Psychopathy is most commonly assessed with the PCL-R,82 which is a clinical rating scale with 20 items. Each of the items in the PCL-R is scored on a three-point (0, 1, 2) scale according to two factors.
PCL-R Factor 2 is associated with behavioral deficits or antisocial lifestyle,83 more specifically: reactive anger, anxiety, increased risk of suicide, criminality, & impulsive violence. PCL-R Factor 1, in contrast, is associated with personality deficits or aggressive narcissism,83 more specifically: extraversion & positive affect. Factor 1, the so-called core personality traits of psychopathy, may even be beneficial for the psychopath (in terms of non‑deviant social functioning).84 Both case history & a semi-structured interview are used in the analysis.
Because an individual's scores may have important consequences for his or her future, the potential for harm if the test is used or administered incorrectly is considerable. The test can only be considered valid if administered by a suitably qualified & experienced clinician under controlled conditions.3285
edit PCL-R items
The following findings are for research purposes only, & are not used in clinical diagnosis. These items cover the affective, interpersonal, & behavioral features. Each item is rated on a score from zero to two. The sum total determines the extent of a person's psychopathy.86
Factor 1
Aggressive narcissism
Glibness/superficial charm
Grandiose sense of self-worth
Pathological lying
Cunning/manipulative
Lack of remorse or guilt
Emotionally shallow
Callous/lack of empathy
Failure to accept responsibility for own actions
Factor 2
Socially deviant lifestyle
Need for stimulation/proneness to boredom
Parasitic lifestyle
Poor behavioral control
Promiscuous sexual behavior
Lack of realistic, long-term goals
Impulsiveness
Irresponsibility
Juvenile delinquency
Early behavioral problems
Revocation of conditional release
Many short-term marital relationships
Criminal versatility
One issue related to the assessment of individuals who may exhibit affective, interpersonal, & behavioral features associated with psychopathy is the ability to overcome gender myths when the psychopathy features are present in females.87 The Hare Psychopathy Checklist-Revised has both percentiles & T-score tables for male & female offenders.
In his 1941 book, Mask of Sanity, Hervey M. Cleckley introduced 16 behavioral characteristics of a psychopath: 90
Superficial charm & good "intelligence"*
Absence of delusions & other signs of irrational thinking*
Absence of nervousness or psychoneurotic manifestations*
Unreliability
Untruthfulness & insincerity
Lack of remorse & shame
Inadequately motivated antisocial behavior
Poor judgment & failure to learn by experience
Pathologic egocentricity & incapacity for love
General poverty in major affective reactions
Specific loss of insight
Unresponsiveness in general interpersonal relations
Fantastic & uninviting behavior with drink & sometimes without
Suicide threats rarely carried out*
Sex life impersonal, trivial, & poorly integrated
Failure to follow any life plan.
*These characteristics have since been depreciated.58
Hare Psychopathy Checklist
Main article: Hare Psychopathy Checklist
Psychopathy is most commonly assessed with the PCL-R,82 which is a clinical rating scale with 20 items. Each of the items in the PCL-R is scored on a three-point (0, 1, 2) scale according to two factors.
PCL-R Factor 2 is associated with behavioral deficits or antisocial lifestyle,83 more specifically: reactive anger, anxiety, increased risk of suicide, criminality, & impulsive violence. PCL-R Factor 1, in contrast, is associated with personality deficits or aggressive narcissism,83 more specifically: extraversion & positive affect. Factor 1, the so-called core personality traits of psychopathy, may even be beneficial for the psychopath (in terms of non‑deviant social functioning).84 Both case history & a semi-structured interview are used in the analysis.
Because an individual's scores may have important consequences for his or her future, the potential for harm if the test is used or administered incorrectly is considerable. The test can only be considered valid if administered by a suitably qualified & experienced clinician under controlled conditions.3285
edit PCL-R items
The following findings are for research purposes only, & are not used in clinical diagnosis. These items cover the affective, interpersonal, & behavioral features. Each item is rated on a score from zero to two. The sum total determines the extent of a person's psychopathy.86
Factor 1
Aggressive narcissism
Glibness/superficial charm
Grandiose sense of self-worth
Pathological lying
Cunning/manipulative
Lack of remorse or guilt
Emotionally shallow
Callous/lack of empathy
Failure to accept responsibility for own actions
Factor 2
Socially deviant lifestyle
Need for stimulation/proneness to boredom
Parasitic lifestyle
Poor behavioral control
Promiscuous sexual behavior
Lack of realistic, long-term goals
Impulsiveness
Irresponsibility
Juvenile delinquency
Early behavioral problems
Revocation of conditional release
Many short-term marital relationships
Criminal versatility
One issue related to the assessment of individuals who may exhibit affective, interpersonal, & behavioral features associated with psychopathy is the ability to overcome gender myths when the psychopathy features are present in females.87 The Hare Psychopathy Checklist-Revised has both percentiles & T-score tables for male & female offenders.
