Looking For The Hannibal Behind The Cannibal

Articles
International Journal of
Offender Therapy and
Looking for the Hannibal Comparative Criminology
55(3) 350369
Behind the Cannibal: 2011 SAGE Publications
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DOI: 10.1177/0306624X10362659
Case Research http://ijo.sagepub.com
Aina Sundt Gullhaugen1,2 and

Jim Aage Nttestad1,2
Abstract
The character Hannibal the Cannibal Lecter, best known from the motion picture The
Silence of the Lambs from 1991, has become a cultural icon and model for later portrayals
of seriously disturbed offenders. He displays key characteristics of the Psychopathy
ChecklistRevised, such as arrogance, manipulation, callousness, and lack of remorse.
From a clinical point of view, one of the most fascinating aspects with Lecter is his
display of a variety of capacities alternating between cold-blooded predatory behavior,
affection toward FBI special agent Starling, and mourning of the loss of his sister Mischa.
Many authors have described the ruthless characteristics of the psychopath. Through
the lens of object relations theory, this review systematically examines case descriptions
of severely psychopathic offenders published between 1980 and March 2009. In contrast
to the prevalent opinion, case material (n = 11) demonstrates that severely psychopathic
offenders do suffer from psychological pain.
Keywords
psychopathy, PCL-R, psychological pain, object relations, defense
Introduction
We cannot treat, except empirically, what we do not understand and we cannot prevent,
except fortuitously, what we do not comprehend.
Brittain, 1970, p. 206
1
St. Olavs University Hospital, Trondheim, Norway
2
The Norwegian University of Science and Technology (NTNU), Trondheim, Norway
Corresponding Author:
Aina Sundt Gullhaugen, Forensic Department Broset, Center for Research and Education in Forensic
Psychiatry, St. Olavs University Hospital, P.O. 1803 Lade, Trondheim, Norway, N-7440
Email: aina.gullhaugen@svt.ntnu.no
Downloaded from ijo.sagepub.com at PENNSYLVANIA STATE UNIV on March 5, 2016

Gullhaugen and Nttestad 351
A problem facing clinical personnel working with psychopathic offenders has been the
view that these individuals cannot be treated (see Gacono, Nieberding, Owen, Rubel,
& Bodholdt, 1997, and Salekin, 2002, for a review of the literature). One reason for
this may originate from research where personality is described as a stable condition
(Roberts & DelVecchio, 2000). Psychopathy in this context is a static personality dis-
order variable in risk assessment (Webster, Douglas, Eaves, & Hart, 1997). Furthermore,
studies using interventions that are neither sufficient nor necessary for personality
disorder issues (Harris, Rice, & Cormier, 1991) have influenced todays understand-
ing of psychopathy to a disproportionate degree. However, the single most decisive
reason for the pessimistic stance on treatment probably stems from intuitively appeal-
ing and enduring notions such as psychopaths do not suffer (in the words of Cleckley,
1988: Mature, wholehearted anger, true or consistent indignation, honest solid grief,
sustaining pride, deep joy, and genuine despair are reactions not likely to be found
within this scale, p. 348) and thus have no motivation to change. As a consequence,
many clinicians abandoned the curative treatment model, and the psychopath became
the least loved patient (Strasburger, 1986, p. 191).
Considering the fact that we lack an integrated understanding of and an empirically
supported treatment for psychopathy, we should be searching for new ways of address-
ing the problem. And because some of the most interesting research comes from
hypotheses that challenge what we believe today (Popper, 1963), it seems relevant to
dispute that psychopathy and suffering are mutually exclusive constructs. But how
and where to look for psychological vulnerability and pain in psychopaths?
The approach must be different from earlier research comparing psychopaths and
nonpsychopaths in experimental and artificial settings (capturing the physiological
hyporeactivity or callousness of the psychopath; Stanford, Houston, & Barrat, 2007),
and comorbidity ratings, where results are mixed (Hale, Goldstein, Abramowitz,
Calamari, & Kosson, 2004). Furthermore, one would have to omit the biogenetic
concept of callousness (Blair, Mitchell, & Blair, 2005), because this concept, and the
interpretation of it, rests on a static idea of personality. Looking for vulnerability and
pain in psychopaths implies searching for some sort of subjective discomfort (cf.
World Health Organization [WHO] general criteria for personality disorder; WHO,
1993) that does not necessarily meet the specificity of the psychiatric nomenclature,
nor reflect the usual conceptions of vulnerability and pain. Finally, a sound theoretical
understanding of how vulnerability and pain might manifest itself in the psychopathic
individual will need to be presented.
The Psychopath in Interpersonal Relations

Examining case information with a theoretical anchor in the object relations tradition
provides a naturalistic and interpersonal framework for analyzing vulnerability and
pain in individuals often characterized as lacking in profound relationships (Psychopathy
Check ListRevised [PCL-R], Item 17; Hare, 2003). Generally speaking, personality
disorder is characterized by stable states and behavioral patterns that seem to express

