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INTRODUCTION
The characteristics of psychopathy as a personality disorder include the presence of antisocial behavior, lack of empathy, a tendency to manipulate others, lack of guilt and remorse, and a tendency to impulsiveness which leads to premeditated and violent acts 1. It is estimated that around 1 to 2% of female individuals worldwide have psychopathic traits, while 2 to 4% of male individuals worldwide have traits 2. In Peru, socioeconomic conditions combined with societal problems such as violence, corruption, and delinquency, have been linked to the presence of psychopathic traits and their display 3.
Psychopathy in psychiatry is approached from two different outlooks. Some authors consider that psychopathy leads to maladapted individuals, with a tendency to criminal behavior 4. Other authors, however, consider psychopathy as a combination of complex aspects of an individual's personality, with adaptive and maladaptive behaviors playing a role in its manifestation 5. Psychopathic individuals are described as possessing excessive confidence, with high charisma, a lack of guilt, and a tendency towards dishonesty 6. These traits may be recognized as adaptations that give said individuals an advantage over stressful or dangerous situations, as they may react in a calmer and contained manner 7. As such, these "positive traits" help the psychopathic individual in highly competitive activities, conferring them a degree of versatility that, whilst it has a strong tendency to criminal activity, it also can lead them towards prestigious positions in society, which include the medical field 8.
Psychopathic traits harm the professional development and interpersonal relations of the general population, including healthcare professionals. This can be seen not only in already licensed physicians, but it may also be evidenced since their formative years as medical students 9. Psychopathic traits are more prevalent in surgeons, who previously have been found to display a more fearless, short-term orientated, and calculated train of thought, and reduced sensitivity, while having a high degree of self- control regarding emotions, both their own and of others. This stands in contrast to internal medicine physicians, who have been ascertained to be more empathetic and warmer towards others and to be more long-term orientated 10. There is little information regarding medical students, although previous studies have shown an association between academic success and psychopathic traits. Certain traits have positive outcomes on the individual, as they provide resilience to stress and contribute towards better handling of complex problems involving people management 8. However, others have found that psychopathic traits can be risk factors towards dropping out of the medical career 11.
Taking into consideration that research on psychopathy is scarce, especially when involving medical students, we propose the following study, which aims to evaluate the presence of psychopathic traits in students and the factors associated with it.
METHODS
Study design
This is a cross-sectional study. The participants were enrolled during the last two weeks of november 2020, at the end of the first wave of the COVID-19 pandemic.
Context
The present study was carried out in "Facultad de Medicina Humana - Universidad San Martín de Porres", a private medical school founded on July 6th, 1983, which is in La Molina, a high-income district of Lima, Peru 12. Currently, it has an enrollment of over two thousand medical students, mostly from both middle-class and high-class families, from across the country. The faculty distributes its seven-year undergraduate study curriculum in two main parts: The first part is pre-clinical studies which take three years to complete, during which the students prepare before being sent to hospitals, and do not actively enter in contact with patients. The second part is clinical-surgical studies, which occur in the following four years, and involves active participation and development of the skills learned during their pre-clinical studies and medical rounds, dealing with patients and basic medical procedures. Upon completion of the study curriculum, the medical students are formally recognized as physicians.
Participants
We invited 1824 students from all years of study. The information regarding how many students were taking classes during the deployment of the survey was given by the faculty's administrative area. The students were recruited via an invitation sent to their institutional e-mail address, and a recruitment campaign through social media groups comprised of students, which are subdivided according to the academic year of study and are monitored by faculty staff.
Because the study was conducted considering all students, it was not necessary to calculate the sample size. Of the 1824 prospective participants, we had a total of 497 participants (response rate of 27.3%), after withdrawing those students that declined to participate further (n=14) and eliminating any duplicate responses (n=29), we were left with 497 participants.
