Assessing risk for violence among male and female civil psychiatric patients: the HCR-20, PCL:SV, and VSC

This study evaluated the predictive validity of violence risk assessments conducted using the HCR-20, the Psychopathy Checklist: Screening Version (PCL:SV), and by the Violence Screening Checklist (VSC) in a sample of 268 involuntarily hospitalized male and female psychiatric patients. Information pertaining to violence and crime was coded from medical charts and correctional records. The HCR-20/PCL:SV evidenced modest non-significant associations in postdictive assessments of inpatient violence among men. Moderate to strong significant associations were found between the HCR-20/PCL:SV and inpatient violence among women. Pseudo-prospective assessments using the HCR-20 and PCL:SV resulted in moderate to large relationships with violence and crime in men and women following community discharge. It is concluded that the VSC is a promising tool for assessing acute inpatient violence risk with men. Findings offer preliminary validation of the predictive validity of the HCR-20 and PCL:SV with female civil psychiatric patients.     

Violence risk assessment and women: predictive accuracy of the HCR-20 in a civil psychiatric sample

Research to date has not adequately demonstrated whether the HCR-20 Violence Risk Assessment Scheme (HCR-20; Webster, Douglas, Eaves, & Hart, 1997), a structured violence risk assessment measure with a robust literature supporting its validity in male samples, is a valid indicator of violence risk in women. This study utilized data from the MacArthur Study of Mental Disorder and Violence to retrospectively score an abbreviated version of HCR-20 in 827 civil psychiatric patients. HCR-20 scores and predictive accuracy of community violence were compared for men and women. Results suggested that the HCR-20 is slightly, but not significantly, better for evaluating future risk for violence in men than in women, although the magnitude of the gender differences was small and was largely limited to historical factors. The results do not indicate that the HCR-20 needs to be tailored for use in women or that it should not be used in women, but they do highlight that the HCR-20 should be used cautiously and with full awareness of its potential limitations in women.     

Personality disorder and violence: understand violence risk: an introduction to the special section personality disorder and violence

This paper introduces the Special Section on personality disorder and violence. The first paper evaluates the impact of removing the Psychopathy Checklist (PCL-R) as a mandatory element of a major approach to the assessment of violence risk-the HCR-20. The second paper considers violence to self as well as violence to others; it examines the influence of dysfunctional personality traits in a sample of female offenders. The third paper provides a systematic framework for risk formulation, discussing how to bridge the gap between nomothetic research and the individual case. This paper concludes by arguing that there is a need to shift perspective from asking "what?" dysfunctional traits are relevant to future violence to "why?" are particular traits relevant. The "why?" question is particularly germane in the forensic arena where expert testimony must endeavor to provide a causal explanation of risk processes at the level of the individual.     

Screening for Psychopathy: Validation of the Psychopathic Personality Inventory-Short Form with Reference Scores

The current study reports validation results for the Psychopathic Personality Inventory (PPI) and its subscales, and for a newly developed PPI-Short Form (PPI-SF) in forensic and non-forensic populations. We also provide criterion reference scores for the PPI and the PPI-SF. In Study 1, we used PPI data from 1,065 participants and supplementary PCL-R data from a subsample of 91 forensic offenders. Mokken scale analysis was used to construct the PPI-SF. In Study 2, PPI-SF and PCL-R data were collected from 60 participants. The study yielded promising but preliminary support for the construct validity of the PPI and the PPI-SF. The PPI-SF is of interest for risk assessment because of its (a) strong relationship with the PCL-R total score and (b) subscales known for their predictive value for violence and criminal recidivism.     

Using dynamic risk and protective factors to predict inpatient aggression: Reliability and validity of START assessments