352 International Journal of Offender Therapy and Comparative Criminology 55(3)
a persons typical lifestyle and way of relating toward oneself and others (WHO,
1993). The observed rigidness often attracts more attention than the interpersonal
dynamics of the disease. But symptoms will never be purely static, as we are always
what we are in relation to something. We should ask: Is the psychopath nothing but an
isolated and unaffected antisocial organism, or is he or she rather immersed in and
influenced by a relational web of human interaction, just like anyone else? With a
mask of sanity that Cleckley saw and others now recognize hides the psychopaths
pathology, which is a source not only of consternation for others but also of pain and
sadness for him (Reid, 1986, p. X). This clinical experience by Reid differs markedly
from the view of Cleckley (1988), has never been tested, and may be easily dismissed
as clinical anecdotes and theoretical speculations (Weiss, 1987). Through the lens of
object relations theory, this article reviews case descriptions of severely psychopathic
offenders to test whether these individuals suffer and experience psychological pain in
interpersonal relations. For additional illustrative purposes, author Tomas Harriss
fictitious character Hannibal Lecter is used to highlight this important aspect of the
psychopaths functioning.
Lecter is a gifted and highly educated health professional, and a cunning murderer,
sometimes torturing and cannibalizing his victims without regret. Behind a well-
articulated, impressive appearance lurks a ruthless character that has been referenced
in scientific articles (Gacono, 1992; Gregory, 2002; Patrick & Zempolich, 1998) and
has become a cultural icon influencing later portrayals of seriously disturbed offend-
ers. He is callous, arrogant, manipulative, and lacks empathy and remorse. These are
central items in todays gold standard for assessing psychopathy, the PCL-R (Hare,
2003). Confer the ICD-10 F60.2 Dissocial personality disorder (WHO, 1994) for the
closest we get to a diagnostic description of the disorder.
Thomas Harris has not revealed to what extent he researched the psychopathic
personality in the process of creating Hannibal Lecter. According to an electronic
article by author Anthony Bruno (n.d.), Harris did research at the FBIs Behavioral
Science Unit and learned the specifics of serial murderers and their habits from real
profilers. Bruno establishes as probable that the fictional Lecter character is a com-
posite of many of the characteristics of real murderers by illustrating how the character
resembles real-life serial killers such as Jeffrey Dahmer, who was profiled by the FBI,
and by referring to Sexton (2001), who reports that Harris at some point told a librar-
ian in his hometown of Cleveland, Mississippi, that Lecter was inspired by a local
murderer named William Coyne, whose crimes included acts of cannibalism.
An examination of Harriss four novels about Lecter (1981, 1988, 1999, 2006)
makes it evident that the character fulfils 8 of 10 items of the PCL-R Factor 1 criteria
(the interpersonal and affective domain) and also 4 of 10 items of the criteria from
Factor 2 (the behavioral domain), which gives the character a PCL-R total score of 24
(Max = 40). In addition, his lack of intimate relationships may indicate a limited
attachment capacity that corresponds to a tendency to engage in many short-term rela-
tionships (PCL-R, Item 17) and hence may describe a symptom not accounted for by
the PCL-R but included in risk assessment instruments (Webster et al., 1997). Lack of

intimate relationships still makes sense according to the interpersonal and affective
core of the psychopathy concept (Boyd, 2003; Cook, Michie, Hart, & Clark, 2005;
Schrum & Salekin, 2006). As a consequence, the term psychopath could be applicable
to individuals with the observed interpersonal and affective disturbance, without the
behavioral criteria necessary to reach PCL-Rs North American (30) or European
(25) cutoff for severe psychopathy. This interpersonal and affective core lies at the
heart of object relations theory.
Object Relations Theory

Object relations theory is a collective term for theories focusing on how early interper-
sonal interaction, or object relations, construct psychological structure (an inner
experience of a self and an other; St. Claire, 2000), which serves as a foundation for
future relationships. In normal object relations, experiences are characterized by the
capacity to regard others as multifaceted individuals with separate needs (whole
objects), a well-modulated capacity for self- and affect-regulation, and mature emo-
tions such as empathy and reciprocal pleasure (St. Claire, 2000). In short, well-developed
psychological structures indicate a psychologically balanced individual who is able to
appreciate himself or herself and others for who they are.
According to this theory, narcissism and disorders of the self imply that the very
central structures of the personality (inner experiences of self and others) are defective
(St. Claire, 2000, p. 139). In the PCL-R, narcissism is covered by Item 2: Grandiose
sense of self-worth, and research has demonstrated that the PCL-R Factor 1 (the inter-
personal and affective domain) is correlated with narcissistic personality disorder
(Harpur, Hare, & Hakstian, 1989). Individuals with defective personality structure/
pathologically developed object relations are distinguished by a tendency to define
others as one-dimensional need-satisfying objects (partobjects), deviances in self- and
affect regulation, primitive feelings such as anxiety and rage, and projection and split-
ting as primitive defense (St. Claire, 2000). The theory has proved relevant with
different approaches and measures in samples of psychopathic offenders (Brody &
Rosenfeld, 2002; Frodi, Dernevik, Sepa, Philipson, & Bragesj, 2001; Hartmann,
Nrbech, & Grnnerd, 2006; Meloy & Gacono, 1998).
Vulnerability, Pain, and Object Relations Theory

