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PREFACE

We would like to express our sincere gratitude and appreciation to all those who gave us the possibility to complete this student project. A special thanks to our lecturer. Not forgetting our small group discussion members, whose help, stimulating suggestions and encouragement, helped us to coordinate our student project especially in writing this paper. We would also like to acknowledge with much appreciation the crucial role of the facilitator of our small group discussion. Besides, we also like to thanks our other friends who really helped us to complete this student project.Not only that through this student project we had learned more information regarding our topic. This student project made our relationship grow fonder. Before we forget we would like thank God for giving this opportunity.

TABLE OF CONTENTSCover Page1Preface2Table of Contents3CHAPTER I: INTRODUCTION51.1.Background51.2.Aims61.3.Benefit6CHAPTER II: CONTENT72.1.Psychopathic Personality Disorder72.2.Approach to Determine the Risk Factors of Psychopathic Personality Disorder82.2.1.Environment Factor82.2.2.Behavior Factor102.2.3.Health System Factor112.2.4.Genetic Factors12CHAPTER III: DISCUSSION15CHAPTER IV: SUMMARY18

CHAPTER IINTRODUCTION1.1. Background The term psychopath is used to describe the condition of individuals who have lack of conscience or guilt, lack of empathy, egocentricity, pathological lying, repeated violations of social norms, ignoring the law, shallow emotions, and a history of victimizing others. For clinical, legal or research purposes, psychopath is often assessed by a tool which has 20 items that measure central elements of the psychopathic character known as PCL-R instrument or Hare Psychopathy Checklist-Revised (PCL-R).1 Guidelines for the diagnosis of mental disorders of DSM-IV or ICD 10 dont explain specifically about psychopath personality disorder, but psychopathic personality disorder is has similarity to antisocial personality disorder although it still debated.2Several criminal cases have long been reported has correlation to psychopathic personality disorder. This has been proven by empirical researches which suggest that psychopath is a robust predictor of criminal behavior and recidivism. A literature review study shows that according to research approximately 1% of the total world population is suffering from psychopathic personality disorder. Study using PCL and self report measure men have higher score (15 to 30 per cent) than female (9 to 23 per cent) means that psychopath personality disorder is higher among men. Although there is a difference, this number is not statistically significant. There is also a study said that female psychopaths are less aggressive and violent than male and they may not display the same emotional deficit with male psychopath. Psychopath personality disorder in youth and adulthood can be predict since they were three years of age.3Some causes can explain how someone becomes a psychopath and it also influence by many risk factors. Risk factors which lead someone become a psychopath can be multifactorial whether it comes from internal or external. A research stated that Head injury has correlation to psychopathic personality disorder. Damage of theamygdala can affect the prefrontal cortex to interpret feedback from thelimbic system so signals are unhibited and manifest in violent and aggressive behavior.4 Biochemical factor also reported has correlation in psychopathic personality disorder. HVA(adopaminemetabolite),5-HIAA(aserotoninmetabolite), and also monoamine oxidase A are biochemical factor which reported correlates to psychopathic personality disorder.5,6 Environment also plays important rule in psychopathic personality disorder. It has been reported that poor parental bonding correlates to psychopathic personality and aggressiveness.7 The risk factors of psychopath personality disorder can be well explained by a theory arranged by Henrik L. Blum known as Blum Theory. Blum Theory stated that there are four major factors influence personal healths status. The four major factors are environment, behavior, health services and heredity or genetic.8 Psychopath personality disorder is become serious since it cannot be identified easily in a person but the case still exist.3 The important thing to do is doing prevention. Prevention can be well established if the risk factor is known.1.2. AimsThis topic has purpose to extent knowledge about risk factors which affects psychopath personality disorder in terms of Blum Theory.

1.3. BenefitThe benefit of this paper is to provide a reference about the risk factors for psychopathic personality disorder in terms of Blum Theory. This also can be used as consideration in establishing prevention to the danger of psychopathic personality disorder.