edit DSM & ICD
There are currently two widely established systems for classifying mental disorders — Chapter V of the International Classification of Diseases (ICD-10) produced by the World Health Organization (WHO) & the Diagnostic & Statistical Manual of Mental Disorders (DSM-IV) produced by the American Psychiatric Association (APA). Both list categories of disorders thought to be distinct types, & have deliberately converged their codes in recent revisions so that the manuals are often broadly comparable, although significant differences remain.
While previous versions of the DSM listed psychopathy as a personality disorder, currently it is not an diagnosis in these classifications. Labeling a person as a psychopath involves forensic measurement, using a diagnostic tool such as the Hare Psychopathy Checklist (PCL-R). The PCL-R is widely considered the "gold standard" for assessing psychopathy. Psychopathy is most strongly correlated with DSM-IV antisocial personality disorder (ASPD), & the ICD-10 antisocial personality disorder & dissocial personality disorder (DPD). However, the PCL-R criteria for identifying a psychopath are stricter than the diagnostic criteria for ASPD or DPD; psychopaths represent a subset of those with ASPD, & psychopaths' traits are more severe.86 A psychopath will score high on both PCL-R factors, whereas someone with ASPD who is not a psychopath will score high only on Factor 2.84
Some researchers are critical of the changed diagnostic criteria. Antisocial personality disorder is diagnosed via behavior & social deviant behaviors, whereas a diagnosis of psychopathy also includes affective & interpersonal personality factors. The Hare Psychopathy Checklist is better able to predict future criminality, violence, & recidivism than the diagnosis of ASPD using the DSM-III-R. Robert D. Hare writes that there are also differences between psychopaths & others on "processing & use of linguistic & emotional information" while such differences are small between those diagnosed with ASPD & not.8889 However, the Hare Psychopathy Checklist requires the use of a rather long interview & availability of considerable additional information89 as well as depending in part on judgements of character rather than observed behavior. Hare writes that the field trials for the DSM-IV found personality traits judgements to be as reliable as those diagnostic criteria relying only on behavior but that the personality traits criteria were dropped in part because it was feared that the average clinician would not use them correctly. Hare criticizes the instead used DSM-IV criteria for being poorly empirically tested. In addition, the introductory text description describes the personality characteristics typical of psychopathy, which Hare argues make the manual confusing & actually containing two different sets of criteria. He also argues that confusion regarding how to diagnose ASPD, confusion regarding the difference between ASPD & psychopathy, as well as the differing future prognoses regarding recidivism & treatability, may have serious consequences in settings such as court cases where psychopathy is often seen as aggravating the crime.88
The DSM-V working party is recommending a revision of antisocial personality disorder to include "Antisocial/Psychopathic Type", with the diagnostic criteria having a greater emphasis on character than on behavior.5
edit Cleckley Checklist
In his 1941 book, Mask of Sanity, Hervey M. Cleckley introduced 16 behavioral characteristics of a psychopath: 90
Superficial charm & good "intelligence"*
Absence of delusions & other signs of irrational thinking*
Absence of nervousness or psychoneurotic manifestations*
Unreliability
Untruthfulness & insincerity
Lack of remorse & shame
Inadequately motivated antisocial behavior
Poor judgment & failure to learn by experience
Pathologic egocentricity & incapacity for love
General poverty in major affective reactions
Specific loss of insight
Unresponsiveness in general interpersonal relations
Fantastic & uninviting behavior with drink & sometimes without
Suicide threats rarely carried out*
Sex life impersonal, trivial, & poorly integrated
Failure to follow any life plan.