The Short-Term Assessment of Risk and Treatability (START; C. D. Webster, M. L. Martin, J. Brink, T. L. Nicholls, & S. L. Desmarais, 2009; C. D. Webster, M. L. Martin, J. Brink, T. L. Nicholls, & C. Middleton, 2004) is a relatively new structured professional judgment guide for the assessment and management of short-term risks associated with mental, substance use, and personality disorders. The scheme may be distinguished from other violence risk assessment instruments because of its inclusion of 20 dynamic factors that are rated in terms of both vulnerability and strength. This study examined the reliability and validity of START assessments in predicting inpatient aggression. Research assistants completed START assessments for 120 male forensic psychiatric patients through review of hospital files. They also completed Historical-Clinical-Risk Management-20 (HCR-20; C. D. Webster, K. S. Douglas, D. Eaves, & S. D. Hart, 1997) and Hare Psychopathy Checklist: Screening Version (PCL:SV; S. D. Hart, D. N. Cox, & R. D. Hare, 1995) assessments. Outcome data were coded from hospital files for a 12-month follow-up period using the Overt Aggression Scale (OAS; S. C. Yudofsky, J. M. Silver, W. Jackson, J. Endicott, & D. W. Williams, 1986). START assessments evidenced excellent interrater reliability and demonstrated both predictive and incremental validity over the HCR-20 Historical subscale scores and PCL:SV total scores. Overall, results support the reliability and validity of START assessments and use of the structured professional judgment approach more broadly, as well as the value of using dynamic risk and protective factors to assess violence risk. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Field validity of the Psychopathy Checklist-Revised in sex offender risk assessment

Several studies have concluded that scores from Hare's (2003) Psychopathy Checklist-Revised (PCL-R) predict reoffense among sexual offenders, but most of those studies examined the predictive validity of scores from trained research staff, not clinicians in the field scoring the measure as part of actual forensic assessments. Therefore, we examined the field validity of PCL-R scores that forensic evaluators assigned to 333 male sexual offenders who underwent evaluations during a civil commitment selection process. Overall, no PCL-R score was a significant predictor of sexually violent recidivism. Facet 4 was the only PCL-R score with an area under the curve (AUC) greater than .50 (AUC = .53, p = .85) and the only PCL-R score that approached statistical significance for predicting the combined category of violent or sexually violent offending (AUC = .63, p = .08). However, scores from a subset of evaluators revealed stronger predictive effects, indicating that predictive validity was higher for scores from some evaluators than others. Overall, these results suggest that the stronger predictive validity values in controlled research studies may not apply to all evaluators when the PCL-R is administered in the field.     

A prospective comparison of two measures of psychopathy in the prediction of institutional misconduct

This study examined the predictive validity of two widely used measures of psychopathic traits, the Psychopathy Checklist--Revised (PCL-R; Hare, 2003) and the Psychopathic Personality Inventory (PPI; Lilienfeld & Andrews, 1996). Records of institutional infractions were obtained for a young adult sample of prison inmates (N = 46), who were followed for approximately two years following administration of these two scales. The PPI total and two factor scores predicted the total number of infractions committed (r ranging from .28 to .36). PPI Factor I showed some evidence of stronger associations with non-aggressive infractions (r = .36), whereas PPI Factor II was the strongest correlate of aggressive misconduct (r = .24). The total and facet scores of the PCL-R were not significantly predictive of any form of institutional misconduct, with effect sizes ranging from negligible to small (median r = .14, r ranging from -.01 to .21).     

The accuracy of risk assessment instruments in the prediction of impulsive versus predatory aggression

Actuarial violence risk assessments, many of which include the construct of psychopathy, have been shown to be superior to clinical judgment in the prediction of long-term risk of community violence and recidivism. While these instruments initially appeared to provide similarly accurate judgments of risk of institutional aggression, recent research has indicated that such assessments may be less robust in this setting. One explanation may lie in the types of aggression most frequently observed in each setting. Impulsive (or reactive/affective) is the type of physical aggression most commonly exhibited in psychiatric facilities. This research examines the relationship between risk assessments and aggression in an inpatient forensic setting, with such aggression categorized as impulsive, predatory or psychotic aggression. Consistent with previous research, impulsive aggression was the most frequent type observed (58%). Anger (as measured by the Novaco Anger Scale) and clinical issues (as measured by the HCR-20) were most associated with impulsive aggression, with AUC values of .73 and .71 respectively. In contrast, anger and psychopathy (as measured by the PCL-R) were more associated with predatory aggression, with AUC values of .95 and .84 respectively. Psychotic symptoms were highly associated with psychotically motivated aggression (AUC = .90). These results suggest that traditional violence risk assessments may have limited utility in predicting aggression in an institutional setting and that psychiatric symptoms and heightened affect are more relevant. Copyright © 2008 John Wiley & Sons, Ltd.     

