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The nature of communication in the talking cure.

Posted on January 12, 2014 at 6:36 PM Comments comments (106)

Mark Solms is the director of the Arnold Pfeffer Center for Neuro-Psychoanalysis at the New York Psychoanalytic Institute; a lecturer at the University College Londons Department of Psychology; a consultant in neuropsychology at the Anna Freud Center in London; and an honorary lecturer in the Academic Department of Neurosurgery at St. Bartholomews and the Royal London School of Medicine. Over the last 15 years, Dr. Solms has been the driving force in establishing the new field of neuro-psychoanalysis, which brings together the fields of neuroscience and psychoanalysis.

What is the nature of communication between the analyst and the patient 

Defining psychoanalysis as "the talking cure" is somewhat misleading, a misnomer. We have the mystical-sounding phrase from Freud about the communication from the unconscious of the patient to the unconscious of the analyst. We speak of empathic attunement and projective identification as a form of communication between patient and analyst, which is reflected in the countertransference. The nature of communication in the analytic room somehow fails to be conveyed in the words that are transcribed down from a recording of the analytic session. Something goes on inside of the patient and the analyst in parallel with the talking which cannot be readily captured. 

The building blocks of the meaning-making process. 

The most rudimentary form of a conscious thing that stands for something occurs within ourselves about ourselves, to ourselves. Communication is communication of meaning. The best theory that we are working with revolves around the notion that consciousness originates in structures within the very deep core of our brain stems. These structures which project very widely to the forebrain, are representing aspects of the state of ones self, the subjective state, the visceral bodily state. This state of self is meaningfully being represented as a feeling of consciousness which either feels good or bad. Action tendencies are intrinsically interwoven to these feeling states. Pleasurable feelings are associated with approach behaviours, they motivate approach behaviours. 

Negative/painful feelings are associated with avoidance behaviours. These raw feeling states originate in the periaqueductal gray (PAG). Even in such elementary forms of consciousness, something is conveyed but not necessarily intentionally. We see that in herd-contagion behaviour. 

The approach mechanism is essentially a seeking mechanism. It has to do with detecting needs that can only be met in the outside world. It is almost an implicit predictive mechanism: "Unless I go looking for food, I am not going to survive". The feeling that comes with it is mildly optimistic, mildly curious - "something good is going to happen and I want to be there kind of feeling". Freud defined emotions as "mnemic residues of biological situations of universal significance". The universality of significance makes us all know what it means when we see it. Basic emotion systems link our core consciousness to the outside world and those around us. Emotions are a perceptual modality, they are a medium of consciousness just as vision, smell, hearing are a medium of consciousness.  

When another animal (human) feels something and another sees it, hears it, smell it (there are all sorts of ways in which the state of an animal is conveyed) then one knows what the other animal is feeling. These are things which we can't afford to learn, they are "mnemic residues" - we just know what it means, although we may not be able to demonstrate. Empathic knowing When I see that experience it activates the same system in me. I know what it is because it is activated in me. Mirror-neurons allow a higher level elaboration of this basic system. Mirror-neurons were accidentally discovered in a research lab in Italy. When a monkey with a brain activity recording device on its brain observes another monkey eating a banana, the same areas in the brain of the observing monkey are activated. There is a mirroring of the motor-neuron activity in the acting monkey, which is activated in the brain of the perceiving monkey. 

The prefrontal cortex allows for a suppression of the basic emotional systems, inhibiting the action tendencies associated with them. They enable us to not have to act on the feeling, to create virtual scenarios, to represent the relation between things. A 'non-doing' kind of thinking evolves - a highly abstracted, symbolic thinking removed from the emotional core. It is our 'pride and joy' but the price is that it alienates us from our feelings. We develop this curious inability to know what is driving our own actions. 

In therapy the analyst is taught to listen with his "third ear", with an evenly suspended attention. The analyst does not listen to the words, because they only convey part of the story - she picks something up, she feel something, which is akin to a biological situation with universal significance. This way we recognise the patient's emotional configuration, and we use the words to convey our understanding. The talking cure is not about the talking - the talking is about feelings. 

