R=-.348, p=.223). The result, that we did not find any significant correlations with the PCL-R scores, can be due to the lack of variation of PCL-R scores as a consequence of the extreme psychopathy values of this group ("plafond effect"). Accordingly, these findings point towards an ability to learn brain self-regulation in high and less-high psychopathic offenders.
Besides questionable validity of staff observations inside prisons or high security forensic

C) Study Subject Recruiting
Only participants with a PCL-R score of ≥ 26 were accepted in the study, which is above the proposed cut-off score for the German and European samples 11,12. .
Only patients according to section §63 or §66 of the German Criminal Law were recruited for this study.

Section 63: Placement in a Psychiatric Hospital
If someone committed an unlawful act and at the time lacked capacity to be adjudged guilty (Section 20) or was in a state of diminished capacity (Section 21), the court shall order placement in a psychiatric hospital if a comprehensive evaluation of the perpetrator and his act reveals that, as a result of his condition serious unlawful acts can be expected of him and he therefore presents a danger to the general public.

Section 20: Lack of Capacity to be Adjudged Guilty due to Emotional Disorders
Whoever upon commission of the act is incapable of appreciating the wrongfulness of the act or acting in accordance with such appreciation due to a pathological emotional disorder, profound consciousness disorder, mental defect or any other serious emotional abnormality, acts without guilt.

Section 21: Diminished Capacity to be Adjudged Guilty
If the capacity of the perpetrator to appreciate the wrongfulness of the act or to act in accordance with such appreciation is substantially diminished upon commission of the act due to one of the reasons indicated in Section 20, then the punishment may be mitigated pursuant to Section 49 subsection (1).

Section 66 Placement in Preventive Detention
(1) If someone is sentenced for an intentional crime to a fixed term of imprisonment of at least two years, then the court shall order preventive detention collateral to the punishment, if: (2) If someone has committed three intentional crimes for which he incurred, respectively, imprisonment for at least one year, and if he is sentenced to a fixed term of imprisonment of at least three years for one or more of these acts, then the court may under the provision indicated in subsection (1), no. 3, order preventive detention collateral to the punishment even without a prior sentence or deprivation of liberty (subsection (1), nos. 1 and 2).  Tab. 2: In the first two lines, every cell consists of the Mean µV for the first, respectively the last 6 training sessions, and the standard deviation (sd) in italic. The related T-value, including the degrees of freedom in parentheses and subscripted, as well as the P-value is depicted in line three and four.

d2) Regression Analysis over 25 SCP-Training Sessions
Regarding the learning process over the whole 25 SCP-sessions, regression analysis showed a significant increase in negative SCP-shifts in the feedback condition (R = -.347, p = .045), but not in positive SCPs in the feedback condition, as depicted in Table 3. Regarding the transfer condition, a trend for an increase in positive SCP amplitude was found (R = .320, p = .059), while the amplitude of negative SCP increased only minimal over time. Tab. 3: In the first lines the correlation coefficient R is presented. The second line depicts the P-value of the regression.
For all polarity-sensitive analysis which are not based on SCP differentiation, but on separate analysis differentiating negative and positive SCP shifts, the setup of the training-protocol including its different phases (first phases 50% : 50% negativity/positivity; second phase 80% : 20%) has to be considered.