In general terms, vulnerability can be defined as a capability of being physically or
emotionally wounded or openness to attack or damage, and pain as acute mental
or emotional distress or suffering (Merriam-Websters Online Dictionary, n.d.). In
this, it is implicitly stated that pain, or acute mental or emotional distress or suffering,
is something that is inflicted on us (and hence requires differentiation between a self
and an other), and that in order to feel something, you must be capable or open. In
traditional diagnostics, we count symptoms and may lose the interpersonal drama of an
individuals disease. In object relations theory, vulnerability and pain are of relational

character and have a developmental origin. Following Hughes (2006), infants and
young childrens first interest is the interpersonal world. Theory and observations point
to the fact that infants are specifically receptive to subjective states in other persons
(Trevarthen & Aitken, 2001), and that children discover a sense of self in the eyes, face,
voice, gestures, and touch of their caretakers (Hughes, 2006). Attachment is mediated
through the infants instinctive behaviors, organized and maintained through proximity-
seeking behavior toward the mother (Bowlby, 1969, in Meloy, 1998, p. 54).
According to theory, psychopaths have acquired the capacity for differentiating between
a self and an object, or a dyadic object-relational world (Meloy, 2001). The psychopathic
character formation crystallizes toward the later sub-phases of separation-individuation
with the failure of object constancy, deactivation of a need for attachment (Bowlby,
1980), and primary narcissistic attachment to the grandiose self-structure to subserve
individual survival (Meloy, 1998, p. 54). Meloy (1998) argues that instead of the childs
emergence into the third and fourth year of life with internally stable, affectively gratify-
ing, and clearly delineated self- and object representations (object constancy), what we
see is the defensive workings of fused self- and objects concepts within the grandiose self
structure (p. 56). As a consequence, psychopaths are potentially vulnerable in their capac-
ity for differentiation of objects (on a perceptive and not conceptive level; Meloy, 1998)
but in the process of deactivation of the need for attachment become more or less incapable
of, or closed to, normal variants of psychological pain (acute mental or emotional distress
inflicted by others). Yet the psychopath is not unaffected by others. Meloy (2002) asks: If
psychopaths are so emotionally detached, why must they continually aggress against other
people in such hurtful and destructive ways? (p. 84).
Psychopathy, or The Search for a Painless Freedom From Object Relations

Because of the failure of object constancy, the psychopath will be caught between the
strong need for relationship with other objects, and anxiety arising from efforts trying
to fulfill this need. This developmental conflict has interpersonal and affective implica-
tions, as can be identified in the psychopathic struggle with keeping others at a
distance, and the anger arising as a reaction to separation (Bowlby, 1973, in Meloy,
1998). In the psychopathic search for a painless freedom from object relations lies
both tragedy and hope, because implicit in this concept is the idea that painless free-
dom from object relations can never be found in humans and must remain an abstract
(Halleck, 2001, p. 160). As a consequence, looking for vulnerability and pain in psy-
chopaths requires interpersonal variables, and one way to systematize such data is
through the hallmarks of object relations theory. Do we find this pattern in the instru-
mental character Dr. Lecter?
Hannibal and the Making of Hypotheses

Hannibal was orphaned under extremely brutal conditions in Lithuania during the
Second World War. Placed in an orphanage, he was an object of abuse and started

Table 1. Hannibal Lecter PCL-R Score, Current Offense, Early Relations, Part Objects,
Regulation, Feelings, and Defense
T. Harris (1981, 1988, 1999, 2006)
PCL-R 24
Current offense Serial killing.
Early relations Suffered several extreme traumas at 11 years. After this, he was raised
and abused in an orphanage, and lived in a pseudo-romantic relationship
with his aunt/caretaker.
Characteristics Male, born in 1933. Highly intelligent. Post-traumatic stress disorder.
Part objects Attempts on establishing a relationship with agent Starling, based on
a reunion fantasy as regards idealized sister. Detached, but longings
for love. Difficulties in maintaining consistent boundaries between
people. Superficially charming. Extremely manipulative. Grandiose
behavior. Lying/different aliases. Fixation with cannibalism and torture.
Degradation of victims. No remorse. Good to animals.
Regulation Hypervigilant, especially for smells and odors. Extremely controlled, but
strongly activated under certain circumstances.
Feelings A need for revenge. Rage. Persecutory anxiety. Pleasure derived from
dominance over victims.
Defense Rationalization, dissociation, splitting, projective identification and
delusions (cf. Gregory, 2002).
living inside his own head, until rescued by his uncle and aunt. Hannibals uncle soon
died, which forced him to live with his aunt under reduced circumstances (T. Harris,
2006). After some time, Hannibal developed a special relationship with his aunt. One
day at the local market, a male butcher insulted her. This is described to trigger his
underlying vulnerability, and shortly after the attack, young Hannibal went out on a
mission hunting the men who had previously killed and eaten his sister.
In Hannibal Rising (T. Harris, 2006), the young Hannibal is torn by anger and
tortured by dreams. The fact that he is somewhat drawn and attracted to his aunt
seems not enough to keep him from reaching a state of detachment, which Harris
poetically describes as, He dined alone and he was not lonely. Hannibal had entered
his hearts long winter. He slept soundly, and was not visited in dreams as humans
are (p. 310). As an adult, Hannibals interpersonal relations are centered on the sat-
isfaction of his needs (partobject relations). Before being convicted, he manages to
give the impression of leading a normal life by being extremely controlled and by
using primitive defense to rid him of his strong destructive urges (Table 1). In Han-
nibal (1999), Harris states that Lecter kills to show his contempt for those who
exasperate him. When interrogated by agent Starling in The Silence of the Lambs, a
strongly upset Lecter reveals: discourtesy is unspeakably ugly to me, as if his own
killings somehow cleanse him from other forms of discourtesy (T. Harris, 1988, p.
25). Both examples illustrate the primitive affect (Meloy & Gacono, 1998) of the