A new way of thinking about the nature of reality

Posted on February 6, 2013 at 7:15 PM Comments comments (101)

The clock is an archetype of the old classical physics. What we have in the quantum mechanics is something that is not at all like that. A new way of thinking is required. 

Relativity theory
Einstein was at the crosswords between the old world and the new one. He said: "Behind the tireless efforts of the investigator there lurks a stronger, more mysterious drive: it is existence and reality that one wishes to comprehend." (Einstein, 1934) We all wish to comprehend reality, but what is our expectation about how that reality will show up?

Intrinsic properties have been defined as unique enduring properties that identify an object. Galileo made a distinction between primary and secondary qualities. He wrote" I think that tastes, odours, colours and so on are no more than mere names and they reside only in consciousness. Hence if the living creature were removed, all these qualities would be wiped away and annihilated." Secondary qualities are colour, smell, taste, sound, warmth.  Primary qualities are size, shape, location, movement, contact, mass.

The failure of classical realism
The mystery is from the point of view of quantum physics: are these primary qualities truly primary? Is there a world of intrinsic objects or is the world intrinsically subjective - is it the world of experience?

Two great theories of modern physics
Relativity, which is a revolution in our understanding of space and time and simultaneity becomes significant only at high velocity. Quantum mechanics, which has revolutionised our understanding of light and matter becomes relevant only at small scales such as atoms.

Thought experiment. A relativistic challenge. To fit a 25cm pole in a 20cm long barn. Classically it is impossible because the pole is too long to fit in the barn. However at 75% the speed of light, the pole shrinks when seen from the barn to 18cm. If the barn is observed moving at 75% the speed of light towards the pole, the barn will shrink to 14 cm. Any object that moves becomes shorter in the direction of moving. Viewed from the barn the pole fits inside. Viewed from the pole, the pole is too long. These two views are classically inconsistent, but consistent from a relativistic point of view both are true, but with respect to two different observers, two different frames of reference.  

What you are looking for is always in a context, a relationship. When you are asking what is the single true state of affairs you are presuming there can be a view from nowhere - no person just a situation with its own truth. When we forget the context we come into great difficulties. Difference reference frames create different contexts and lead to different understandings. The vantage point is absolutely important to even something like size. Every primary property is affected by relativity. From a standpoint of physics we have to keep into account the frame of reference of the observer. There is no privileged reference frame. Each observer has the same claim to truth. 

Length shortening, time slowing and the relativity of simultaneity make analysis in terms of objects inappropriate and this becomes the new framework for understanding the new physics. David Bohm: "The analysis of the world into constituent objects has been replaced by its analysis in terms of events and processes" (Special theory of relativity) We so much want the world to be made up of objects - cells, neurons, atoms but this is a wrong view. We have phenomena and processes arise in time and they give the appearance of objects of enduring nature, but what is primary is the process. 

It is a wrong view to look for a single objective state of affairs that everyone will see in a consistent way.There is a fundamental observer dependence (real or imagine). There is always a vantage point. To forget the observer is a fallacy. We find that primary atributes are relative. Properties are relational - they depend on the relationships that we experience. We are always looking for the objective reality beyond experience, we are looking for something other than experience to support experience, but this, on the basis of Einstein's theory is not a good choice. When you look ever more deeply you find context dependent relationships that give rise to phenomena that may be more and more subtle. What one has context dependent experience and there is no need for any foundation other than that. We need to not be stuck in a vantage point. If you get stuck on a vantage point you see everything from your own side and you fight from that truth. 
A reality which you circle - you actually learn to take the point of view and position of others. Engaging with something different gives a fresh view on reality.