*These characteristics have since been depreciated.58
edit Other diagnostic considerations
edit Primary-secondary distinction
Primary psychopathy was defined by those following this theory as the root disorder in patients diagnosed with it, whereas secondary psychopathy was defined as an aspect of another psychiatric disorder or social circumstances.91 Today, primary psychopaths are considered to have mostly Factor 1 traits from the PCL-R (arrogance, callousness, manipulativeness, lying) whereas secondary psychopaths have a majority of Factor 2 traits (impulsivity, boredom proneness, irresponsibility, lack of long-term goals).92
The primary psychopath engages in antisocial behavior as a result of a genetic-biological predisposition directed by particular psychodynamic forces that occur in infancy. The secondary psychopath's antisocial behavior is the result of strictly environmental forces (e.g., membership in a deviant group) that occur at developmental stages beyond infancy. The fundamental distinction between the two is the ability to attach emotionally to others & to experience the natural anxiety associated with human attachment. The primary psychopath forms no attachments as a result of early developmental obstruction, & thus is capable of harming others with little or no anxiety. The secondary psychopath forms human attachments, possibly to deviant subgroups, or not. However, whether or not the secondary psychopath appears to be attached to others, emotional connection to other human beings is present.3
Secondary psychopaths show normal to above-normal physiological responses to (perceived) potential threats; their crimes tend to be unplanned & impulsive with little thought of the consequences.17 According to those using this theory, this type have hot tempers & are prone to reactive aggression. They experience normal to above-normal levels of anxiety but are nevertheless highly stimulus-seeking & have trouble tolerating boredom. Their lifestyle may lead to depression & even suicide.
Mealey uses the term "primary psychopathy" to differentiate between psychopathy that is biological in origin & "secondary psychopathy" that results from a combination of genetic & environmental influences.93 Lykken prefers sociopathy to describe the latter.
Sellbom & Ben-Porath (2005) describe the distinction:
Some people who engage in violent behavior possess psychopathic personality traits, such as callousness, grandiosity, & fearlessness, & presumably engage in such conduct because they care little about others. Others are impulsive & experience considerable anger, anxiety, & distress & may commit violent acts as a reaction to negative emotions, which are sometimes referred to as "crimes of passion." Indeed, the distinction between primary & secondary psychopathy (including so-called neurotic psychopathy) has long been noted in the psychopathy literature (Karpman, 1947; Lykken, 1995).94
This distinction closely resembles the distinction between instrumental & impulsive/reactive crime/violence in the field of criminology.citation needed
Joseph P. Newman et al., who use this concept of psychopathy, have validated David T. Lykken's conceptualization of psychopathy subtypes in relation to Gray's behavioral activation system & behavioral inhibition system.95 Newman et al. found measures of primary psychopathy to be negatively correlated with Gray's behavioral inhibition system, a construct intended to measure behavioral inhibition from cues of punishment or nonreward.95 In contrast, measures of secondary psychopathy to be positively correlated with Gray's behavioral activation system, a construct intended to measure sensitivity to cues of behavioral approach.95
edit Psychopathy vs. sociopathy
Hare writes that the difference between sociopathy & psychopathy may "reflect the user's views on the origins & determinates of the disorder." The term sociopathy may be preferred by sociologists that see the causes as due to social factors. The term psychopathy may be preferred by psychologists who see the causes as due to a combination of psychological, genetic, & environmental factors.96
David T. Lykken proposes psychopathy & sociopathy are two distinct kinds of antisocial personality disorder. He believes psychopaths are born with temperamental differences such as impulsivity, cortical underarousal, & fearlessness that lead them to risk-seeking behavior & an inability to internalize social norms. On the other hand, he claims sociopaths have relatively normal temperaments; their personality disorder being more an effect of negative sociological factors like parental neglect, delinquent peers, poverty, & extremely low or extremely high intelligence. Both personality disorders are the result of an interaction between genetic predispositions & environmental factors, but psychopathy leans towards the hereditary whereas sociopathy tends towards the environmental.92
edit Three-factor model
Recent statistical analysis using confirmatory factor analysis by Cooke & Michie97 indicated a three-factor structure, with those items from factor 2 strictly relating to antisocial behaviour (criminal versatility, juvenile delinquency, revocation of conditional release, early behavioural problems, & poor behavioural controls) removed from the final model. The remaining items are divided into three factors: Arrogant & Deceitful Interpersonal Style, Deficient Affective Experience, & Impulsive & Irresponsible Behavioural Style.97
Hare & colleagues have published detailed critiques of the Cooke & Michie hierarchical ‘three’-factor model, citing severe statistical problems. Hare & colleagues note that the Cooke & Michie model actually contains ten factors, & results in impossible parameters (negative variances). Hare & colleagues also note conceptual problems with this model.98
edit Discrete vs. continuous