CHAPTER IICONTENT2.1. Psychopathic Personality DisorderPsychopathy is a personality disorder which consists of two components: an emotional dysfunction and antisocial behavior. Emotional dysfunction characteristics of psychopaths are described as lack of empathy, have no remorse or guilt, self-righteous, aggressive, impulsive, and not responsible for their actions. The antisocial behavior component involves a predisposition to antisocial behavior from an early age. Psychopaths are one type of mental disorder in which people suffering from this disease are aware of what they do.9 In DSM-5, psychopathy is categorized in antisocial personality disorder.2,10 However, some studies declare that those terms are similar but not synonymous. In antisocial personality disorder, the behavioral trait is dominant. For psychopathy, affective and interpersonal trait is more dominant.11 Psychopathy seems to be less common and to occupy a space at the severe end of the antisocial distribution.10 Twenty five percent of adult with antisocial personality disorder will demonstrate psychopathic trait.12A psychopath is usually hard to be recognizable directly in the community because they tend to make a complicated camouflage.9 Psychopaths can often be seen by others as being charming and trustworthy. They can hold steady, normal jobs. Some even have families and seemingly-loving relationships with a partner. While they tend to be well-educated, they may also have learned a great deal on their own. When a psychopath engages in criminal behavior, they tend to do so in a way that minimizes risk to themselves. They will carefully plan criminal activity to ensure they dont get caught, having contingency plans in place for every possibility.13 Psychopaths present risks to society. Knowing the risk factors of psychopathy is a great challenge. If the risk factors have been fully understood, another steps are to find the action plan as well as its prevention.132.2. Approach to Determine the Risk Factors of Psychopathic Personality DisorderA risk factor is a personal characteristic or circumstance that is linked to a negative event and that either causes or facilitates the event to occur.13 In this paper, we want to know what are the risk factors that can cause a person to become a psychopath. There are several methods/models that can be used. At this time we will consider using the theory of Henrik L. Blum. The blum theory is using multifactor theories to explain one's health. According to Blum, a person's health status is influenced by four main factor; environment, behavior, health care, and genetic.Environment factor is divided into a physical environment such as waste, soil, water, air, climate, housing, and so on as well as the social environment in the form of individual interaction with other individuals such as culture, education, economy, politic and others. The behavior factor encompasses things such as customs, beliefs, education, social and others. Health care was also influential in a person's health status, such as the availability of adequate facilities, the availability of prevention program, information about health provided to citizens as well as the motivation of citizens to participate in maintaining the health of themselves and the people around them. In heredity or genetic factor, the abnormality is already inborn from genetic family.14 2.2.1. Environment FactorThe environment factors of psychopathy are mostly consist of nonphysical factors. Some of these factors are happened in childhood. Childhood maltreatment, exposure to adversity, and poor parental bonding was associated with later psychopathic personality and aggressiveness. Early separation between parents and their children made poor boding more likely to happen.15,7 During childhood period, displays of aggressive behavior were also associated with aggressive behavior occurence in adulthood. By observing aggressive behavior and its effect on obtaining a potential reward (e.g., resolution of a conflict, obtaining what they want), an individual may use similar behavior when confronted with a similar problem. In children, this is supported by evidence that exposure to family violence is often associated with displays of aggressive behavior among the children in that family. Individuals who watch violence in television or film were also found to have increased aggressive behavior.16 Aggressive behavior that appears later in life may also be associated with increased substance abuse. Among the substances linked to aggressive behavior, alcohol appears particularly noxious. However, its causal relationship have not properly established yet.16 Other study found that male offspring exposed to medium and high pre- and postnatal anxiety had higher odds of conduct disorder than males with low exposure levels. The fetal programming hypothesis asserts that during the prenatal period, high maternal anxiety and depression may lead to elevated levels of maternal stress hormones, particularly cortisol. These hormones will cross the placental barrier and affecting fetal development. In the postnatal period, infants and mothers form emotional attachment patterns. Exposure to maternal depression and anxiety symptoms during this period may disrupt the development of healthy attachment patterns and negative attachment styles.17 Other study focused on twins found that psychopathy is influenced in certain level by non-shared environmental factors.18 Non-shared environmental factors are environmental differences between children in the same family. Examples of non-shared environmental factors are birth-order, gender differences, illnesses, and differential treatment.19 The affective-interpersonal trait of psychopathy is moderately influenced by non-shared environmental factors. The non-shared environmental factors also associated with the antisocial-externalizing trait of psychopathy but the estimate varies.18 This study did not describe which non-shared environmental factor(s) are responsible for each trait. 