Stanford prison experiment

Posted on December 12, 2012 at 6:30 AM Comments comments (98)
"The Stanford prison experiment was a study of the psychological effects of becoming a prisoner or prison guard. The experiment was conducted from August 14 to 20, 1971 by a team of researchers led by Psychology professor Philip Zimbardo (Also the host of the documentary series Discovering Psychology) at Stanford University. It was funded by a grant from the U.S. Office of Naval Research and was of interest to both the US Navy and Marine Corps in order to determine the causes of conflict between military guards and prisoners.

Twenty-four students were selected out of 75 to play the prisoners and live in a mock prison in the basement of the Stanford psychology building. Roles were assigned randomly. The participants adapted to their roles well beyond what even Zimbardo himself expected, leading the "Officers" to display authoritarian measures and ultimately to subject some of the prisoners to torture. In turn, many of the prisoners developed passive attitudes and accepted physical abuse, and, at the request of the guards, readily inflicted punishment on other prisoners who attempted to stop it. The experiment even affected Zimbardo himself, who, in his capacity as "Prison Superintendent," lost sight of his role as psychologist and permitted the abuse to continue as though it were a real prison. Five of the prisoners were upset enough by the process to quit the experiment early, and the entire experiment was abruptly stopped after only six days. The experimental process and the results remain controversial.

The results of the experiment are said to support situational attribution of behavior rather than dispositional attribution. In other words, it seemed the situation caused the participants' behavior, rather than anything inherent in their individual personalities. In this way, it is compatible with the results of the also-famous Milgram experiment, in which ordinary people fulfilled orders to administer what appeared to be agonizing and dangerous electric shocks to a confederate of the experimenter."

The role of the Anterior Insula in compassion

Posted on December 10, 2012 at 7:23 PM Comments comments (96)
Social emotions in social neuroscience: From emotion contagion to empathy and fairness (from 0:43:54) presented by Tania Singer from the University of Zurich at the 2012

Emotional contagion. Empathy. Theory of mind. 

Empathy is different from emotion contagion.  When we are empathic we are aware that the emotion that we experience is carried vicariously for the other, that they are the source of our affective state. A self-other distinction is important in the experience of empathy. In the case of emotion contagion we are unaware of the source of our emotion. All mammals exhibit emotion contagion.

Empathy is also different from cognitive perspective taking or "Theory of mind", which is a cognitive empathy. When we have "theory of mind" we have an abstract concept of the other person, we aware of the others'  thoughts but we don't share the affective state with the other person.  The brain circuits underlying these two routes to the understanding of the other are very different. In psychopathy the affective empathy missing.

Sympathy and compassion

Sympathy is feeling sorry that someone is experiencing a negative emotion, but not experiencing that emotion with the other. Sympathy can have a condescending aspect to it, it comes from a one-up position. Compassion is the appreciation that we are all on the same level, a deep understanding of connectivity and of the sameness of everyone. Compassion has a motivational element - wanting to help relieve the other of suffering.

There is an ontogenetic and phylogenetic sequencing between emotional contagion, empathy and compassion, which leads to prosocial behaviour. Emotion contagion developmentally precedes emotion and compassion. (Singer, 2006, Neuroscience behaviour review). Emotion regulation capacity, which reliant on the prefrontal cortex is related to the ability to understand another person. Young children have an "ego-centricity bias" that is they tend to be influenced by their own emotional state when judging the emotional state of another - they project their emotions onto the other. The prefrontal cortex allows us to inhibit our own emotional state and to come to an accurate understanding of the other as different from us (PFC is still being developed up to the age of 25 years old.)

There is an overlap activation in the anterior part of the Insula in experiencing a bad smell and watching someone experience a bad smell. There are also shared networks in the domain of pain for self and others. Researchers worked this out by observing couples. People who were asked to watch their partner experience pain showed the same brain activation in the Anterior Insula (AI) and Anterior Cingulate Cortex (ACC) as when they themselves experienced pain. (Singer, 2004, Science) 

The theory about the neuro-function of this activity

the Insula is the interoceptive cortex, which has the function of looking into the condition of your body, registering how you feel. The better the interoceptive awareness of one person the higher the size of the AI and the activity in the AI. Singer suggests that we we use representations of our own feeling state to make a model about what other people feel. To test this she turned to looking at the brains of people of Aperger's Syndrome and Alexithymia to investigate whether people who show deficits in understanding their own internal state also show deficits in interoceptive awareness and in the empathic understanding of another.

