Antisocial personality disorder and psychopathy: diagnostic dilemmas in classifying patterns of antisocial behavior in sentencing evaluations

Antisocial Personality Disorder (APD) and PCL-R psychopathy are critically examined regarding their application to sentencing determinations. PCL-R psychopathy is emerging in the literature as a more useful forensic diagnostic construct than APD, which appears flawed by multiple weaknesses. These include shifting diagnostic criteria, innumeracy problems, absence of symptom weighting, temporal instability, and the equivalence of some symptoms with substance abuse disorders. Additionally, APD overdiagnosis may result from inattention to issues of social context, trauma history, and symptom pervasiveness. Neither objective nor projective personality testing reliably differentiates APD. Finally, an APD diagnosis does not always indicate criminal, much less incorrigible criminal behavior. By contrast, PCL-R psychopathy results are strongly predictive of criminal behavior and violent recidivism for Caucasian males through mid-life residing in the community. Emerging research with the PCL-R regarding other important populations and contexts is promising but generalization is currently limited. © 1998 John Wiley & Sons, Ltd.     

Unique roles of antisocial personality disorder and psychopathic traits in distress tolerance

Previous research indicates that individuals with antisocial personality disorder (ASPD) evidence low distress tolerance, which signifies impaired ability to persist in goal-directed behavior during an aversive situation, and is associated with a variety of poor interpersonal and drug use outcomes. Based on theory and research indicating that psychopathic traits are associated with hypo-reactivity in emotional responding, a unique hypothesis emerges where psychopathic traits should have the opposite effect of ASPD and be related to high levels of distress tolerance. In a sample of 107 substance-dependent patients in an inner-city substance use residential treatment facility, this hypothesis was supported. ASPD was related to lower distress tolerance, while psychopathic traits were related to higher distress tolerance, with each contributing unique variance. Findings are discussed in relation to different presentations of distress tolerance as a function of psychopathic traits among those with an ASPD diagnosis.     

Inhibitory control and negative emotional processing in psychopathy and antisocial personality disorder

The field of personality disorders has had a long-standing interest in understanding interactions between emotion and inhibitory control, as well as neurophysiological indices of these processes. More work in particular is needed to clarify differential deficits in offenders with antisocial personality disorder (APD) who differ on psychopathic traits, as APD and psychopathy are considered separate, albeit related, syndromes. Evidence of distinct neurobiological processing in these disorders would have implications for etiology-based personality disorder taxonomies in future psychiatric classification systems. To inform this area of research, we recorded event-related brain potentials during an emotional-linguistic Go/No-Go task to examine modulation of negative emotional processing by inhibitory control in three groups: psychopathy (n = 14), APD (n = 16), and control (n = 15). In control offenders, inhibitory control demands (No-Go vs. Go) modulated frontal-P3 amplitude to negative emotional words, indicating appropriate prioritization of inhibition over emotional processing. In contrast, the psychopathic group showed blunted processing of negative emotional words regardless of inhibitory control demands, consistent with research on emotional deficits in psychopathy. Finally, the APD group demonstrated enhanced processing of negative emotion words in both Go and No-Go trials, suggesting a failure to modulate negative emotional processing when inhibitory control is required. Implications for emotion-cognition interactions and putative etiological processes in these personality disorders are discussed.     

Treatment of antisocial personality, psychopathy, and other characterologic antisocial syndromes

Treatment of antisocial personality disorder (APD) and ";core" psychopathy is usually considered a pessimistic clinical exercise. This paper reviews the importance of accurate diagnosis (including differences between APD and other antisocial syndromes), limited techniques for predicting and preventing adult antisocial syndromes, several kinds of treatment that have been attempted with varying success, management of specific antisocial behaviors, and the frustrations-even dangers-of working with severely antisocial patients.     