2.2.2. Behavior FactorPsychopathy is characterized by a constellation of affective, interpersonal and behavioral traits including impulsivity, lack of empathy and guilt, manipulativeness, lack of depth of emotion, a persistent violation of social norms, lack of anxiety, low withdrawal, and high levels of attention seeking. High attention seeking and low withdrawal capture the social potency (assertive/dominant) component of psychopathy, whereas low anxiousness captures the stress immunity (emotional stability/resilience) component.20 Another study said the behavioral factor was consistently associated with low levels of self-reported positive affect, elevated stress reactivity, aggression, and behavioral disinhibition. Not surprisingly, this constellation of traits was linked to poor behavioral outcomes, reflected in associations with substance abuse, reactive physical aggression, anti personality disorder, and low socioeconomic status. Thus, the behavioral factor appears to index a pattern of poor behavioral restraints in the presence of significant subjective distress, which is expressed via deviant and aggressive behavior. However, the behavioral factor exhibited more robust relationships with multiple indicators or traits impulsivity. The antisocial factor, in contrast, was more closely associated with violent criminal charges.21 Several childhood behavioral disorders are now thought to be associated with later antisocial behavior or psychopathic personality disorder. Conduct disorder is a serious emotional and behavioral disorder. Children with conduct disorder may display a pattern of disruptive and violent behavior and have problems following rules.22 Conduct disorder in childhood is a significant risk factor for the development of later antisocial behavior in adulthood. Children with early-onset conduct disorder tend to show more pervasive and chronic course of illness.12 ADHD is highly comorbid with conduct disorder. About 30% of boys with severe ADHD develop conduct disorder. Conversely, ADHD is strongly associated with an earlier onset and a more severe course of conduct disorder. About half of the children who have both ADHD and conduct disorder will develop antisocial personality disorder in adulthood. Another comorbidity of conduct disorder is CU traits. Up to 50% of children with conduct disorder also have CU traits. Boys with CU traits have intact cognitive-perspective taking ability but lack emotional empathy for others feelings or emotions. Children with conduct problems and CU traits have a more severe, violent, and chronic course of antisocial behavior. When they reach adulthood, they appear to be more antisocial and more likely to demonstrate proactive and reactive aggression. The high reward-oriented and low punishment-responsive behavioral profile of children with CU trait is similar to behavior seen in adults with psychopathy.18 2.2.3. Health System FactorPeople with antisocial personality disorder will externalize their difficulties, it is not surprising that they rarely present in healthcare settings requiring help to deal directly with problems arising from their personality disorder. In general, therefore, they can be described as treatment rejecting rather than treatment seeking.Those with antisocial personality disorder actively resist having to accept help, and that coercion into treatment directly challenges their core personality structure, it is clear that therapeutic interventions are also likely to be under threat in such circumstances. Hence, one might expect a high drop-out rate from treatment and indeed that is what has been found. Nonetheless, people with antisocial personality disorder do present to healthcare services (either willingly or otherwise), so it is important that such services have an understanding of the core personality issues so that they can respond appropriately.In a population that is largely treatment rejecting, issues concerning patient preference and information can be challenging. However, given the propensity of people with antisocial personality disorder not only to reject treatment but also to drop out of treatment, additional efforts to engage people may be required.It is important to recognize that while antisocial personality disorder is associated with considerable harm to the individual with the condition, this harm extends more broadly to have an impact not only on immediate family members, but on society at large. Extended harm leads not only to high levels of personal injury and financial damage for victims but also to increased costs of policing, security, and so on. Recognition of these extended costs is important in making a case for what appear to be, on occasion, expensive interventions.23 2.2.4. Genetic FactorsCallous-unemotional (CU) traits include lack of guilt and empathy, as well as shallow effect. Adults with combination of CU traits and antisocial behavior are labeled psychopaths. Although no one would call children as psychopaths, CU traits can be used to distinguish a subgroup of children who are capable of premeditated antisocial behavior and violence and who are at an elevated risk for developing psychopathy when they reach adulthood.24A study indicates that the heritability of CU traits remained consistent across time and 58% of the stability of CU traits was due to genetic influences. Recent reviews and meta-analyses have shown evidence of strong genetic effects on antisocial behavior and shared and individual specific environmental influences. A meta-analysis reported both additive and non-additive genetic contributions to antisocial behavior along with 16% of the variance explained by shared environmental and the remaining 43% explained by individual specific environmental. Since the publication of meta-analysis, other studies have yielded heritability estimates in a similar range, 38% genetic contribution to the variance in antisocial behavior.11A study conducted to measure CU traits (as well as impulsivity and grandiosity) and examined genetic and environmental contributions to the stability of these traits between ages 16 and 19. It focused on a hierarchical model of psychopathic personality in which a higher-order general factor substantially explained the variation in the three psychopathic personality dimensions in mid- and late adolescence. The results showed that the observed test-retest correlation of the higher-order psychopathic personality factor was high. In addition, as