Alexithymia is characterized as a sub-clinical phenomenon, marked by difficulty in identifying and describing feelings and a tendency to focus on external events rather than inner experiences. Alexythimia is thought to characterize 10% of the typically-developing population. The estimated prevalance rate among patients wiht Asperger Syndrom is around 60-80%. Patients with ASD have a deficient in cognitive perspective taking. 

The results show that people who have a deficit in understanding their own emotions also have deficits in understanding the emotions of others - and there is a lack of activation in AI. Empathy training may concentrate first on training interoceptive awareness in the self. 

The results show that autism is not per se associated with a lack of empathy. It depends on the degree of alexythimia. Adolescents with Conduct Disorders have less grey matter volume in the AI, and show less empathy. (Sterzer et al., 2006) 

Modulating factors of empathy

Empathy is modulated by the intensity of emotions (love, hatred), relationship (familiarity, similarity, affective link), context (appraisal of the situation) as well as the gender, personality traits and emotional repertoire of the person who is empathizing. (Viznemont and Singer, 2006, TICS)

Empathy is modulated by fairness (Singer, 2006, Nature). We resonate with the pain of someone we like and are familiar with and less with someone we don't like or are unfamiliar with. We resonate with the pain of someone from our own group more. Fairness based motivation predicts revenge but compassion motivation doesn't produce the same pattern. Could we use compassion and equanimity training to reduce the incidence of conflict?

Singer wants to experiment with biofeedback - by showing subjects images of their activated insula and getting them to focus on increasing the activity in this part of the brain. She also wants to investigate the effect of compassion training on overall wellbeing. 

Cooperation and fairness

Both fairness and compassion based motivation can support cooperation in the case of positive reciprocity, that is when someone responds to fairness with fairness. Fairness based motivation leads to a breakdown in cooperation manifested as a a desire for revenge and punishment when norms are being violated. Punishment is somewhat helpful in maintaining cooperation in the case of lack of fair-play.

In compassion based motivation - generosity and forgiveness can counteract a desire for revenge buffer the decline into tit-for-tat pattern. (Batson and Ahmad, 2001). However those who are compassionate may be exploited, so some training in fairensess based motivation is important.

The affective states underlying fariness are fear and anger and underlying compassion are love and wish for the others' well-being. They have different impact on health.

The science of compassion 2012. Polyvagal theory

Posted on December 7, 2012 at 7:53 PM Comments comments (0)
Origins of compassion. A phylogenetic Perspective. This was a presentation delivered at the Compassion Conference (Telluride, 2012)

Stephen A. Porges, Phd, is the author of the polyvagal theory, which states that the tenth cranial nerve plays an important role in affiliative motivation. He focuses on core processes in the body on which psychological processes may reside. 

Dr Porges states that compassion is uniquely mammalian and  neuro-physiologically incompatible with judgemental, evaluative and defensive behaviours and feelings that recruit older (reptilian) neural circuits regulating autonomic function. The effectiveness of meditation, listening, chant, posture and breath on fostering mental states and health is due to a common phylogenetic change in the neural regulation of the autonomic nervous system. These practices are all recruiting the newer mammalian circuits. 

Unlike reptiles, mammals have two vagal circuits. The ancient vagus is unmyelinated and regulates gut and sub-diaphragmatic organs. The myelinated vagus is specifically mammalian and regulates supra-diaphragmatic organs (lungs and heart).

