- Published: September 1, 2022
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Psychopathy is defined under Antisocial Personality Disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Antisocial personality disorder is defined as socially deviant behaviour that causes distress while psychopathy includes and emphasizes interpersonal and affective traits. Hervey Cleckley and Robert D. Hare have created the modern concept and assessment of psychopathy, respectively. The PCL-R, created by Hare, is the superior tool used in assessing psychopathy for treatment and recidivism. Due to bias and misuse, the PCL-R has extensive qualifications for usage and is still a work in progress.
Psychopathy and The Personality-Checklist Revised
Psychopathy is a personality disorder that is often confused and used interchangeably with Antisocial Personality Disorder (ASPD). The criteria for psychopathy can be separated into two factors, interpersonal, affective traits and the socially deviant actions one participates in. Psychopathy is a more severe form of ASPD that includes behaviours. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-V) has defined psychopathy as a degree of severity of ASPD. Using the DSM-V definition of ASPD as a foundation, psychopathy’s unique conditions will be described. Prominent researchers Hervey Cleckley and Robert D. Hare have created a distinct definition and criteria for psychopathy that differs from ASPD. From Cleckley’s effort, Hare created today’s gold standard for measuring psychopathy, the Personality-Checklist Revised (PCL-R). The PCL-R is the highest quality version and there is continuous improvement due to frequent scrutiny. The PCL-R is useful in measuring reoffending and violence risks. Treatment for psychopathy is difficult as it is a chronic disorder. This review of psychopathy will explore its conceptual differences from ASPD, prominent researchers and history, the gold standard for measuring psychopathy and its challenges, reoffending risks and the intricacies of treatment.
Antisocial Personality Disorder and Psychopathy
Antisocial Personality Disorder is defined in the DSM-V as a continuous pattern of violating the rights of others (5 th ed.; DSM-5; American Psychiatric Association, 2013). It differs from the increased antisocial behaviour during adolescence as it is a chronic disorder and follows a similar pattern to the life-course persistent offenders described by Moffitt (1993). ASPD is only diagnosed if there were previous symptoms of conduct disorder prior to age 18. It is required that the person’s traits be inflexible, maladaptive, and persistent while causing distress. The conduct disorder must continue to adulthood as well as fulfilling at least three of the following: inability to follow societal norms, deception, impulsivity, aggressiveness, reckless disregard for anyone’s safety, irresponsibility, or a lack of remorse (American Psychiatric Association, 2013). ASPD personalities are characterised as conceited, self-inflated and lacking guilt. Consistent with Moffitt’s life-course persistent offenders, a person with ASPD will have a troubled lifestyle failing to hold jobs and meaningful relationships. Parental commitments may falter and lead to child abuse and neglect.
Criminal behaviour is not a disorder, ASPD is a distinct pattern with which the behaviours are correlated with increased risk of criminal behaviour. ASPD individuals may use deception and exploitation to manipulate others. Most criminal behaviour is for social or financial gains, people with ASPD differ in they aim to cause distress.
Psychopathy is a more severe version of ASPD and it is mentioned briefly in the DSM-V. Influential researchers have argued that psychopathy deserves its own entry in the DSM due to its distinctive criteria (Lilienfeld, Watts, Smith, Patrick, Hare, Widiger, 2018). Not all individuals with ASPD have psychopathy but all individuals with psychopathy have some form of ASPD. Psychopathy is a personality disorder with combines emotional, interpersonal, lifestyle, and antisocial behaviours. From the criteria, psychopathic individuals’ interpersonal traits will be grandiose, manipulative, devious, authoritative, and artificial. Emotionally, they cannot form strong bonds, are simplistic and lack guilt and compassion (Hare, Neumann, 2009). These behaviours may and have an increased risk with deviance and violate social norms. A major distinction between ASPD and psychopathy is the added emphasis of socially deviant lifestyle combined to the personality traits. With the two personality disorders similar in their diagnostic criteria, the heritability of both are highly influenced by additive genetic factors and non-shared environmental factors (Werner, Few, Bucholz, 2015).
With ASPD being diagnosed primarily on behaviour, the prevalence rates in public are 1-4%. Psychopathy, being more severe and having personality deficits along with behaviour problems, is investigated within the criminal population. It is estimated that 1-1. 2% of the general population meet the PCL-R scores for psychopathy (Neumann, Hare, 2008). Men are three to five times more likely to be diagnosed with ASPD, following the gender tendencies for crime (Werner, Few, Bucholz, 2015).