Instruments
We employed a four-stage self-administered online questionnaire through Google Forms. The first stage was a survey about the sociodemographic characteristics of the participants. The second, third, and fourth stages, respectively were the Levenson Self-Report Psychopathy Scale, Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7).
Levenson Self-Report Psychopathy Scale (LSRP)
LSRP is a self-administered test that allows the evaluation of psychopathic traits in non- institutionalized adults. The scale includes 26 items graded on a four-point Likert scale (strongly disagree to strongly agree). It provides a total score and two derived dimensions for the clinical subtypes of psychopathy 4. The first derived score refers to the cognitive component of personality, which translates into primary psychopathy, and it is assessed by the first 16 items. The second derived score refers to the behavioral component of personality, which translates into secondary psychopathy, and it is assessed by the last ten items of the test. The scores are reflected in three groups: non-psychopathic (0-48), mixed (49- 57), and psychopathic (58-104) 13. In this research, the spanish version of the LSRP was used, which has been shown to have adequate psychometric properties in a sample of participants from Spain 14.
Additionally, the RLRP has also shown adequate psychometric properties in the general population of Mexico 15.
Patient Health Questionnaire-9 (PHQ-9)
PHQ-9 is a self-administered test, both reliable and validated, comprised of 9 items that are directly related to the severity of symptoms encompassed in depressive disorder during the two weeks before the self-administration of the test 16. Each item is punctuated through a Likert scale that goes from 0 (zero days) to 3 (almost every day). The scores are reflected in five categories of ascending severity of the depressive disorder: none (0-4), mild (5-9), moderate (10-14), moderately severe (15-19), and severe (20- 27). A score of ≥10 has been recommended as the cut-off score for detecting clinically relevant major depressive disorders 17. Furthermore, PHQ-9 has been validated in Peru 18.
Generalized Anxiety Disorder-7 (GAD-7)
GAD-7 is a self-administered test for assessing the severity of anxiety disorders in a clinical setting. Being both effective and validated in several languages, it is one of the most used scales in psychiatric research 19. It is comprised of 9 items, which are directly related to the symptoms encompassed in anxiety during the two weeks before the self-administration of the test. Scores for all 7 items range from 0 (not at all) and 3 (nearly every day). The total scores are reflected in four categories of ascending severity of the anxious disorder: none (0-4), mild (5-9), moderate (10-14), and severe (15-21) 20. A score of ≥10 has been recommended as the cut-off score for indicating clinically relevant anxiety 20. This scale has been translated into spanish and validated in Peru 21.
Further variables
Besides, information regarding the following variables was collected: sex, age, profess religion, year of study, presence of a model for treating patients, medical specialty preferences (person-oriented - specialties that involve dealing directly with conscious patients most of the time, such as internal medicine and pediatrics; or technique-oriented - specialties that involve working with equipment instead of actively dealing with patients, or that do involve dealing with patients, but they are unconscious most of the time, such as radiology or surgery), grade point average, precedent psychiatric diagnosis, and area of study (pre- clinical or clinical-surgical).
Statistical analyses
A descriptive analysis of the participants was carried out using frequencies and percentages. Cohort-points from each of the scales were used to determine levels of depressive symptoms (none, mild, moderate, moderate-severe, and severe), anxious symptoms (none, mild, moderate, and severe), and psychopathic symptoms (non-psychopathic, mixed, and psychopathic).
To evaluate the factors associated to psychopathic traits we applied a generalized linear model with robust variance, assuming a Poisson Distribution with log-link functions. "Non-psychopathic" was used as the basal category, and it was compared against "mixed" and "psychopathic". Possible confounding factors included in the adjusted model were sex, age group, profess religion, if the student has a role model for treating patients, specialty, precedent psychiatric diagnosis, area of study, depressive symptoms (clinically irrelevant: none-mild vs. clinically relevant: moderate to severe), and anxious symptoms (clinically irrelevant: none-mild vs. clinically relevant: moderate to severe). Prevalence ratio (PR) and adjusted prevalence ratio (aPR) were used as a measure of association.