psychopath, in this case filtered through a more sophisticated lens than what you
would hear from most offenders.
After the movie The Silence of the Lambs (1991), the question was raised of
whether Lecter earned a romantic interest in Starling? The answer is probably no, as
we get the impression that his intense attraction is of a more primitive character. This
becomes evident in the end of Hannibal (T. Harris, 1999), when the Lecter character
kidnaps Starling and attempts to transform her to get back his beloved sister
Mischa. At this time, he has developed into a full-born psychopath yet still not unaf-
fected by others and very much in need of remedy for his awakening pain. Hannibal
is fiction. Do we find this pattern in real-life, severely psychopathic offenders, or is
psychopathy and suffering mutually exclusive constructs? According to object
relations theory, two hypotheses will be tested:
Hypothesis 1: Early interpersonal relations are unstable and insecure.

Hypothesis 2: Vulnerability and pain can be identified through part-object relations,
deviant self- and affect regulation, primitive feelings, and primitive defense.
Method
Sample of Studies
This review systematically examines all English-language case reports of severely

psychopathic adult offenders (PCL-R 30, PCL:SV 18; Hart, Cox, & Hare,
1995) published between 1980 and March 2009, with the aim of identifying vul-
nerability and pain according to object relations theory. Excluded were child and
adolescent offenders because of their ongoing personality development. Excluded
also were nonoffending populations and cases with a PCL-R score lower than 30,
to secure inclusion of only the most psychopathic offenders who fit the affective
and interpersonal core, and who are often described as indifferent to psychological
vulnerability and pain.
The databases PsycINFO and PubMed were searched with a combination of the
terms psychopath/y and case, in any field. The search produced 1,431 hits, of which
eight studies describing a total of 11 severely psychopathic offenders could be
included. The reference lists of the included articles were examined for information
about potentially relevant cases.
Coding the Studies

Information from the eight papers was systematized according to the object relations
categories described above: early relations, partobjects, deviant self- and affect regu-
lation, primitive feelings, and primitive defense. The information was placed in the
different categories according to the judgment of the first and second author of this
article. The direct wording was excerpted from the original texts.

Results
All offenders have experienced gross instability, neglect, and/or abuse in their family
of origin (Table 2). All cases demonstrate partobject relations, in that the offenders
ruthlessly use other individuals to satisfy their needs. Their interpersonal relationships
are further characterized as unstable and intense (Studies 1, 3, 5, 6, 7, 8, 9, and 11). As
regards to self- and affect regulation, case descriptions include individuals who are
always on edge (Studies 5 and 9), with intense mood swings (Studies 2, 4, 5, 9, 10, and
11), a deficiency in the ability to set or maintain long-term goals (Study 3), and recur-
rent self-mutilation, suicidal, and impulsive behavior acted out while experiencing
intense feelings (Studies 6, 2, 9, and 10). Several offenders are characterized with
primitive feelings such as anxiety, sadism, and especially rage (Studies 1, 3, 4, 8, 9, 10,
and 11), and some reportedly rely on the primitive mechanisms of splitting, projection,
dissociation, and denial as psychological defense (Studies 4, 5, and 8). Oddities of
thoughts, cognitive and perceptual distortion, identity disturbance, and poor reality
testing under stress were also reported (Studies 4, 5, 8, 9, 10, and 11).
All but one offender (Study 7) are diagnosed with symptom- and/or character disor-
ders, according to the diagnostic manuals. The majority have a substance and/or drug
disorder (Studies 1, 3, 5, 8, 10, and 11) and some comorbid personality disorders (Stud-
ies 2, 4, 5, and 10). Three offenders were diagnosed with symptom disorders, including
diagnosable anxiety and depression and schizophreniform disorder (Studies 2, 5, and 9).
Explicit, self-reported indications of vulnerability and pain (direct wording by the
authors) were auditory hallucinations; mood swings and tension, which are relieved
by acting out; desire to exact revenge for the pain endured throughout life; derealiza-
tion; powerful feelings of isolation; edginess and anger; depression and suicidal
thoughts and plans: perceptions of being unfairly treated; a tendency to compare one-
self negatively to others; and uncomfortableness with care.
Explicit, author-reported indications of vulnerability and pain were frantic efforts
to avoid real or imagined abandonment; feelings of emptiness and longings for love;
dysphoria; fear; self-mutilation; abnormally undervalued sense of self, seeing perse-
cution and abandonment where there is none; unstable and intense interpersonal
relations; intense mood swings; recurrent suicidal behavior; identity disturbance with
unstable self-image; reality-testing deficits; a tendency toward both isolation and
dependency on others; defensive against own affect; and a deeply felt sense of being
injured and damaged.
Discussion
The present review used object relations theory to examine whether psychopathy
and suffering (vulnerability, pain) are mutually exclusive constructs. The detailed
descriptions of the 11 psychopaths in the eight studies that were identified suggest
vulnerability and pain in accordance with the theory as well as Reids (1986) con-
ceptualization of sadness and pain. The results are incongruent with Cleckleys
(text continues on page 364)