History and Assessment
There are two important figures that have shaped the perception and assessment of psychopathy, American psychiatrist Hervey Cleckley and Canadian psychologist Robert D. Hare. As for Cleckley, his seminal publication of “ The Mask of Sanity” has been cited thousands of times and even influenced popular culture (Lilienfeld et al, 2018). His work has been the foundation of the PCL-R. In “ The Mask of Sanity”, Cleckley defined 21 criteria involved in the core of a psychopath. These include superficial charm, good intelligence, absence of nervousness, insincerity, unreliability, lack of remorse and others mentioned previously (Lilienfeld et al, 2018). With the fundamental criteria, Cleckley included in-depth case studies on 15 individuals that exhibited his model psychopathic traits. Cleckley’s observational and theoretical work was investigated and replicated numerous times. In 1985 using Cleckley’s criteria, Hare created a 7-point scale to measure psychopathy in inmates (Patrick, 2006). This was the first draft of the PCL and later it was expanded to a 20 point-scale with a plethora of variations. Versions of the PCL-R exist to measure the traits in different populations, such as the general population or in adolescents. Today, the PCL-R is considered the golden standard for measuring psychopathy (Hare, Neumann, 2009). The PCL-R requires a detailed historical review of the person and a standardized semi-structured interview. The historical review determines functioning over a lifespan and cannot be used to measure immediate changes after treatment. It is a 20-point scale that separates into two factors, Factor One is interpersonal traits, and Factor Two is deviant social lifestyle. A person receives a 40-point score; greater than 20 having ASPD and 30-40 being a psychopath. The PCL-R is not designed to solely determine antisocial or criminal risk or create treatment options (Hare, Neumann, 2009). It is used to assess the severity and the problems that will be encountered within the justice, mental health and societal systems.
The DSM-III and DSM-IV have had a confusing history with psychopathy. The diagnosis of psychopathy was obtained using interpersonal traits. In the DSM-III, psychopathy was renamed to ASPD and shifted away from those traits as they were difficult to reliably measure (Hare, Hart, Harpur, 1991). Instead measured social interactions became the diagnostic focus from the DSM-III but it lacked validity. This continued into the DSM-IV and created an issue as severity was not accounted for. ASPD is prevalent two to three times higher in society than psychopathy (Hare, 1996). Most people with ASPD have relatively low scores on the PCL-R while those who are the prototypical psychopath score very high on the PCL-R. These scores also focus on Factor Two of the PCL-R, the deviant social life, and have little focus on the interpersonal traits. Hare among many other psychopathy researchers are dissatisfied with the ASPD criteria in the DSM (Crego, Widiger, 2014). They believe personality features are essential to the model and are underrepresented.
There are other measurements and scales that measure psychopathy, they vary in their target demographic and purpose. The main target of the PCL-R is prison inmates with a research purpose. The PCL-R and Screening Version requires an interview which makes it expensive and time-consuming to administer to the public. Other methods include the Minnesota Multiphasic Personality Inventory (MMPI) (psychopathic deviate scale), the Psychopathy Personality Inventory (PPI), and the Self-Report Psychopathy Scale (SRPS) (Brinkley, Schmitt, Smith, Newman, 2001). The aforementioned scales all use a pen and paper system allowing ease of access. The MMPI is better at measuring antisocial behaviour however and the PPI presents limited data on how it relates to the psychopathic model that Cleckley developed. Levenson et al. (1995) created the SRPS for use on college samples. The SRPS has been designed on the PCL-R criteria and follows the same two factor model. It focuses on the behaviours rather than the criminal activity. Not until 2001 was it used on a prison sample, in which it demonstrated similar scores to the PCL-R. The results were weaker but promising, having the study conclude that the SRPS was not measuring the same concept as the PCL-R (Brinkley, Schmitt, Smith, Newman, 2001). While the gold standard for measuring psychopathy remains the PCL-R, there have been criticisms and shortcomings.
The PCL-R has gone through many changes since its conception in 1980. Versions improved interrater reliability, refined the weight of questions, and streamlined the process for investigators and researchers (Hare, 1998). Some issues are not related to the PCL-R but rather how it was used. The categories, Factors One and Two, separate interpersonal traits and deviant lifestyle. In order to fully represent psychopathy, Hare has responded with a Four-Factor model (Patrick, 2006). The four factors separated are interpersonal, affective, behavioural lifestyle, and antisocial factors. This doesn’t change the PCL-R drastically as it concisely defines the traits from the previously two-factor model using the same questions.
The PCL-R has a unique situation as a risk instrument. It influences decisions on sentencing, treatment, and eligibility for parole despite its original purpose. There is potential misuse as it holds weight and can be used to assess other offenders, particularly sex offenders. This misinterpretation and misjudged administration of the PCL-R poses an ethical threat. There is recommended qualifications for the use of the PCL-R which include an advanced degree in social, medical or behavioural sciences, provincial or state registration with an association that manages assessment and diagnosis of mental disorders, and experience with forensic populations (Hare, 1998). If the qualifications are met, the individual is required to be unbiased and cautious in the use of the PCL-R. Along with the individual requirements, attendance to a training workshop and achieving the certification is mandatory.
With the synonymous use of psychopathy and ASPD, a clinician may use them interchangeably with severe consequences. The DSM-5 uses ASPD as the umbrella term, however psychopathy is a more severe version of ASPD. The treatment and recidivism patterns are different for ASPD and psychopathy. As a result, clinicians have been using the PCL-R as treatment measurements, noting that individuals have lower PCL-R scores after certain treatments. The PCL-R cannot provide an accurate indication of change in personality within a period of 10 years (Hare, 1998). Noting the previous requirements, individuals in the legal field have sought to use the PCL-R for their litigation. The PCL-R has been documented supporting an offender of not being violent to questioning the clinician who performed the PCL-R on the defendant.