Ethical aspects
The research was carried out with the authorization of the "Comité de Ética" of the "Facultad de Medicina Humana - Universidad de San Martín de Porres" (approval number 837-2020-CIEI-FMH-USMP). The participants' identity was not linked to their results, and as such, anonymity was assured. A waiver was provided for informed consent to participate in the study, and it included a clause of voluntary removal in case a participant did not wish to collaborate any further with the study.
RESULTS
Description of participants and prevalence
67.8% were female, with an average age of 20.86 ± 3.02 years, and belonged to the clinical-surgical area of study (52.5%). 55.1% reported being interested in a person-oriented specialty, such as internal medicine or psychiatry, whilst 44.9% were more inclined towards a technique-centered specialty, such as radiology or surgery. The majority did not report a prior psychiatric diagnosis (87.5%). Finally, 62.2% stated having a role model that influenced their relationship with their patients (Table 1).
Table 1 Sociodemographic characteristics and prevalence of psychopathic, depressive, and anxious symptoms (n = 497)
| Variable | Frequency | Percentage |
|---|---|---|
| Sex | ||
| Male | 160 | 32.2 |
| Female | 337 | 67.8 |
| Age group (years) | ||
| < 18 | 58 | 11.7 |
| ≥ 18 | 439 | 88.3 |
| Profess a religion | ||
| No | 193 | 38.8 |
| Yes | 304 | 61.2 |
| Year of study | ||
| First | 137 | 27.6 |
| Second | 48 | 9.7 |
| Third | 51 | 10.3 |
| Fourth | 101 | 20.3 |
| Fifth | 131 | 26.4 |
| Sixth | 18 | 3.6 |
| Seventh | 11 | 2.2 |
| Do you have a role model for treating patients? | ||
| No | 188 | 37.8 |
| Yes | 309 | 62.2 |
| Medical specialty preference | ||
| Technique-oriented | 223 | 44.9 |
| Person-oriented | 274 | 55.1 |
| Grade point average | ||
| 11.0 to 13.9 | 92 | 18.5 |
| 14.0 to 16.9 | 243 | 48.9 |
| 17.0 to more | 39 | 7.9 |
| Missing | 123 | 24.8 |
| Precedent psychiatric diagnosis | ||
| No | 435 | 87.5 |
| Yes | 62 | 12.5 |
| Area of study | ||
| Pre-clinical | 236 | 47.5 |
| Clinical-surgical | 261 | 52.5 |
| Depressive symptoms | ||
| Clinically relevant | 296 | 59.6 |
| Clinically not relevant | 201 | 40.4 |
| Anxious symptoms | ||
| Clinically relevant | 353 | 71.0 |
| Clinically not relevant | 144 | 29.0 |
| Psychopathic traits | ||
| Non-psychopathic | 234 | 47.1 |
| Mixed | 165 | 33.2 |
| Psychopathic | 98 | 19.7 |
52.9% of the participants were within the psychopathic spectrum: 33.2% of mixed group and full psychopathic group (19.7%). In addition, we estimated that 76.5% of the participants presented some degree of depressive symptoms, and 67.4% presented some degree of anxious symptoms. Regarding the clinically relevant symptoms (moderate-severe), 40.4% were depressive and 29% anxious (Table 1).
Factors associated with psychopathic symptoms
In the regression analysis, the variables associated with a higher frequency of belonging to the psychopathic group were male sex (aPR = 2.10, 95% CI: 1.58-2.79, p < 0.05), having clinically relevant symptoms of depression (aPR = 2.05, 95% CI: 1.41 - 2.96, p < 0.05) and anxiety (aPR = 1.46, 95% CI: 1.01 - 2.09, p < 0.05) (Table 2).