Table 2. Vulnerability and Pain According to Object Relations Theory: Early Relations, Part
Objects, Deviant Self- and Affect Regulation, Primitive Feelings, and Primitive Defense
Study 1 Beasley (2004)
PCL-Ra 38
Early relations Extremely unstable early life. Alcoholic, cold, and distant mother
with multiple marriages. Fought with and often beaten by
stepfather. Foster home and juvenile detention center. Ran
away from home at 13. Lived for several years with an older
homosexual man and engaged in sexual relations with him.
Characteristics Male. 32 years. Substance abuse.
Part objects Sexually promiscuous. Engaged in homosexual activity to make
money from the men. Extremely manipulative. Professed to be
mostly interested in what he could obtain of monetary value
from his victims. Degradation of victims. Grandiose behavior. No
remorse. After the second or third murder, he was beginning to
enjoy what he was doing. Conceded to have no feelings for
those he killed. He forcible shoved objects or debris into some
victims mouths after death.
Regulation Little control over behavior.
Feelings Generalized anger and rage. A need to exact revenge on all the
people who have ruined my life. Finds relish in the attention he
gets from his murders. Stated motives: anger, retaliation, revenge.
Defense Not reported.
Method Standardized protocol interview. Detailed case material.
Study 2 Bruce-Jones & Coid (1992)
PCL-Rb 37
Current offense Intending to destroy or damage property.
Early relations Emotionally cold and socially isolated family home. The father,
who she believed was her grandfather, was troubled by frequent
illnesses. Her mother was cold, showing little affection and
infantilized her. Harsh discipline during childhood. Shy and isolated
at school.
Characteristics Female. 21 years. Full-scale IQ of 105. Genderless appearance.
A fragmented personality shifting between four different
personalities. Claimed to have five different identities.
Auditory hallucinations. Bizarre behavior. Antisocial,
borderline, and narcissistic personality disorder.
Schizophreniform disorder. Possible atypical bipolar disorder.
Pyromania.
Part objects Lying. Using different identities. Absence of a stable sense of identity.
Regulation Mood swings and tension, which are relieved by acting out.
Disinhibition. Self-mutilation from age 11.
(continued)

Table 2. (continued)
Feelings Not reported.
Defense Regressive behavior (wearing childrens clothes, smearing feces,
attachment to soft toys).
Method CT;c EEG;d DSM-III-R.e
PCL-Ra 36
Early relations Highly unstable upbringing. Frequent verbal and physical abuse
by father.
Characteristics Male. 35 years. Drug abuse. Divorced. Intense hatred of women.
Part objects Extremely manipulative. Limited remorse. Superficially charming.
Voyeuristic: excited by peering into windows.
Regulation Lacks ability to set and maintain long-term goals. Impulsive.
Continuous need for stimulation.
Feelings Rage-filled view of the world. Anger. Choice of weapon derived
from desire to exact revenge for the pain he had endured
throughout his life. Wanted to offend those who found his victims.
Defense Related that he was influenced by a force in the form of an
imaginary person (which allowed him to dissociate himself from
his actions).
Study 4 Gacono (1992)
PCL-Ra 34
Current offense Sexual homicide.
Early relations A family history of alcoholism, psychiatric problems, instability of
residence, and physical and mental abuse. Abandoned by father.
Negative relationships with male caretaker figures and dominant
biological mother. Absence of role models. Perceptions of being
unfairly treated. I was going to kill someone for what was done
to me (referring to his being abused as a child).
Characteristics Male. 31 years. Antisocial, borderline, narcissistic, and histrionic
personality disorder. A history of depression and suicidal
thoughts and plans: I had planned to kill myself on that day, but
after I picked the girl up I killed her instead.
Part objects Narcissistic, primitive, and borderline object relations. Emotionally
and interpersonally detached. Callous lack of empathy.
Egocentricity.
Regulation Affective dysregulation. Rage and erotic arousal temporarily
dissipate his depression. Increasing rehearsal fantasies prior to
the murder. Poor control of anger.
Feelings Aggression and sadism. Chronic dysphoria.
(continued)