Differential effects of psychopathy and antisocial personality disorder symptoms on cognitive and fear processing in female offenders

Psychopathy and antisocial personality disorder (APD) have long been considered important risk factors for criminal behavior and incarceration. However, little is known about the psychobiological underpinnings that give rise to the disinhibited behavior of female offenders. Using an instructed fear-conditioning paradigm and a sample of incarcerated female offenders, we manipulated attentional focus and cognitive load to characterize and differentiate between the dysfunctional cognitive and affective processes associated with these syndromes. We used fear-potentiated startle (FPS) and event-related potentials as measures of affective and cognitive processing, respectively. After controlling for APD symptoms, psychopathic women displayed greater FPS while attending directly to threat-relevant stimuli and displayed less FPS while performing a demanding task that directed attention to threat-irrelevant information. Conversely, controlling for psychopathy, women with high APD symptoms displayed less overall FPS, especially when instructed to focus on threat-relevant stimuli. However, as the demands on cognitive resources increased, they displayed greater FPS. For both psychopathy and APD, analysis of the event-related potentials qualified these findings and further specified the abnormal cognitive processes associated with these two syndromes. Overall, simultaneous analysis of psychopathy and APD revealed distinct patterns of cognitive processing and fear reactivity.     

Effects of comorbid psychopathy on criminal offending and emotion processing in male offenders with antisocial personality disorder

Antisocial personality disorder (ASPD) and psychopathy are two syndromes with substantial construct validity. To clarify relations between these syndromes, the authors evaluated 3 possibilities: (a) that ASPD with psychopathy and ASPD without psychopathy reflect a common underlying pathophysiology; (b) that ASPD with psychopathy and ASPD without psychopathy identify 2 distinct syndromes, similar in some respects; and (c) that most correlates of ASPD reflect its comorbidity with psychopathy. Participants were 472 incarcerated European American men who met Diagnostic and Statistical Manual (4th ed., American Psychiatric Association, 1994) criteria for ASPD and Psychopathy Checklist criteria for psychopathy, who met the criteria for ASPD but not for psychopathy, or who did not meet diagnostic criteria for either ASPD or psychopathy (controls). Both individuals with ASPD only and those with ASPD and psychopathy were characterized by more criminal activity than were controls. In addition, ASPD with psychopathy was associated with more severe criminal behavior and weaker emotion facilitation than ASPD alone. Group differences in the association between emotion dysfunction and criminal behavior suggest tentatively that ASPD with and ASPD without prominent psychopathic features may be distinct syndromes.     

Sadistic personality disorder in sex offenders: relationship to antisocial personality disorder and sexual sadism.

To investigate the relationship of sadistic personality disorder (SPD), as defined in the appendix of DSM-III-R, to other personality disorders and to sexual sadism, 70 sex offenders (27 child molesters, 33 rapists, and 10 murderers) were assessed by the International Personality Disorder Examination. In 19 subjects (27.2%) from the total sample, SPD was diagnosed. The highest overlap appeared with borderline personality disorder (31.6%) and antisocial personality disorder (42.1%). However, in four cases SPD was the only personality disorder diagnosed. Factor analysis of the antisocial and sadistic criteria resulted in four major factors--one factor with high loadings on the sadistic criteria and the violent criteria of antisocial personality disorder, two factors with different forms of adult and juvenile aggression, and a fourth factor with high loadings on the antisocial criteria covering exploitative behavior. The results do not support SPD as a discrete disorder. Nevertheless, SPD may be seen as an important subdimension of antisocial personality disorder, distinct from more exploitative forms of antisocial behavior with less violence. Of those patients with SPD, 42.1% also had a DSM-III-R diagnosis of sexual sadism, which may be the most dangerous configuration.     