The interpersonal measure of psychopathy: construct and incremental validity in male prisoners

The authors examined the construct and incremental validity of the Interpersonal Measure of Psychopathy (IM-P), a relatively new instrument designed to detect interpersonal behaviors associated with psychopathy. Observers of videotaped Psychopathy Checklist-Revised (PCL-R) interviews rated male prisoners (N = 93) on the IM-P. The IM-P correlated significantly with the PCL-R total score. Moreover, the IM-P was preferentially related to the interpersonal rather than the affective and antisocial lifestyle features of psychopathy. IM-P scores were significantly correlated with age, antisocial behaviors, and self-reported fear, anxiety, and socialization (in reverse). Hierarchical multiple regression analyses demonstrated that although the IM-P exhibited incremental validity beyond the PCL-R total score in detecting self-reported fear, anxiety, and several personality traits, it did not exhibit much incremental validity beyond PCL-R Factor 1. These findings raise questions concerning the unique assessment contribution of the IM-P beyond PCL-R Factor 1. Potential reasons for these findings and alternative means of enhancing the interpersonal assessment of psychopathy are discussed.     

Moderators of the predictive efficacy of the Historical,Clinical and Risk Management-20 for aggression in psychiatric facilities: Systematic review and meta-analysis

This paper presents results from a systematic review and meta-analysis of studies of the predictive efficacy of the Historical, Clinical, and Risk Management-20 (HCR-20) for aggressive behavior in residential psychiatric facilities. Variations in efficacy were investigated based on aggression-type, HCR-20 scale used, and as moderated by clinical, demographic and methodological variables. Comprehensive terms were used to search seven electronic databases between January 1995 and August 2012. Additional papers were located by examining references lists and hand-searching. Twenty non-overlapping studies involving 2067 participants were identified. Few (n = 4) studies reported methodology and results sufficiently to ensure a transparently low risk of bias. The summary judgment (d_w = 1.166) had the largest mean effect size for prediction of any inpatient aggression. HCR-20 had best predictive efficacy among samples containing higher proportions of patients with schizophrenia, women, Caucasians, and those with greater risk of bias. Predictive efficacy was reduced in studies containing higher proportions of patients with personality disorder. HCR-20 is a significant predictor of aggression in residential psychiatric facilities but does not appear to have equal efficacy across groups. Future research should aim to verify current findings using more heterogeneous samples and should report methodology with greater rigor.     

Four-facet PCL-R structure and cognitive functioning among high violent criminal offenders

High violent inmates (N = 126) were administered the Psychopathy Checklist-Revised (PCL-R; Hare, Clark, Grann, & Thornton, 2000; Hare et al., 1990) and neuropsychological measures. No significant correlations were present between the overall PCL-R score and 14 cognitive measures. A violence score, computed as the total number of violent acts across all situations and types, was significantly correlated with the PCL-R total score and Facet 2 but not with the other three facets. Our data suggest that Facet 2 elevations may prove relevant to violence risk assessment; this link, however, needs further exploration with larger samples.     

Verläufe bei sexuellen Tötungen

This article summarizes main results of studies on forensic psychiatric court reports on 166 men who had been persecuted between 1963 and 1991 for a sexual offence leading to the death of the victim. Comparing perpetrators with a single victim and those with multiple victims we found similar results as in two previous studies with smaller samples: Multiple sexual homicide perpetrators showed more often sexual sadism and other paraphilias, as well as antisocial, schizoid and sadistic personality disorders. Follow-up data from the federal criminal records could be obtained for 139 offenders. Ninety perpetrators had been released after a mean detention of 12.2 years, whereas the 49 offenders who were still in prison or forensic psychiatric hospitals had been detained for a mean period of 20.6 years. The non-released offenders showed more often paraphilias as well as antisocial and sadistic personality disorders than the released perpetrators. Paraphilias and antisocial personality traits are empirically well proven risk factors for criminal recidivism with sexual reoffences. In addition, the non-released sexual homicide perpetrators had higher scores in all applied risk assessment instruments (PCL-R, HCR-20, SVR-20, Static-99). Among the released offenders only 1.1% (n=1) reoffended with a completed homicide and 2.2% (n=2) with attempted homicide. The recidivism rates with sexual and other violent reoffences in this sample of sexual homicide perpetrators were similar to those in a large meta-analysis on recidivism in sexual offenders by Hanson and Morton-Bourgon (4). Since well established risk factors had apparently been “used-up” for the decisions about release or non-release, in the follow-up data about the released offenders only age at the sexual homicide and age at the time of release were found as risk factors for recidivism with any violent (sexual or non-sexual) reoffence, i.e. the younger the offender at the time of the homicide and the younger at the time of release, the more likely is the risk of violent reoffending.     