Bi-directional interactions among brainstem source nuclei of the myelinated vagus and several cranial nerves that regulate the striated muscles of the face and head result in "face-heart" connection with "portals" that regulate "state". The myelinated vagus down-regulates stress response. This system provides portals of manipulation. These state regulating portals are the voice (self-talk, chants), ear (listening to another), facial muscles (relaxing them), breathing (prolonging exhalation) and posture (dance, open posture) 

Compassion requires turning off our defenses. Our physiological state colours our perception of the world. The same stimuli can trigger different responses depending on our physiological states. The autonomic nervous system is also related to the brain. Our visualisations, thoughts can be transmitted from brain to body, but also the body can promote information upward, changing our cognitive states and our capacity to relate to the world. The vagus nerve essentially reads our body and sends the information to the cortex.

Defense turns off the mammalian "innovations", essentially the ANS and the face-heart connection. Faces become blank or flat when people become scared or challenged or in pain. The neural tone to the heart increases. When the face becomes animated, the vagal activity to the heart is calming. 

Compassion requires turning off biobehavioural defense systems in the "dyad" to enable both "compassionate" individual and the other to be safe, to be proximal and to enable physical contact. We are capable of picking up from facial cues whether someone is genuinely compassionate or acting out of duty. The delivery of service in a medical model requires the person to be genuinely loving and caring for the target person to be receptive to that type of support. 

Polyvagal Theory. Explains the functional relevance of the mammalian modifications of the ANS and emphasizes the adaptive consequences of detecting risk on physiological state, social behaviour, psychological experience and health. We use our newer circuits first and when they don't serve to put us in safer environments, we use older and older circuits. It is not a cognitive or a perceptual response. 

Neuroception is the body's ability to detect risk outside awareness and when it detects risk it shifts us into these different states. We take cues both from the external world and from inside the body and this is interpreted by the nervous system (an unconscious response) and this triggers different physiological states. In a state of safety we can spontaneously engage with others (eye contact, good facial expression, voice has prosody and when we do all this this supports visceral homeostasis and health). When we feel safe we are able to use another person in the dyadic interaction to help regulate our state. 

When our nervous system detects features that are not safe, then it goes into a more mobilised state. Muscle tension increases, heart rate increases, the voice is squeaky - you are now prepared for fight-flight behaviour. If the nervous system identifies the situation as life threatening and there is no possibility of getting away, the system shuts down (immobilisation, death feigning). Society is always pushing people to their limits. We need to down-regulate mobilisation to put people in the safe state and in this state we can be bold, creative and engaged.

The dyad is essential in regulating physiological state. Mother-infant interaction promotes a feeling of safety. This is not solely a human response - this is shared by other mammals. Face to face interaction helps tie the vagal nerve (the tenth)
to facial muscles, the larynx and the heart. When you are safe you can be immobilised without fear. This can only occur following the establishment of "safety" via the social engagement system. Without feeling safe, immobilisation triggers life-threat experiences. 

Bodily feelings influence our awareness of others and either potentiate spontaneous social engagement behaviours and feelings of compassion or defensive reactions and judgemental feelings. Compassion is a manifestation of our biological need to engage and to be with others and a component of our biological quest for safety in the proximity of another. 

Research into the brain of a psychopath

Posted on November 26, 2012 at 11:58 AM Comments comments (97)
BBC News Health online article by Matthew Taylor: Psychopaths: Born evil or with a diseased brain?

The article presents the work of neuroscientist Dr Kent Kiehl of the University of New Mexico who travels across prisons in the USA scanning the brains of people with custodial sentences for serious offences such as rape or murder. He sees psychopaths not as evil, but as people who suffer from a disorder of brain function. 

Death and the doctor

Posted on November 19, 2012 at 4:52 PM Comments comments (1)
After hearing dr. Elaine Kasket on Digital Human I became interested in her research on the many facets of how we experience death and mourn. I found two articles Death and the Doctor published by Dr. Kasket in the Journal of Existential Analysis (2006). These are extracts from her doctoral thesis. (Death and the Doctor I and II) I was excited to find this research because it links in with my current interest into how the death of a client through suicide is affecting mental health clinicians such as psychotherapists, counsellors psychiatrists and clinical psychologists. 