Problems have been mentioned for the individuals using the PCL-R, there are issues concerning the individuals who have been the focus of the PCL-R. Labelling is a consistent issue as the higher the score, the more negative their perspective on the situation (David, Lynn, Montgomery, 2018). The prison staff use ASPD and psychopathy interchangeably meaning that the large proportion of inmates will be considered psychopaths despite the distinct difference. Higher scores for the individual equate to more problems within the prison system for the offender. While lower scores are confused with risk of recidivism and a hopeful ideal.
Recidivism and Treatment
The use of psychopathy and the PCL-R to cover a myriad of other offenses has its uses. The PCL-R can be used to assess the risk factor for violence and recidivism. This can be done with limited strength as certain behavioural traits are associated with violence and criminal behaviour. Impulsivity, lack of fear of punishment and guilt are criteria for psychopathy and are strongly linked to antisocial and criminal behaviour. These measurements shouldn’t be the only condemning factor, but they are helpful in creating the larger picture of determining reoffending risk. It is often combined with recidivism tools like the Violence Risk Appraisal Guide, the Historical, Clinical, Risk Management-20, and the Sexual Violence Risk-20 (Hare, Neumann, 2009). The predictive value of psychopathy helps in a range of offenders including women, adolescents, and certain psychiatric patients. Psychopathy and the PCL-R have been rather successful in determining risk for sexual reoffending and violence. The PCL-R can reliably predict future violent behaviour (Neumann, Hare, 2008). Psychopathy is the most generalizable of risk factors with a plethora of research supporting the PCL-R in validity and reliability. The PCL-R should be used in conjunction with qualified, unbiased individuals and with various assessment tools to achieve a full understanding of the unique and complex situations that each person presents.
Psychopathy is a chronic disorder that is influenced by environment and biological interactions. As the person ages, the antisocial behaviour that they display will spike during adolescence and diminish as they age. There is a negative connotation with treatments for psychopathy (D’Silva, Duggan, McCarthy, 2004). Treatments are complicated in their focus and goal. Individuals with psychopathy suffer little personal distress due to their lack of remorse and guilt and do not see any fault in their behaviours or attitudes. The diminished propensity to form emotional connections and engage in manipulation and deception hinder the treatment process. The focus of emotion-based, talk therapy or psychodynamic therapies have small effects (Werner, Few, Bucholz, 2015). This is due to the entrenched and difficult to change personality traits. Treatments might be abused by the offender with psychopathy as they would manipulate the treatment in order to return to the outside world sooner. Treatment for psychopathy should be focused on accountability of the person and redeveloping their strengths and abilities for more prosocial methods. Cognitive-behavioural programs have some success in predicting reduction in reoffending risk. There are no treatments for high scoring individuals and some treatments may make some individuals worse (D’Silva, Duggan, McCarthy, 2004). There is denial of treatment due to high scores as it is considered untreatable.
Issues for treatment of psychopathy have been noted but the problems do not just lie within the person but within the treatments. The problem begins with the inability for the research community to agree on a single conceptualization and measurement despite Cleckley and the PCL-R. Most of the community agrees on using the PCL-R and Cleckley’s criteria. Another issue is the treatment methodologies, in that they lack contemporary, experiential, meticulous studies. Most of the psychopathy treatment studies have been before 1980 and a large portion have not had psychopathy as their target (Werner, Few, Bucholz, 2015). Most of the studies also do not identify change mechanisms or active ingredients in treatments. The treatments have also been administered with multiple treatments at the same time, making it difficult to isolate a single factor. Cognitive-behavioural approaches have a broad success rate but again lack the crucial instrument of change (Werner, Few, Bucholz, 2015). These changes have been measured in one of the two factors, mainly Factor Two of the PCL-R. Overall, the study of treatments for psychopathy needs improvement specifically in targeting a behaviour or impulsivity and a catalyst for change.
Psychopathy is a unique personality disorder that is measured using the PCL-R to assess reoffending risks and treatment opportunities. Two influential researchers created the modern concept of psychopathy, Hervey Cleckley with the personality construct and Robert D. Hare creating the assessment tool of the PCL-R. Previous versions of the DSM-III and DSM-IV have relabeled psychopathy using the broader term of ASPD and excluded the importance of personality traits. The DSM-V continues this trend as ASPD is an umbrella term to include psychopathy due to their similarities. As a result, the treatments for ASPD and psychopathy differ and administering the wrong treatment can exacerbate the condition. Psychopathy differs due to the socially deviant behaviours, treatment differences, and recidivistic tendencies. The PCL-R can implicate violence and recidivism risk in non-psychopathic offenders as it measures traits associated with reoffending. To use the PCL-R, an unbiased, academically advanced, meticulous clinician is required to avoid misuse. Despite the possible user error, the PCL-R, and its other versions, is the highest quality test for psychopathy that undergoes constant revision to stay relevant and beneficial for society, the affected individual and researchers. The PCL-R can not be used alone when assessing for other risks but can be a useful predictive tool.
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