Incremental validity of the Psychopathy Checklist facet scores: predicting release outcome in six samples

The incremental validity of the 4 facet scores (Interpersonal, Affective, Lifestyle, Antisocial) of the Psychopathy Checklist-Revised (PCL-R; R. D. Hare, 1991, 2003) and the Psychopathy Checklist: Screening Version (PCL:SV; S. D. Hart, D. N. Cox, & R. D. Hare, 1995) was evaluated in 6 forensic/correctional samples with average follow-ups ranging from 20 weeks to 10 years. Results indicated that whereas Facet 4 (Antisocial) achieved incremental validity relative to the first 3 facets (Interpersonal, Affective, and Lifestyle) in predicting recidivism in all 6 samples, a block of the first 3 facets achieved incremental validity relative to the 4th facet in only 1 sample. Thus, although there was consistent support for the incremental validity of Facet 4 above and beyond the first 3 facets, there was minimal support for the incremental validity of Facets 1, 2, and 3 above and beyond Facet 4. The implications of these findings for the psychopathy construct in general and the PCL-R/SV in particular are discussed.     

Reconstructing psychopathy: clarifying the significance of antisocial and socially deviant behavior in the diagnosis of psychopathic personality disorder

A survey of clinical views suggests that the significance of antisocial and socially deviant behavior in the diagnosis of psychopathic personality disorder is unclear. To investigate this issue, we evaluated Psychopathy Checklist-Revised ratings (PCL-R; Hare, 1991) using structural equation modeling. One model, referred to as the measurement model, included PCL-R ratings related to antisocial behavior as primary symptoms of psychopathy; a second, referred to as the causal model, included the same PCL-R ratings as secondary symptoms or consequences. Compared to the measurement models, the causal model included more PCL-R items, was more parsimonious, and had equal or superior fit indices. These findings suggest that antisocial behavior is best viewed as a secondary symptom or consequence of psychopathy, In addition, the findings have important implications for future research and clinical-forensic practice, especially concerning the assessment of risk for criminality and violence.     

Psychopathy and the predictive validity of the PCL-R: an international perspective

Its controversial past notwithstanding, psychopathy has emerged as one of the most important clinical constructs in the criminal justice and mental health systems. One reason for the surge in theoretical and applied interest in the disorder is the development and widespread adoption of reliable and valid methods for its measurement. The Hare PCL-R provides researchers and clinicians with a common metric for the assessment of psychopathy, and has led to a surge in replicable and meaningful findings relevant to the issue of risk for recidivism and violence, among other things. Most of the research thus far has been based on North American samples of offenders and forensic psychiatric patients. We summarize this research and compare it with findings from several other countries, including England and Sweden. We conclude that the ability of the PCL-R to predict recidivism, violence, and treatment outcome has considerable cross-cultural generalizability, and that the PCL-R and its derivatives play a major role in the understanding and prediction of crime and violence.     

Incremental validity analyses of the violence risk appraisal guide and the psychopathy checklist: screening version in a civil psychiatric sample

This study compares two instruments frequently used to assess risk for violence, the Violence Risk Appraisal Guide (VRAG) and the Psychopathy Checklist: Screening Version (PCL:SV), in a large sample of civil psychiatric patients. Despite a strong bivariate relationship with community violence, the VRAG could not improve on the predictive validity of the PCL:SV alone, even though the VRAG includes several ostensible violence risk factors other than psychopathy. Moreover, incremental validity analyses indicated that the remaining VRAG items accounted for little or no variance in violent outcomes once psychopathy scores were controlled. Conversely, the PCL:SV continued to account for considerable variance after controlling for the VRAG. These results reflect the limited validity of the VRAG items in civil psychiatric samples beyond the variance that is explained by the PCL:SV alone.     