Ultimate rescuer
Dr. Kasket is reflecting on the status of the physician in relation to the modern experience of dying.  She says: “With the modern decline of religion and elevation of science and technology, the fight against death is a war, with the charge led by the physician. Society and patients cast physicians in a highly pressurized role that is both potentially rewarding and potentially awkward” (p. 137) The doctor thus  becomes the "ultimate rescuer" (Yalom, 1980), a role both imposed and eagerly accepted by the physician, who may himself be motivated to enter the medical field by a personal need to overcome his death anxiety. 

"Be strong" as a professional norm
Dr. Kasket reviews the existing literature on how doctors' responses to their patients and their suffering or demise is subtly shaped by their training and work culture. Physicians supervise their own emotional response by considering informal professional norms and client expectations.
“When emotional expression is discouraged and not allowed space, when faculty members do not ask about students’ affective responses, when it is explicitly stated that too much emotional involvement will interfere with good patient care, and when hard work and academic pressures are so strong as to cause emotional blunting, medical students get the message that negative emotions and their management are a private matter and their own “problem”, to be dealt with by themselves and not part of their professional development” (p. 140)

Physicians are expected to maintain “affective neutrality” – a highly valued aspect of professional identity, associated with power, knowledge and being above challenge. The underlying assumption seems to be that an effective physician does not become emotionally involved with patients. 

Strategies against the experience of emotional pain
Defense mechanisms such as intellectualisation, use of scientific technical language, thinking about the patient as a "case",  black humour and  suppression of feelings are learned and employed, leading to blunted emotional awareness and a reduced capacity to communicate effectively. 
Other emotion management strategies employed by doctors are: deflecting attention from personal feelings, blaming the patient, making the patient responsible for the doctor’s feelings, projecting. Some doctors may choose specializations where they believe they are less likely to be confronted by death – such as psychiatry, cosmetic surgery, pathology.

Dr. Kasket conducted a qualitative research into the experience of eight doctors and found that they are impacted deeply by the death of their patients and become frequently experience grief and a radical re-assessment of their professional capacity. 
“The dying patient challenges physician’s carefully constructed and reinforced view of themselves that they are experts, who know what is wrong and who know what needs to be done to cure the patient. Not being able to effect that cure can lead to identity confusion, feelings of personal failure and self-esteem crises. (…) After a death, physicians are left doubting themselves: Did they do something wrong? Could something more have been done to prevent the death? Is their grief reaction abnormal? Will it interfere with their work?” (p.144)
Physicians who lose clients become uncertain about diagnosis and about treatment. Terror of making a mistake that could result in death, which could provoke a crisis of identity and have important consequences legally and professionally.
Common coping strategies include: seeking support socially, self-talk, avoidance and wishful thinking. Negative strategies: lashing out, blaming self and others, taking alcohol or drags, intellectualisation, avoidance, crying. They may not be able to take time to reflect or have a private emotional moment. Other behaviours: heroic attempts to sustain life, resuscitation at any cost, unnecessary tests for a patient who is dying, over-prescribing medication.

Zero degrees of empathy

Posted on November 7, 2012 at 8:03 AM Comments comments (99)
Empathy. It is considered an essential skill and a core condition (Rogers) in psychotherapy and counselling. It is the ability to put oneself in another person's shoes, to experience the world as they are experiencing it. In essence when we are being empathic we are recreating in our own mind and body a map of another person's mind, we are resonating with their pain and experiencing it as our own. 

A while ago I read a book by Simon Baron-Cohen "Zero degrees of empathy". Baron-Cohen asked the question "why does evil exist?" and wanted to find a scientific answer rather than a religious one. Baron-Cohen is an expert in autism, a condition which is characterised by a person's reduced ability to pick up and interpret another person's facial and bodily expressions in order to understand what they are feeling. This causes a considerable amount of strain socially. People are unable to gauge whether what they are doing is appropriate to the situation at hand. For instance, they might tell you a story about a subject that they are passionate about and fail to notice that you are drifting off, getting bored and would like them to stop. People with autism feel lost in social situation. They find it difficult and confusing - a minefield. They notice that people frequently get irritated and fed-up and this is scary because they don't understand what they've done wrong. 