Defense Reality-testing deficits. Identity disturbance. Derealization: It was

like watching a film in slow motion. Rationalization: It was
like a mercy killing. I thought that if she lived she would be a
veg. Splitting, idealization, devaluation, projective identification,
omnipotence, dissociation, and denial.
Method SILS;f MMPI;g MCMI;h DSM-III-R;e Rorschach.j Reliability testing.
Study 5 Leach & Meloy (1999)
PCL-Ra 34
Current offense Sexual homicides
Early relations Absent father. Sexual and physical abuse by mother, stepfather, and
neighbor. Witness to adult sex and violent pornography. Safe
attachment to grandmother.
Characteristics Male. 22 years. Borderline and mild mental retardation. Diagnosable
anxiety and depression at various times. Antisocial and schizoid
personality disorder. Substance abuse. Enuretic until age 16.
Generally compares himself negatively to others.
Part objects Pleasure derived from dominance over victims. A tendency toward
both isolation and dependency on others. Capacity to represent
others as whole objects.
Regulation Characterizes the homicides as an urge that I had to do.
Defensive against own affect, but when felt it is explosively
expressed. Hypervigilant, searching the stimulus field for relevant
details.
Feelings A deeply felt sense of being injured and damaged. A lack of any real
affectionate connection with others.
Defense Defensive against own affect. Psychotic reality testing when
sexual or aggressive imagery is evoked. Fantasies that have
never changed (reflected in his crimes). Grandiose ideational
compensation for very low self-esteem.
Method Complete review of records; DSM-III-R;e Rorschach;j MCMI-III;h
WAIS-R;k PPVT-R;i B-GT;l MMPI-II.g PCL-R consensus rating.
PCL-Ra 33
Early relations Highly unstable home. Verbally abused by father. Extremely isolated.
Characteristics Male. 34 years. IQ of 68. Speech impediment.
Part objects Motives of profit and revenge. Chronic lying. No remorse.
Regulation Impulsiveness.
Feelings Proneness to boredom.
(continued)

PCL-Ra 33
Early relations Family instability. Some supervision from grandmother, who
eventually died. Everything went downhill after that. Powerful
feelings of isolation. When frustrated as a child he went off by
himself to release his pent-up feelings, brooding silently, avoiding
contact with others.
Characteristics Male. 40 years.
Part objects Fantasies about, and starting to blend the needs for, sexual
gratification and inflicting violence and pain in others. Parasitic
lifestyle. Enormously manipulative. Lacks remorse. Voyeuristic.
Sexually aroused through violence alone.
Regulation Few behavioral controls.
Feelings Not reported.
Study 8 Porcerelli, Abramsky, Hibbard, & Kamoo (2001)
PCL-Ra 33
Early relations Gross neglect and abuse. Raised in foster homes and state
institutions. Always felt second rate. His only stable bond
was with his brother. Sexual relationship with institution staff.
Characteristics Male. 24 years. Drug abuse. Low-average to average intelligence.
Part objects Difficulty in maintaining consistent boundaries between people.
Superficial relationships, organized around a need-gratifying
mode of relatedness. Limited investment in people. Feelings of
emptiness and longings for love were pervasive in descriptions
of interactions. Reunion fantasy as regards idealized mother
(in jail). Deficits in capacity to experience pleasure via mutual
relatedness.
Regulation Extremely oppositional in school.
Feelings Rage. Dysphoria. Blurring aggressive and libidinal feelings. Feeling
empty and unloved.
Defense Projection and denial to rid himself of aggressive and sadistic
impulses. Mild to gross impairment in attributions of others
thoughts, feelings, and behavior.
Method MMPI-II;g SCORS;m DMM.n Independent coding on two measures.
Study 9 Brown (1996)
PCL-Ra 32
Current offense Possession of an illegal substance.
(continued)

Early relations Moving every year. Alcoholic father. Physically abusive and always
angry mother. Ran away from home at 6 with her mothers
blessing. Mother also tried to get rid of her at age 11 through
court. Rejected, slept outside under bushes.
Characteristics Female. 38 years. Symptoms of major depression.
Part objects A multitude of aliases and social security numbers. Living with
others, who paid her living expenses. Detached. Becomes
uncomfortable when others tell her that they care. Does not
expect cooperation from others. Intelligence in the low-average
range. Remorse. Longing for a connection with others.
Regulation Always on edge, scanning her environment in a hasty manner, often
missing crucial information. Impulse-based decisions acted out
in moments of anger, frustration, grief, or fear. When intense
feelings surface, she has difficulty controlling her behavior.
Frequent intense emotional disruptions and explosiveness that
make social adjustment difficult. Self-mutilation in moments of
anger and fear. Abnormally undervalued sense of self.
Feelings Sees persecution and abandonment where there is none. Everything
turns into anger for her. Easily bored. Does not avoid emotions in
herself or others.
Defense Poor reality testing under stress. Denial. Projective identification.
Oddities of thoughts. Perceptual distortion.
Method Historical information; MMPI-II;g MCMI-III;h BORRTI;o Rorschach.j
Consensus rating.
Study 10 Myers, Gooch, & Meloy (2005)
PCL-Ra 32
Early relations Several losses. Emotionally and physically abused by grandparents.
Early childhood attachment disruptions.
Characteristics Female. 34 years. Antisocial and borderline personality disorder.
Hearing and visual problems. IQ of 81. Drug abuse.
Part objects Conning/manipulative. Multiple aliases. Lack of remorse, guilt, or
empathy. Parasitic lifestyle. Unstable and intense interpersonal
relations alternating between idealization and devaluation. Stole
from victims.
Regulation Cold and unemotional. Intense mood swings. Difficulty in controlling
anger. Recurrent suicidal behavior. Need for stimulation. Poor
behavioral control. Identity disturbance with unstable self-image.
Impulsivity.
Feelings Inappropriate, intense anger. Proneness to boredom.
Defense Frantic efforts (manipulation, suicide attempts) to avoid real or
imagined abandonment.
Method Extensive file review. Clinical interview. DSM- IV-TR.e Consensus scoring.
(continued)