Psychopathy and the DSM-IV criteria for antisocial personality disorder

The Axis II Work Group of the Task Force on DSM-IV has expressed concern that antisocial personality disorder (APD) criteria are too long and cumbersome and that they focus on antisocial behaviors rather than personality traits central to traditional conceptions of psychopathy and to international criteria. We describe an alternative to the approach taken in the rev. 3rd ed. of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987), namely, the revised Psychopathy Checklist. We also discuss the multisite APD field trials designed to evaluate and compare four criteria sets: the DSM-III-R criteria, a shortened list of these criteria, the criteria for dyssocial personality disorder from the 10th ed. of the International Classification of Diseases (World Health Organization, 1990), and a 10-item criteria set for psychopathic personality disorder derived from the revised Psychopathy Checklist.     

Putting the brakes on antisocial behavior: Secondary psychopathy and post-error adjustments in reaction time

Psychopathy is both a clinical disorder and an individual difference dimension that is strongly predictive of antisocial behavior. The present work focuses on a dimensional understanding of psychopathy and recognizes the distinction between primary and secondary psychopathy. Following from the conceptualization of secondary psychopathy as a type of impulsivity which renders an individual less capable of learning from prior mistakes, the authors hypothesized that individuals high in secondary psychopathy would be less likely to adjust behavioral performance following errors. Two studies, involving a total of 104 undergraduate volunteers, were conducted. As hypothesized, individuals high in secondary (but not primary) psychopathy exhibited a reduced tendency to slow behavioral performance following errors. The findings highlight the manner in which an error self-regulation model can shed light on the processing basis of secondary psychopathy and its correlates.     

Clarifying the role of defensive reactivity deficits in psychopathy and antisocial personality using startle reflex methodology

Prior research has demonstrated deficits in defensive reactivity (indexed by potentiation of the startle blink reflex) in psychopathic individuals. However, the basis of this association remains unclear, as diagnostic criteria for psychopathy encompass two distinct phenotypic components that may reflect differing neurobiological mechanisms-an affective-interpersonal component and an antisocial deviance component. Likewise, the role of defensive response deficits in antisocial personality disorder (APD), a related but distinct syndrome, remains to be clarified. In the current study, the authors examined affective priming deficits in relation to factors of psychopathy and symptoms of APD using startle reflex methods in 108 adult male prisoners. Deficits in blink reflex potentiation during aversive picture viewing were found in relation to the affective-interpersonal (Factor 1) component of psychopathy, and to a lesser extent in relation to the antisocial deviance (Factor 2) component of psychopathy and symptoms of APD-but only as a function of their overlap with affective-interpersonal features of psychopathy. These findings provide clear evidence that deficits in defensive reactivity are linked specifically to the affective-interpersonal features of psychopathy and not to the antisocial deviance features represented most strongly in APD.     

The inclusion of antisocial behavior in the construct of psychopathy: A review of the research

The psychopathic personality, or the construct of this disorder, has a long and contentious history. Psychopathy has been identified anecdotally for centuries; however, the ability to accurately define this construct continues to challenge researchers and clinicians. Of preliminary concern is the relevance of antisocial behavior to this disorder. Theoretical conceptualizations of psychopathy have changed over the past 65 years. Some have stressed the interpersonal and affective deficits of psychopathy [Cleckley, H. (1941). The mask of sanity (1st ed.). St. Louis, MO:C.V. Mosby.], while later conceptualizations have included both personality traits as well as antisocial behavior as criteria of psychopathy [Hare, R. D. (1991/2003). The Hare Psychopathy Checklist—Revised. Toronto, Canada: Multi-Health Systems]. This article will review the literature, particularly the relevance of antisocial behavior to the core personality structure of the psychopath. In doing so, historical theories will be reviewed, followed by later theoretical and empirical research. A great deal of this research has been conducted over the past 15 years, since the publication of the Psychopathy Checklist (PCL) and the Psychopathy Checklist-Revised (PCL-R; [Hare, R. D. (1991/2003). The Hare Psychopathy Checklist—Revised. Toronto, Canada: Multi-Health Systems]). The PCL-R has provided the field of psychopathy research with a consistent measurement device, and, therefore will be discussed at length. The limitations of the psychopathy construct will be discussed as well as needed future research and the policy implications of such research.     