Table 2 Factors associated with psychopathic traits following adjustment for sociodemographic variables (n=497)
| Variable | Non-psychopathic vs Mixed | Non-psychopathic vs Psychopathic | ||
|---|---|---|---|---|
| Crude PR | Adjusted PR a | Crude PR | Adjusted PR a | |
| Sex | ||||
| Female | 1 | 1 | 1 | 1 |
| Male | 1.20 [0.87-1.66] | 1.37 [0.98-1.92] | 1.81 [1.37-2.40] | 2.10 [1.58-2.79] |
| Age group (years) | ||||
| < 18 | 1 | 1 | 1 | 1 |
| ≥ 18 | 0.81 [0.51-1.27] | 0.90 [0.55-1.49] | 0.64 [0.44-0.94] | 0.81 [0.53-1.23] |
| Profess religion | ||||
| No | 1 | 1 | 1 | 1 |
| Yes | 1.02 [0.75-1.40] | 1.07 [0.77-1.49] | 0.91 [0.68-1.20] | 1.01 [0.76-1.35] |
| Do you have a model for treating patients? | ||||
| No | 1 | 1 | 1 | 1 |
| Yes | 0.96 [0.70-1.31] | 1.04 [0.74-1.47] | 0.82 [0.61-1.08] | 0.99 [0.73-1.34] |
| Medical specialty preference | ||||
| Technique-oriented | 1 | 1 | 1 | 1 |
| Person-oriented | 0.91 [0.67-1.24] | 0.94 [0.69-1.28] | 0.83 [0.63-1.09] | 0.99 [0.74-1.33] |
| Precedent psychiatric diagnosis | ||||
| No | 1 | 1 | 1 | 1 |
| Yes | 1.18 [0.74-1.86] | 1.07 [0.66-1.74] | 1.60 [1.11-2.29] | 1.37 [0.94-1.99] |
| Area of study | ||||
| Pre-clinical | 1 | 1 | 1 | 1 |
| Clinical-surgical | 1.27 [0.94-1.73] | 1.24 [0.88-1.74] | 1.65 [1.24-2.19] | 1.24 [0.89-1.71] |
| Depressive symptoms | ||||
| Clinically irrelevant | 1 | 1 | 1 | 1 |
| Clinically relevant | 1.55 [1.14-2.10] | 1.66 [1.14-2.40] | 2.51 [1.88-3.33] | 2.05 [1.41-2.96] |
| Anxious symptoms | ||||
| Clinically irrelevant | 1 | 1 | 1 | 1 |
| Clinically relevant | 1.26 [0.90-1.76] | 0.92 [0.61-1.41] | 2.33 [1.76-3.08] | 1.46 [1.01-2.09] |
PR: Prevalence Ratio. a Adjusted model by sex, age group, profess religion, if have a role model, specialty, precedent psychiatric diagnosis, area of study, depressive symptoms, and anxious symptoms.
DISCUSSION
This study determined a high prevalence of psychopathic traits in medical students (19.7%). This result is similar to what was reported in a previous study conducted in another peruvian medical school, where 19% of the students surveyed had a positive result on a locally adapted version of the Dissocial Behavior Scale (ECODI-27), aimed to study antisocial and dissocial behavior 22. In another study conducted in Colombia, 20.1% of antisocial personality traits have been reported in health sciences students 23. This high prevalence of psychopathic traits may be explained by the population selected for the study. Medicine is regarded as a highly demanding field, and both medical students and physicians are expected to be able to control and manage the emotions of their patients, establish and direct both long-term and short-term strategies, and mix both level-headedness alongside fearlessness when confronting highly stressful situations that may push other individuals over the edge 24. These traits are associated with good academic and labor performance and could be considered adaptive personality traits 7. However, these very traits are also found in antisocial behavior, which alongside recklessness and lack of empathy, constitute the personality disorder known as psychopathy 25.