Study 11 Whitehead & Collie (2007)
PCL-SVp 18
Current offense Aggravated robbery.
Early relations Raised in a family where he was exposed to violence and sexual
abuse. Alternated between living with parents and grandfather,
and often chose to live with his grandfather to avoid severe
physical punishment from his parents. Left home in his teenage
years. Acceptance by gang associates.
Characteristics Male. 28 years. Abuse of alcohol and cannabis.
Part objects A pattern of serial-rape activity, beginning at 12 years of age (self-
report). An attitude that sex was a commodity that could be
bought with money or forcefully taken by those with greater
physical power. Early modelled and experiential exposure to
forced sex accompanied with feelings of sexual excitement,
dominance, and peer approval appeared likely to have severely
limited his capacity for developing loving, intimate, and equal
relationships.
Regulation Displays aggression when other people challenge his worldview.
Offense-related sexual arousal.
Feelings The enjoyment he derived from using violence sometimes resulted
in a desire to be drug and alcohol free so as to enjoy the
experience more.
Defense Believed that rape only occurred if a woman verbally said no,
which resulted in further forced sex occurring under the context
of unspoken threat.
Method File review. Clinical interview. RoC RoIq
Note: The cases are ranked according to PCL-R score, current offense, characteristics, and quality of
reviewed papers.
a. PCL-R cut off for severe psychopathy is 30.
b. The authors report to have used the Hare 22-item psychopathy scale.
c. Computer tomography.
d. Electroencephalogram.
e. Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.) (DSM-III-R; American Psychiatric
Association [APA], 1987) and DSM-IV-TR (APA, 2000).
f. Shipley Institute of Living Scale (Shipley, 1940) Zachary, 1986
g. Minnesota Multiphasic Personality InventorySecond Edition (Butcher, Dahlstrom, Graham, Tellegen, &
Kaemmer, 1989).
h. Millon Clinical Multiaxial InventoryIII (Millon, 1994).
i. Peabody Picture Vocabulary TestRevised (Dunn & Dunn, 1981).
j. Rorschach (Exner, 1990, 1993).
k. Wechsler Adult Intelligence ScaleRevised (Wechsler, 1981).
l. BenderGestalt Test (Bender, 1946)
m. Social Cognition and Object Relations Scale (Westen, Lohr, Silk, & Kerber, 1989).
n. Defense Mechanisms Manual (Cramer, 1991).
o. Bell Object Relations Reality Testing Inventory (Bell, 1995).
p. PCL-SV cutoff for severe psychopathy is 18 (Hart, Cox, & Hare, 1995).
q. Risk of Conviction Risk of Imprisonment (Bakker, OMalley, & Riley, 1999).

(1988) description of general poverty in major affective reactions, illustrating the

close tie between primitive early relations and the presence of intense primitive
affect. In some of the psychopaths, vulnerability and pain could be identified at a
diagnostic level, which is in accordance with the type of suffering that can be identi-
fied in the normal and in other patient populations. The cases form a heterogeneous
group, and at the same time are similar on important variables, in that most of the
self- and author-reported difficulties are of relational (to self or other) nature. The
results indicate that all psychopaths were raised in severely dysfunctional early
relations. These dysfunctional early relations seem to replicate themselves in the
psychopaths current instable and intense relationships, and their primitive urges
and defense. These results are in accordance with empirical studies demonstrating
primitive object relations (Gacono, Meloy, & Berg, 1992); regulatory deficits; prim-
itive affect (Meloy & Gacono, 1998); and primitive defense (Gacono, 1990; Gacono
& Meloy, 1992; Meloy, 2002) in severely psychopathic offenders. The state of con-
tinued interpersonal stress described in these cases is a nondiagnostic indication of
vulnerability and pain. Like in Harriss description of Lecter, this is explicitly stated
in two of the included cases (Brown, 1996; Leach & Meloy, 1999), where the psycho-
paths are described as hypervigilant, always on edge, and scanning the environment
in a hasty manner.
In the Leach and Meloy (1999) case, the psychopath characterizes his homicides as
an urge that I had to do. Following Klein (in Gregory, 2002), there is a causal connec-
tion between a childs fear and its aggressive tendencies. Furthermore, a persons
anxiety will serve to increase its own sadistic impulses by urging it to destroy those
hostile objects so as to escape their onslaughts. The Porcerelli, Abramsky, Hibbard, and
Kamoo (2001) case further illustrates the close tie between instrumental violent behav-
ior and the underlying reactiveaffective and interpersonal aspect of the situation: After
a developmental history of neglect and abuse, and being raised in foster homes and insti-
tutions, this psychopaths only relatively stable bond was with his brother. He was one
day forced to move out from his brothers house, where he was currently living because
of a period of good behavior. He committed a sexual homicide shortly after this. This
pattern was also reported in Leach and Meloy (1999) and Beasley (2004).
Further indications of interpersonal vulnerability and pain in psychopaths are pro-
vided by Porcerelli et al. (2001) in their description of an individual who developed a
reunion fantasy with an idealized mother, currently in jail. This psychopaths feelings
of emptiness and longings for love were pervasive in reports of interactions during
testing, which is comparable to T. Harriss (1999) description of Hannibals delusional
wish for time to reverse and run backwards, to bring Mischa back to life. Bruce-Jones
and Coid (1992) describe a psychopath having a childish attachment to soft toys.
Leach and Meloy (1999) report a tendency toward both isolation and dependency on
others, and Beasley (2004) reports powerful feelings of isolation in one of the included
cases. As for the rest, we just know that they come from backgrounds where they have
been abused and alone.