As part of the larger debate on whether personality disorders are distinct from normal personality, or if they are extremes on various dimensions of normal personality, is the debate on whether psychopathy represents something "qualitatively different" from normal personality, or a "continuous dimension" shading from normality into severely psychopathic. Otto Kernberg believed psychopathy should fall under a spectrum of pathological narcissism, that ranged from narcissistic personality on the low end, malignant narcissism in the middle, & psychopathy at the high end.99
Early taxonometric analysis from Harris & colleagues100 indicated a discrete category may underlie psychopathy, but this was only found for the behavioural Factor 2 items, indicating this analysis may be related to Antisocial Personality Disorder rather than psychopathy per se. Marcus, John, & Edens more recently performed a series of statistical analysis on previously attained PCL–R & PPI scores & concluded psychopathy may best be conceptualized as having a "dimensional latent structure" like depression.101
edit Comorbidity
Psychopaths may have various others mental conditions,102 although, in contrast to people with antisocial personality disorder, comorbidity among psychopaths is generally found to be low.103104
Substance abuse has been associated with psychopathy,105 particularly Factor 2 (anti-social behaviour), but not Factor 1 (emotional) scores of the PCL-R.102103 Conduct disorder & ADHD have both been associated with psychopathy; which may be explained by disruption to dorsolateral prefrontal cortex. This area is associated with executive function, which is affected in all three disorders.102
There is some evidence of an association between ASPD & other personality disorders (i.e. histrionic, narcissistic & borderline personality disorders),103 however, evidence for a link with psychopathy is more tentative.104
Anxiety may be associated positively with antisocial behaviour, but it is inversely associated with Factor I (emotional) scores on the PCL-R.102 Depression is inversely associated with psychopathy.102 There is no conclusive evidence for a link between psychopathy & schizophrenia.102104
It has been suggested that psychopathy may be comorbid with several other diagnoses than these,105 however limited work on comorbidity has been carried out. This may be because of difficulties in using inpatient groups from certain institutions to assess comorbidity, owing to the likelihood of some bias in sample selection.102 Furthermore, comorbidity may be more reflective of poor discriminant validity of categories in the DSM-IV than reflective of underlying aetiologically separate conditions.103
edit Psychopathy & Sexual Deviance
Sexual preferences are usually considered deviant when they stray statistically from the norm and, when acted on, tend to inflict unwanted harm on oneself or others (Lalumière & Quinsey, 1999). In a study conducted by Barbaree et al. (1994) using Penile Plethysmography, psychopaths showed more increased penile blood flow than did controls upon being shown deviant visual & auditory stimuli. This may be due to the psychopath’s complete disregard for social norms & lack of attachment to others. The desire to be socially accepted is so deeply ingrained into the minds & personalities of average humans, that to some extent this dictates our sexual feelings. While the psychopath will attempt to blend in, their undisclosed desires are completely uninhibited by social standards. There is also evidence to suggest that psychopathic sexual offenders use more violence against their victims than do nonpsychopathic sexual offenders, suggesting that the psychopath may have a higher propensity to be sexually sadistic. Woodworth et al. (2003) examined the correlation between PCL-R scores & types of aggression expressed in a sample of 38 sexual murderers. 84.7% of these individuals scored in the moderate to high range (scores significantly higher than those of a group of nonsexual murderers). Also, murders committed by psychopaths (those with a score of 20 or above) showed more gratuitous & sadistic violence than those of nonpsychopaths. 82.4% of psychopaths committed sadistic violence against their victims, compared to only 52.6% of nonpsychopaths.
edit Epidemiology
It is estimated that approximately one percent of the general population are psychopaths.12 A 2009 British study reported a community prevalence of 0.6%, consistent with the estimate given by the screening version of the psychopathy checklist.106
The psychologist Robert Hare in his book, "Without Conscience: The Disturbing World of Psychopaths among Us", argues that psychopathy has a genetic predisposition. He goes on to state that many psychopaths have a pattern of mating with, & quickly abandoning women, & as a result, have a high fertility rate. These children may inherit a predisposition to psychopathy. Hare describes the implications as chilling.107
edit Among criminals
A 2002 literature review of studies on mental disorders in prisoners stated that 47% of male prisoners & 21% of female prisoners had anti-social personality disorder.108 According to an unsourced article in popular science magazine Scientific American, studies indicate that about 25% of prison inmates meet diagnostic criteria for psychopathy.9 A 2009 study of British prisoners found a prevalence for "categorically diagnosed psychopathy" of 7.7% in men & 1.9% in women.109
Homocides by psychopaths were almost always (93.3%) done in "cold blood" & premeditated in a 2002 study. For non-psychopaths the figure was 48.4% due to a much larger share of "crimes of passion".110
Despite having several characteristics that may seem useful to terrorists, there is little evidence that the majority of terrorists are psychopaths. Other characteristics such self-centeredness, unreliability, poor behavioral controls, & unusual behaviors may be disadvantages or make psychopaths unwilling to sacrifice themselves for a perceived higher cause.111 Indeed, the increased narcissism may produce the attitude that there is no higher cause than the pleasure of the psychopath.