On individual differences in person perception: raters' personality traits relate to their psychopathy checklist-revised scoring tendencies

This study investigated raters' personality traits in relation to scores they assigned to offenders using the Psychopathy Checklist-Revised (PCL-R). A total of 22 participants, including graduate students and faculty members in clinical psychology programs, completed a PCL-R training session, independently scored four criminal offenders using the PCL-R, and completed a comprehensive measure of their own personality traits. A priori hypotheses specified that raters' personality traits, and their similarity to psychopathy characteristics, would relate to raters' PCL-R scoring tendencies. As hypothesized, some raters assigned consistently higher scores on the PCL-R than others, especially on PCL-R Facets 1 and 2. Also as hypothesized, raters' scoring tendencies related to their own personality traits (e.g., higher rater Agreeableness was associated with lower PCL-R Interpersonal facet scoring). Overall, findings underscore the need for future research to examine the role of evaluator characteristics on evaluation results and the need for clinical training to address evaluators' personality influences on their ostensibly objective evaluations.     

Predicting physically violent misconduct in prison: A comparison of four risk assessment instruments

Violence in correctional facilities is an important issue for both prisoners and prison staff. Risk assessment instruments have demonstrated their accuracy in predicting the risk of (re) offending and institutional violence in psychiatric settings, but less is known about their ability to predict violent misconduct in prison. The present study applied four risk assessment instruments (Structured Assessment of Protective Factors for violence risk, Historical Clinical Risk Management‐20, Psychopathy checklist – Revised, and Violent Risk Appraisal Guide) to 52 violent offenders in a Swiss prison in order to evaluate the instruments' predictive validities. Outcomes were instances of physically violent, other and any misconduct as recorded in prison files during the 12 months following the prisoners' assessments. Approximately 15% of offenders committed physically violent misconduct and approximately 42% committed any misconduct. The results show that mainly dynamic assessment tools are as good predictors of physically violent misconduct as mainly static assessment tools. Targeting dynamic factors could increase the effectiveness of interventions to reduce the risk of physical violence in prison.     

Two subtypes of psychopathic violent offenders that parallel primary and secondary variants

Although psychopathy usually is treated as a unitary construct, a seminal theory posits that there are 2 variants: Primary psychopathy is underpinned by an inherited affective deficit, whereas secondary psychopathy reflects an acquired affective disturbance. The authors investigated whether psychopathy phenotypically may be disaggregated into such types in a sample of 367 prison inmates convicted of violent crimes. Model-based cluster analysis of the Revised Psychopathy Checklist (PCL-R; R. D. Hare, 2003) and trait anxiety scores in the psychopathic subgroup (n = 123; PCL-R > or = 29) revealed 2 clusters. Relative to primary psychopaths, secondary psychopaths had greater trait anxiety, fewer psychopathic traits, and comparable levels of antisocial behavior. Across validation variables, secondary psychopaths manifested more borderline personality features, poorer interpersonal functioning (e.g., irritability, withdrawal, poor assertiveness), and more symptoms of major mental disorder than primary psychopaths. When compared with the nonpsychopathic subgroup (n = 243), the 2 psychopathic variants manifested a theoretically coherent pattern of differences. Implications for etiological research and violence prevention are discussed.     

Psychopathy, antisocial personality, and suicide risk

H. Cleckley (1976) maintained that psychopaths are relatively immune to suicide, but substantial evidence exists for a relationship between antisocial deviance and suicidal acts. This study was the first to explicitly examine suicidal history among psychopathic individuals as defined by R. D. Hare's (1991) Psychopathy Checklist--Revised (PCL-R). Male prison inmates (N = 313) were assessed using the PCL-R and DSM-III-R and DSM-IV criteria (American Psychiatric Association, 1987, 1994) for antisocial personality disorder (APD), and they completed A. Tellegen's (1982) Multidimensional Personality Questionnaire (MPQ). Presence or absence of prior suicide attempts was coded from structured interview and prison file records. Suicide history was significantly related to PCL-R Factor 2 (which reflects chronic antisocial deviance) and to APD diagnosis but was unrelated to PCL-R Factor 1, which encompasses affective and interpersonal features of psychopathy. Higher order MPQ dimensions of Negative Emotionality and low Constraint were found to account for the relationship between history of suicidal attempts and antisocial deviance, indicating that temperament traits may represent a common vulnerability for both.