Following Kohut (in St. Claire, 2000), narcissistic investment sees objects in
terms of their relation to the selfthat is experienced as part of the self or performing
functions for the self that the self is not yet able to do (p. 13). In object relations
theory, partobject relations characterize a natural stadium in child development.
Hence, part objects in adults are probably not related to callousness but rather to defi-
ciency, vulnerability, and pain. Lack of empathy can be explained from the observed
need for symbiotic relationships. Symbiotic drives signalize a defect in the develop-
ment of a self, which correlates with the psychopathic display of mainly basic emotions
(rage and fear) and less self-aware emotions, such as shame and guilt. According to St.
Claire (2000), healthy development means that the infant distorts relationships less
by rage, love and greed (p. 39). The results demonstrate that in 7 of 11 cases included
in this review, it is explicitly stated that the psychopaths are characterized with rage
and intense anger. One individual, with a PCL-R score of 32 (Brown, 1996), reports
that everything turns into anger for her. She reports being angry when her father passed
away. She cared about her father. As a consequence, the observed rage and anger is
attachment related and possible expressions of vulnerability and pain.
Given that the degree of psychopathy can be explained as variations in pathologic
relationships, the presence of suffering in individuals with primitive object relations
points to the existence of vulnerability and pain in individuals with more mature or
higher levels of object relations. This is supported by research identifying antisocial
personality disorder and comorbid symptom disorders (Goodwin & Hamilton, 2003).
Furthermore, high levels of psychopathology, as in severe psychopathy, correspond to
high, and not low, levels of suffering. If through the process of deactivation of the need
of attachment, the psychopath becomes incapable or closed to normal, ego-dystonic
variants of psychological pain, this leaves us with an unknown entity, or suffering in
an alternate, ego-syntonic form, which fuels the psychopathic behavior but is difficult
to catch sight of with traditional methods.
Until the Lion Learns to Speak, the Tales of

Hunting Will Be Weak (Adage)
In accordance with this articles opening words by Brittain (1970), laying hands on a
theoretical model that fit the problem, we are one step closer to treating the disorder. But
this task is not an easy one. As health providers, it is deeply rooted in us that when some-
one expresses pain, we must help. This comes with the understanding that the effort will
be appreciated. But what if pain is not clearly communicated (e.g., through part objects
and rage), and if helping implies a risk? How do we get from part objects to whole objects,
or create an inner world that is capable of acknowledging others for who they are?
According to the theory, this can gradually be accomplished as the individual
internalizes aspects of the therapist and builds new inner structures (St. Claire, 2000,
pp. 152-153). If symbiosis (as measured by the presence of partobject relations) is
the psychopaths only option with relationships, then the psychopathic individual is
unable to handle the fluctuations that characterize normal relationships (i.e., a partners

independent interests and relationships). Normal relationships are impossible, as

normal partners cannot hold the symbiosis over time. But this can be a significant
ingredient in a therapeutic relationship. A necessary precursor for this is that the thera-
pist is able to see through the psychopathic defense and empathize with the suffering
individual. Acknowledging that the psychopath feels this kind of pain provides a target
for intervention, and gives the strength to continue with empathic intervention in the
midst of psychopathic tumults. It is all about the individual behind the symptoms, or
finding the Hannibal behind the Cannibal.
Declaration of Conflicting Interests

The authors declared no conflicts of interest with respect to the authorship and/or publication of
this article.
Funding
The authors disclosed receipt of the following financial support for the research and/or author-
ship of this article: This study was supported by a grant from The National Program for
Integrated Clinical Specialist and PhD-training for Psychologists, a national recruitment pro-
gram for positions which requires dual competence in psychology funded by the Ministry of
Education and Research and the Ministry of Health and Care Services.
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Defense Reality-testing deficits. Identity disturbance. Derealization: It was

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(1988) description of general poverty in major affective reactions, illustrating the

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Until the Lion Learns to Speak, the Tales of

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independent interests and relationships). Normal relationships are impossible, as

Declaration of Conflicting Interests

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