A 2011 study of conditional releases for Canadian male federal offenders found that psychopathy was related to more violent & non-violent offences but not more sexual offences. For child molesters psychopathy was associated with more offences. Despite "their extensive criminal histories & high recidivism rate", psychopaths showed "a great proficiency in persuading parole boards to release them into the community." "High-psychopathy offenders (both sexual & non-sexual offenders) were about 2.5 times more likely to be granted conditional release than non-psychopathic offenders."112
edit Management
edit Clinical management
In practice, mental health professionals rarely treat psychopathic personality disorders as they are often considered untreatable & no interventions have proved to be effective. However, some of the difficulty has been attributed to the lack of clarity about the concept & diagnosis of psychopathy; the threat of danger to staff, or deceit or poor motivation from patients; & a lack of follow-up to test effectiveness. Despite pessimism, as of 1999, treatment of patients still takes place in a variety of psychiatric hospitals & secure units, & the research has indicated that some individuals do show some improvements when the right treatment is identified, & that longer periods of therapy often produce better results.113
It has been shown that punishment & behavior modification techniques do not improve the behavior of psychopaths. Psychopathic individuals have been regularly observed to become more cunning & better able to hide their behaviour. It has been suggested that traditional therapeutic approaches actually make psychopaths more adept at manipulating others & concealing their behavior. They are generally considered to be not only incurable but also untreatable.8
However, some researchers suggest that psychopaths can benefit as much as others from psychological treatment, at least in terms of criminal behaviors even if not on the central personality traits.9 For example, one therapeutic approach to juveniles reports reduced re-offending over a two year period compared to usual care.114
edit Legal response
edit United Kingdom
In the United Kingdom, "Psychopathic Disorder" was legally defined in the Mental Health Act (UK)115 as, "a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned." This term, which did not equate to psychopathy, was intended to reflect the presence of a personality disorder, in terms of conditions for detention under the Mental Health Act 1983. With the subsequent amendments to the Mental Health Act 1983 within the Mental Health Act 2007, the term 'psychopathic disorder' has been abolished, with all conditions for detention (e.g. mental illness, personality disorder, etc.) now being contained within the generic term of 'mental disorder'.
In England & Wales, the diagnosis of dissocial personality disorder is grounds for detention in secure psychiatric hospitals under the Mental Health Act if they have committed serious crimes, but since such individuals are disruptive for other patients & not responsive to treatment this alternative to prison is not often used.116
edit United States
Psychopathy has quite separate legal & judicial definitions that should not be confused with the medical definition. The American Psychiatric Association is vigorously opposing any non-medical or legal definition of what purports to be a medical condition "without regard for scientific & clinical knowledge." 117 Various states & nations have at various times enacted laws specific to dealing with psychopaths.
In the United States, approximately 20 states currently have provisions for the involuntary civil commitment for sex offenders or sexual predators, under Sexually violent predator acts, avoiding the use of the term "psychopath." These statutes & provisions are controversial & are being reviewed by the U.S. Supreme Court as a violation of a person's Fourteenth Amendment rights.118 (See Foucha v. Louisiana for an example.119)
Washington
Washington State Legislature 120 defines a "Psychopathic personality" to mean "the existence in any person of such hereditary, congenital or acquired condition affecting the emotional or volitional rather than the intellectual field & manifested by anomalies of such character as to render satisfactory social adjustment of such person difficult or impossible."118 The same statute defines the "sexual psychopath" as "any person who is affected in a form of psychoneurosis or in a form of psychopathic personality, which form predisposes such person to the commission of sexual offenses in a degree constituting him a menace to the health or safety of others" for prison sentencing purposes in the Sentencing Reform Act of 1981.120
California
California enacted a psychopathic offender law in 1939, since greatly outmoded & revised,121 that defined a psychopath solely in terms of offenders with a predisposition "to the commission of sexual offenses against children." A 1941 law122 attempted to further clarify this to the point where anyone examined & found to be psychopathic was to be committed to a state hospital & anyone else was to be sentenced by the courts. However, these laws were enacted years before the American Psychiatric Association began publishing the Diagnostic & Statistical Manual of Mental Disorders which is used today for diagnosis & does not include "psychopathic offender". Hence, these laws are of historical interest only.
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