much as 90% of the test-retest correlation was explained by genetic factors. However they also found evidence for specific genetic stability in CU. Thirteen percent of the unique genetic effects in the CU dimension at age 19 were shared with the corresponding effects at age 16.About the heritable component of CU traits, the study on adolescents with attention deficit/hyperactivity disorder (ADHD) and reported associations between "emotional dysfunction" scores of psychopathy (CU) and each of the following allelic variants: the valine allele of the cathechol-O-methyltransferase gene, the low activity allele of the monoamine axidase A gene (MAOA-L), and the short allele of the serotonin transporter linked polymorphic region gene (5HTTLPRs). The latter two of these associations were unexpected given the imaging genetic data suggesting that MAOA-L and 5-HTTLPRs are associated with heightened amygdala activity to emotional stimuli, in contrast to the reduced amygdala activity to emotional stimuli typically seen in adults with psychopathy and children with antisocial behavior/CU. A more recent study reported that the long allele of the 5-HTTLPRl, which is the allele conferring low amygdala reactivity, was associated with CU traits in adolescents from low socioeconomic status backgrounds.Finally new technologies, such as DNA pooling, are enabling genome-wide association studies that search for novel single nucleotide polymorphisms (SNPs) which may be associated with antisocial behavior/CU.24

CHAPTER IIIDISCUSSIONPsychopath is seen as inability to conform to the social norms that ordinarily govern many aspects of a persons adolescent and adult behavior.25 Characteristics of psychopaths are antisocial and disturbing those around them. Most of the cardinal signals of this disorder involve aggressive or illegal activities, deceit, repeated thefts, assaults, evasion of financial obligations, and lying.26 Because of the harmful and dangerous effect that may be caused by the psychopaths, it is important to know the risk factors to prevent this disorder and also to make a good management.According to Blum Theory, a person health status is influenced by four main factors: environment, behavior, health care and heredity or genetic. So we will explain briefly about the risk factors of psychopath.A. Environment FactorThe environmental factors that influence psychopathy are mostly nonphysical factors which happened in childhood. Childhood maltreatment, exposure to adversity, and poor parental bonding was associated with later psychopathic personality and aggressiveness. Displays of aggressive behavior during childhood period also have a role in the risk factor of psychopath. This makes good parenting become crucial to prevent psychopathic personality or other aggressiveness occurs in the adulthood. Aggressive behavior in adulthood may also be associated with increased substance abuse. Among the substances linked to aggressive behavior, alcohol appears particularly noxious.Other factors are non-shared environmental factors. Non-shared environmental factors are environmental differences between children in the same family, includes birth-order, gender differences, illnesses, and differential treatment. The affective-interpersonal trait of psychopathy is moderately influenced by non-shared environmental factors.B. Behavior FactorThe behavioral factor was consistently associated with low levels of self-reported positive affect, elevated stress reactivity, aggression, and behavioral disinhibition. However, the behavioral factor exhibited more robust relationships with multiple indicators or traits impulsivity. The antisocial factor, in contrast, was more closely associated with violent criminal charges. This finding is seemingly in accord with the three-factor model (including the Behavioral factor) reflects underlying traits of psychopathy more so than behavioral adaptations arising from those traits.In childhood, several mental disorders are likely to be the risk factor for developing psychopathy later in adulthood. Conduct disorder and its comorbidities (ADHD and CU trait) are significant risk factors for the development of later antisocial behaviour. Some adult with antisocial personality disorder will demonstrate psychopathic trait in their life.C. Health Care System FactorPeople with antisocial personality disorder will externalize their difficulties, so they rarely present in healthcare settings requiring help to deal directly with problems arising from their personality disorder. Those with antisocial personality disorder actively resist having to accept help, and that coercion into treatment directly challenges their core personality structure, it is clear that therapeutic interventions are also likely to be under threat in such circumstances. Not only reject treatment, people with antisocial personality disorder also drop out of treatment. It is important to recognize antisocial personality disorder because it usually associated with considerable harm to the individual with this condition; this harm extends more broadly to have an impact not only on immediate family members, but on society at large. Extended harm leads not only to high levels of personal injury and financial damage for victims but also to increased costs of policing, security, and so on. So, unidentified psychopath because of rejecting treatment and health system which hard to respond appropriately is one of the risk factor of psychopath.D. Genetic FactorIn genetic factor, CU traits that include lack of guilt and empathy, as well as shallow effect will develop psychopathy when child reach adulthood if combined with antisocial behavior. This is proven by studies that compare between identical twins and non-identical twins about CU traits with result that the gene factor strongly associated with the CU traits. The gene that are contributed with psychopathy and children with AB/CU are: monoamine oxidase A gene (MAOA-L) and short allele of the serotonin transporter linked polymorphic region gene (5HTTLPRs) that associated with amygdala activity to emotional stimuli; long allele of the 5-HTTLPRl that conferring low amygdala reactivity; and single nucleotide polymorphisms (SNPs) which may be associated.