Furthermore, our study found moderate to severe anxiety symptoms in 29% of the students surveyed. Also, moderate to severe depressive symptoms were found in 40.4% of the participants, revealing that these symptoms were highly prevalent in the medical students, which add up to the negative impact that psychopathy has on their academic, professional, and personal wellbeing 26. University students are part of the population vulnerable to developing mental health problems in the context of the COVID-19 for various reasons, one of which is uncertainty about the future and the potential negative effect on academic progress 27. Furthermore, medical students are known to have higher levels of anxiety, depression, and stress compared to students in other university pathways 28.
Previous studies have ascertained that psychopathic trait are more prevalent in males, like our findings in our study. It must be noted that, according to the literature, psychopathy in males is displayed by aggressive conduct and substance abuse, which makes it more evident to identify psychopathy in females, which displays it more subtly, via lying and harmful gossiping 29. The previous literature, however, derives mostly from studies in prison inmates 30. Undergraduate students, particularly medical students are underrepresented. Thus, more research is warranted to determine if there are other manifestations of underlying psychopathy in this group, such as internet abuse, cramming, procrastinating, plagiarizing, or cheating in exams, for example 31. The significant associations found between depressive and anxious symptoms and psychopathy underlie the need for psychologic and/or psychiatric intervention in the students that require it, and overall, more involvement on behalf of the medical schools regarding their student's mental health, even more so considering the aftermath of the COVID-19 pandemic 32.
Studies have shown that personality traits do influence decision-making when selecting a medical specialty after concluding undergraduate studies at medical school, as well as professional performance 33. These shape the professional and personal growth of the medical student throughout his years in medical school and are subject to negative change due to the inherent exigencies of the medical career; empathy particularly, tends to diminish over undergraduate studies 34. In medical students with psychopathic traits, it is a veritable risk that they become desensitized too quickly, especially when considering the possibility of developing depressive and/or anxious symptoms, and thus monitoring is warranted 35. Additionally, a previous study has found a significant correlation between medical specialty and dissocial, impulsive, and borderline personality disorder separately 36.
While not all aspects of psychopathy are inherently detrimental to the sufferer, they can prove to be harmful to others, particularly when it comes to the recklessness and lack of remorse associated with the condition, adding up to the empathetic impairment also associated with the condition, all in all, making the physician prone to moral judgments against the better interests of the patient, but fully justified to the professional as "necessary risk" 37. Therefore, because it is important to foster a healthy patient-clinician relationship, it is paramount that psychopathy is detected early during undergraduate studies to initiate treatment to mitigate the pernicious effects it will provoke if unchecked 38.
Psychopathy is known for being difficult to treat and being underdiagnosed, which leads to patients being entrenched on the negative traits of the condition for decades while not fostering the "positive" ones. Early diagnosis and treatment translate into preventing the fostering of egocentrism and aggressive behavior while emphasizing decision making and empathy, which helps mitigate the life-long impact that psychopathy traits will have on the medical student 39. Finally, it also must be noted that early diagnosis will help the medical school better exploit the "positive" traits that psychopathy does offer to the medical student displaying these traits, by helping him find a medical specialty better suited for his talents and interests in concordance to his personality, but also one that may be sorely required by the community future physician is going to serve in 40.
This study must be understood in the context of its methodological limitations. Since the study is cross-sectional, we were neither able to evaluate a causal relationship nor how the psychopathic traits evolve. Since we only evaluate students from one medical school, we cannot generalize the results to all medical students from other medical schools or other students from other health careers. Also, an additional bias must be considered relating to an erroneous classification of participants, as the validated self- administered tests do not substitute an individualized evaluation performed by a mental health specialist. Finally, the LSRP is not validated in Peru.
In conclusion, the results of this study indicate a high prevalence of psychopathic traits in students from a medical school in Lima, Peru. The variables associated with a higher frequency of belonging to the psychopathic group were male sex, having clinically relevant depressive symptoms, and anxiety symptoms. More involvement on behalf of the medical school is necessary as to the identification of the psychopathic traits in medical students, which would severely hinder their development as individuals and professionals, in detriment to their patients, if left untreated.