People with high-functioning autism (Asperger's) can be helped to manage social situations by being taught about non-verbal communication and the significance of social cues. It's a little bit like learning to colour by numbers. 

There is another category of individuals tthat display zero-empathy. Baron-Cohen suggests that in this category are people on the high-end of spectrum of personality disorders such as borderline personality disorder (BDP), narcissistic personality disorder and antisocial personality disorder. 

Amongst other traits, patients diagnosed with BDP show an inability to connect with the pain caused to others through their self-harming acts and suicidal threats. They do not understand or experience the turmoil and the extreme fear that the other person is overwhelmed with. 

Clients with narcissistic structures are unaware of the other having any needs. They fill up the space with their discourse and tend to put others down. 

Antisocial personality disorder (psychopathy) is a condition rarely encountered in the therapy room. Psychopaths who are also violent and break the law tend to end up in prison. Those who don't break the law may be highly successful professionals. Cambridge trained psychology researcher dr. Kevin Dutton is fascinated by psychopaths. He has interviewed many of these individuals. 

Dutton has a certain admiration for psychopaths. He has found that some psychopathic traits (charm, ruthlessness, low empathy, focus, low stress response under pressure), if  coupled in an individual with high intelligence and low predisposition to violence may be highly useful in certain professions such as surgery, law and the arm and facilitate a high degree of achievement in these areas. (Psychopath in your family is a short film uploaded on his website I also found this documentary: I am fishead that proposes the thesis that corporate leaders are psychopaths)

The psychopath can accurately create a map of another's mind. He (because it tends to be a man) is extremely good at gauging what the other may be experiencing or thinking. However, the psychopath fails to experience another person's pain and are themselves emotionally under-aroused. Functioning MRI brain scans show that in psychopaths the amygdala (the structure of the brain that gets activated when we experience negative emotion and fear) is under-activated. 

In other words psychopaths cannot display the kind of "hot" empathy that translates into compassion and moral restrain. They are very good at thinking on their feet, focused, driven and because they brain/body rarely triggers the stress response, their verbal and manual performance remains highly accurate even in the most daunting situations. 

Why is that? Stress response translates partly into the release of a steroid hormone - cortisol. This hormone triggers bodily reactions that are biased towards facilitating a motor reaction such as running really fast. Prolonged exposure to glucocorticoids however has negative effects on the hippocampus (the part of the brain involved in the retrieval of autobiographical memory). We have all experienced stressful situations in which we feel tongue tied and cannot remember facts that we do know. Cortisol is to blame. In fact, cortisol not only interferes with the functioning of the hippocampus but can also contribute to premature cell death at this site. Prof. Dr. Robert Sapolsky from Stanford University has proved that stress has a negative effect on memory and the hippocampus. (The audio of his talk Stress and memory Forget it! is uploaded on youtube. Ignore the picture of the cat.)

Psychopaths have no such concerns. They are able to withstand extremely stressful situations without their nervous system being overwhelmed and without their body swimming with adrenaline or cortisol. 

Unsurprisingly, it turns out that what all people with zero-degree of empathy have in common is that they are not so good at relationships. The inability to hold someone else's mind in your mind, to respond with compassion is not conducive to being able to form a strong bond with another human being. 

The good news is that we are getting better and better at identifying low-empathy in children and that there are ways to train people in empathy. 

And to end, I found this brilliant short animated history of empathy by Jeremy Rifkin. It is called "The empathic civilisation". Rifkin argues traces the evolution of the empathic brain and argues that our ability to extend empathy to others with whom we don't share the same culture and religion, as well as to other species is essential to our survival on this planet.