CHAPTER IVSUMMARYSeveral criminal cases have been reported has correlation to psychopathic personality that is approached 1% of the world total population suffering with male are higher than female. Its a personality disorder that consists of two components: an emotional dysfunction and antisocial behavior. Individual with psychopathic disorder are seen to have an inability to conform to the social norms. According to Blums theory, this condition is influenced by four main factors: environmental, behavior, health system and genetic. These factors are correlated each other. The environmental factors, mostly nonphysical factors that happened in childhood including childhood maltreatment, exposure to adversity and poor parental bonding was associated with later psychopathic personality and aggressiveness. Several childhood behavioral disorder are thought to be associated to psychopathic personality, including conduct disorder which is known to be a significant risk factor for the development of later antisocial behavior or psychopathic personality in adulthood. Besides of these external factors, the internal factor, the gene (MAOA-L) and 5-HTTLPRs are known to have association with psychopathic personality. From the perspective of health system factor, people with psychopathic disorder are treatment seeking, but in general population they are more likely to describe as treatment rejecting and also drop out treatment. Unidentified psychopath because of rejecting treatment and health system that hard to respond appropriately is one of the risk factor of psychopath.A psychopath is usually hard to be recognized because they tend to make a complicated camouflage. It is important to recognize psychopathic personality because it is usually associated with considerable harm to the individual with this condition and also may extends to people around. Knowing the risk factors that influenced how someone can become a psychopath earlier is noted as an important thing nowadays. If the risk factors have been fully understood, it will guide us to start the prevention and also to make a good management for them who suffering. REFERENCES LIST1. Hare Psychopathy Checklist". Encyclopedia of Mental Disorders. Accessed Mei 30, 20152. American Psychiatric Association. DSM 5 [Internet]. American Journal of Psychiatry. American Psychiatric Publishing; 2013. 991 p. Available from: http://ajp.psychiatryonline.org/article.aspx?. Assessed Mei 30, 20153. Katie D, Daniel B. (2013). Psychopathy and criminal behaviour: a psychosocial research perspective. Journal of Criminal Pyschology. VOL. 3 NO. 2, pp. 84-107. Acceesed Mei 30, 20154. "Protect Watch Your Head".The Franklin Institute Online. The Franklin Institute. 2004. Acceesed June 2, 20155. Tikkanen, Roope; Auvinen-Lintunen, Laura; Ducci, Francesca; Sjberg, Rickard L.; Goldman, David; Tiihonen, Jari; Ojansuu, Ilkka; Virkkunen, Matti (2011)."Psychopathy, PCL-R, and MAOA genotype as predictors of violent reconvictions".Psychiatry Research185(3): 3826.doi:10.1016/j.psychres.2010.08.026. Acceesed June 2, 20156. Glenn, Andrea L.; Raine, Adrian (2008). "The Neurobiology of Psychopathy".Psychiatric Clinics of North America31(3): 46375, vii.doi:10.1016/j.psc.2008.03.004. Acceesed June 2, 20157. Fryers T, Brugha T. Childhood determinants of adult psychiatric disorder. Clin Pract Epidemiol Ment Health [Internet]. 2013;9:150. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3606947&tool=pmcentrez&rendertype=abstract8. Ramadhan, IPA. Muslin Dentist [Internet]. FKGUI: I Putu Arya Ramadhan; 2012. Teori Blum tentang Kesehatan Masyarakat; 2012 June 1[cited 2015 May 29];[about one screen]. Available from : https://mhs.blog.ui.ac.id/putu01/2012/06/01/teori-blum-tentang-kesehatan-masyarakat/9. Craft M. Psychopathic Disorders and their Assessment: The Meanings of the Term Psychopath. Elsevier Inc.; 2013.

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