Personality disorder and antisocial deviance: comments on the debate on the structure of the psychopathy checklist-revised

The recent debate on the structure of the Psychopathy Checklist-Revised (PCL-R: Hare, 1991; 2003) has been presented primarily as a statistical issue, but underlying it are longstanding conceptual issues about the relationship of personality concepts to deviant behavior and of psychopathy to criminality and personality disorder. I discuss these issues in this paper. The antisocial items of the PCL-R seem to reflect a propensity to commit crimes that has long been of interest to criminology. This disposition overlaps with, but differs conceptually from personality dispositions, but these surface dispositions do not provide a causal account of criminality. I present data that indicate that the core personality characteristics of psychopathy are more closely related to narcissistic and histrionic personality disorders than to antisocial personality disorder. Overemphasis on involvement in crime has obscured the nature of psychopathy as a disorder of personality characterised by interpersonally harmful behavior that need not necessarily take criminal form.     

Identifying persistently antisocial offenders using the Hare Psychopathy Checklist and DSM antisocial personality disorder criteria

Early starting, lifetime criminal persistence has been called sociopathy, antisocial personality disorder, and psychopathy. There is, however, disagreement about its core features and which measure is best for identifying such individuals. In the 1st of 2 studies of male offenders (n = 74), we found a large association between scores on the Psychopathy Checklist-Revised (PCL-R; R. D. Hare, 1991) and the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) antisocial personality disorder criteria scored as a scale. The second study (n = 684) replicated this finding and found that, as previously shown for PCL-R scores, a discrete class (or taxon) also underlies scores on items reflecting antisocial personality disorder. The high association among these sets of items and their similarity in predicting violence suggested that the same natural class underlies each. Results indicated that life-course-persistent antisociality can be assessed well by measures of psychopathy and antisocial personality disorder.     

Correspondence between self-report and interview-based assessments of antisocial personality disorder

Antisocial personality disorder (ASPD) is associated with suicide, violence, and risk-taking behavior and can slow response to first-line treatment for Axis I disorders. ASPD may be assessed infrequently because few efficient diagnostic tools are available. This study evaluated 2 promising self-report measures for assessing ASPD--the ASPD scale of the Personality Diagnostic Questionnaire-4 (PDQ-4; S. E. Hyler, 1994) and the Personality Assessment Inventory (PAI; L. Morey, 1991, 2007)--as well as the ASPD module of the Structured Clinical Interview for DSM-IV Axis II (SCID-II; M. B. First, R. L. Spitzer, M. Gibbon, J. B. W. Williams, & L. S. Benjamin, 1997). The measures were administered to 1,345 offenders in court-mandated residential substance abuse treatment programs and prisons. PDQ-4 and PAI scores related strongly to SCID-II symptom counts (rs = .67 and .51, respectively), indicating these measures convey useful clinical information about the severity of offenders' ASPD pathology. The dimensional association between the measures was relatively invariant across gender, race, and site, although differences in mean scores were observed. Levels of agreement of the SCID-II with the PDQ-4 (kappa = .31) and PAI (kappa = .32) in classifying participants as ASPD was limited. Alternative thresholds for both self-report measures were identified and cross-validated.     

A preliminary investigation of the construct of psychopathic personality (psychopathy) in chimpanzees (Pan troglodytes)

Although the construct of psychopathy has received considerable attention in humans, its relevance to other animals is largely unknown. We developed a measure of psychopathy for use in chimpanzees (Pan troglodytes), the Chimpanzee Psychopathy Measure (CPM), and asked 6 raters to complete this index on 34 chimpanzees. The CPM (a) demonstrated satisfactory interrater reliability and internal consistency; (b) exhibited marginally significant sex differences (males > females); (c) correlated positively with measures of extraversion, agreeableness, and observational ratings of agonism, sexual activity, daring behaviors, teasing, silent bluff displays, and temper tantrums, and negatively with observational ratings of generosity; and (d) demonstrated incremental validity above and beyond a measure of dominance. Although further validation of the CPM is needed, these findings suggest that the psychopathy construct may be relevant to chimpanzees.     

Modeling growth in boys' aggressive behavior across elementary school: links to later criminal involvement, conduct disorder, and antisocial personality disorder

The present study used general growth mixture modeling to identify pathways of antisocial behavior development within an epidemiological sample of urban, primarily African American boys. Teacher-rated aggression, measured longitudinally from 1st to 7th grade, was used to define growth trajectories. Three high-risk trajectories (chronic high, moderate, and increasing aggression) and one low-risk trajectory (stable low aggression) were found. Boys with chronic high and increasing trajectories were at increased risk for conduct disorder, juvenile and adult arrest, and antisocial personality disorder. Concentration problems were highest among boys with a chronic high trajectory and also differentiated boys with increasing aggression from boys with stable low aggression. Peer rejection was highest among boys with chronic high aggression. Interventions with boys with distinct patterns of aggression are discussed.     

Abrasive personality disorder: Definition and diagnosis

This article advances a proposal for a newly identified type of personality disorder. While, like some of the other major personality disorders, the abrasive personality disorder (AbPD) shares some features with other Axis II disorders, it may however be considered as possessing sufficient idiosyncratic features as to warrant a separate classification. There are few documented discussions of this disorder within the historical confines of scientific psychology, however a good deal of attention is being focused currently in the popular press, under the rubric of “difficult people,” “control freaks,” and the like. The disorder is defined, its distinguishing characteristics delineated, with theoretical discussion provided. Some rudimentary assessment approaches are noted, with a call for research in this virgin territory.     

The neurobiology of antisocial personality disorder: The quest for rehabilitation and treatment

Psychopathy is perhaps one of the most misused terms in the American public, which is in no small part due to our obsession with those who have no conscience, and our boldness to try and profile others with this disorder. Here, I present how psychopathy is seen today, before discussing the classification of psychopathy. I also explore the neurological differences in the brains of those with psychopathy, before finally taking a look at genetic risk factors. I conclude by raising some questions about potential treatment.     

The role of psychopathic personality disorder in violence risk assessments using the HCR-20

Antisocial and psychopathic traits are essential to evaluate when assessing risk for violence using the HCR-20. The role of the PCL-R on the HCR-20 was investigated using a series of meta-analytic tests. Across 34 samples in which both tools were rated, AUCs for violence were similar (～.69), and exclusion of the psychopathy item (H7) did not reduce the HCR-20's accuracy. Quantitative synthesis of results from multivariate analyses conducted in 7 raw datasets that used both tools demonstrated that the average probability of observing violence for every point increase on the HCR-20 (without H7), while controlling for the PCL-R, was 23%, whereas for the PCL-R it was -1%. The HCR-20 (without H7) added incremental validity to the PCL-R, whereas the converse was not true, and only the HCR-20 (without H7) possessed unique predictive validity. Results suggest the HCR-20's predictive validity was not negatively impacted by excluding the PCL-R. Areas for future study are discussed, including research on various ways to assess and incorporate into risk assessment personality traits related to violence.     

Emotion and aggression in the psychopathic personality

This paper presents an integrative conceptual framework for understanding relationships between psychopathy and aggression, and reviews the extant relevant literature in relation to this framework. Issues pertaining to conceptualization and subtyping of aggression are reviewed with reference to contemporary emotion theory, and recent research on the emotional and temperamental underpinnings of criminal psychopathy is described. It is argued that different forms of aggression may be related to disparate facets of psychopathy, and that these relationships may be mediated by common dispositional factors. Methodological limitations of existing studies are identified, and suggestions for future research are offered.