Hare & Neumann Oxford Textbook 2009

Psychopathy
Robert D. Hare & Craig S. Neumann In P. Blaney and T. Millon (Eds.). Oxford Textbook of Psychopathology , 2009. pp. 622-650 New York: Oxford University Press.
24
Psychopathy
ROBERT D. HARE CRAIG S. NEUMANN
he modern conception of psychopathy is the result of several hundred years of clinical investigation by European and North American psychiatrists and psychologists (Berrios, 1996; Cleckley, 1941, 1976; Herv, 2007a; Millon, Simonsen, Birket-Smith, & Davis, 1998). In North America the writings of Arieti (1967), Karpman (1961), and McCord and McCord (1964), among others, and the case-studies of Cleckley (1941, 1976) were particularly important for providing detailed clinical descriptions of psychopathy as well as speculations and theories concerning the nature of the disorder. These earlyto-mid twentieth-century clinical accounts typically had a psychodynamic orientation and were little concerned with measurement issues. Researchers had a variety of personality scales that purported to measure psychopathy, but most were unrelated to one another, and all lacked evidence of validity (see Hare, 1985). The need for psychometrically sound tools for assessing psychopathy became painfully evident at a 1975 NATO Advanced Study Institute (ASI) in Les Arcs, France, directed by the senior author (Hare & Schalling, 1978). Ten days of heated and unproductive debate about potential operational denitions of psychopathy no doubt played an important role in the subsequent development of the Psychopathy Checklist (PCL; Hare, 1980) and the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.) (DSMIII; American Psychiatric Association [APA], 1980) criteria for antisocial personality disorder (see Hare & Neumann, 2006, for details). The PCL com-
bined personality traits and antisocial behaviors whereas the emphasis in antisocial personality disorder was, and continues to be, antisocial behavior (see Hare, 2003; Ogloff, 2006; Widiger et al.,1996). The PCL represented early attempts by the senior author to devise a reliable, valid, and generally accepted tool for the assessment of psychopathy. It was adopted by many researchers and clinicians, resulting in a substantial body of replicated, theoretically meaningful, empirical ndings. Its successor, the Psychopathy ChecklistRevised (PCL-R; Hare, 1991, 2003), rapidly gained widespread acceptance as the standard for reliable and valid assessments of psychopathy in research and applied contexts (e.g., Acheson, 2005; Fulero, 1995). The result has been the accumulation of a very large body of theoretical and empirical work, basic and applied (e.g., Book, Clarke, Forth, & Hare, 2006; Felthous & Sa, 2007; Hare, 2003, 2007; Hare & Neumann, 2006; Herv & Yuille, 2007; Patrick, 2006). The popularity and importance of the PCL-R and its derivatives (see below) for basic and applied research have led to many reviews, unusually intensive conceptual and statistical scrutiny, and occasional concerns that the measure has become the construct. However, rather than being concerned about its popularity, the PCL-R might better be viewed as an anchor for the burgeoning nomological network of psychopathy (Benning, Patrick, Salekin, & Leistico, 2005, p. 271). This network not only includes diverse measurement tools but input
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Psychopathy Table 24.1 Items and Factors in the Hare PCL-R Interpersonal
1. 2. 4. 5. Glibness/supercial charm Grandiose sense of self-worth Pathological lying Cunning/manipulative
623
Affective
6. 7. 8. 16. Lack of remorse or guilt Shallow affect Callous/lack of empathy Failure to accept responsibility for actions
Lifestyle
3. 9. 13. 14. 15. Need for stimulation/prone to boredom Parasitic lifestyle Lack of realistic long-term goals Impulsivity Irresponsibility
Antisocial
10. 12. 18. 19. 20. Poor behavioral controls Early behavioral problems Juvenile delinquency Revocation conditional release Criminal versatility
Note: The items are from Hare (1991, 2003). Copyright 1991 R. D. Hare and Multi-Health Systems, 3770 Victoria Park Avenue, Toronto, Ontario, M2H 3M6. All rights reserved. Reprinted by permission. Note that the item titles cannot be scored without reference to the formal criteria contained in the PCL-R Manual. Item 11, Promiscuous sexual behavior, and Item 17, Many short-term marital relationships, contribute to the Total PCL-R score but do not load on any factors.
from behavioral genetics, developmental psychopathology, personality theory, cognitive neuroscience, and community studies. These and related issues, including the transition from clinical to empirical conceptions of psychopathy and the overreliance of some researchers and clinicians on early conceptualizations of psychopathy, are discussed in detail elsewhere (Hare & Neumann, 2008). In this chapter, we discuss some of the recent theory and research on the measurement and structure of psychopathy, with emphasis on the PCL-R and its direct derivatives: the Psychopathy Checklist: Screening Version (PCL: SV; Hart, Cox, & Hare, 1995), and the Psychopathy Checklist: Youth Version (PCL: YV; Forth, Kosson, & Hare, 2003). For convenience, we refer to these three instruments as the PCL scales, each of which conceptualizes psychopathy in terms of four interrelated dimensions labeled Interpersonal, Affective, Lifestyle, and Antisocial (see Tables 24.1, 24.2, and 24.3). We only briey describe several other instruments: the Antisocial Process Screening Device (APSD; Frick & Hare, 2001), used in recent research on genetic and longitudinal factors related to psychopathy, several self-report measures of psychopathy, and two related constructs, one described in DSMIV (APA, 1994), and the other in International Classication of Diseases (10th ed.) (ICD-10; World Health Organization, 1992).
available elsewhere and provide the basis for much of the discussion in this chapter (e.g., Hare, 2003; Hare & Neumann, 2005, 2006, 2008). Briey, The PCL-R is a 20-item clinical construct rating scale that uses a semistructured interview, case-history information, and specic scoring criteria to rate each item on a 3-point scale (0, 1, 2) according to the extent to which it applies to a given individual. In some cases, this standard procedure (interview plus le information) is replaced by a nonstandard procedure, in which only le information is used to score the items. The items and the factors they constitute (see below) are listed in Table 24.1. Total scores can range from 0 to 40 and reect the degree to which the individual matches the prototypical psychopathic individual. Internal consistency and interrater reliability generally are high. Although the PCL-R yields dimensional scores, it also is used to classify individuals for research and clinical purposes. In North America a PCL-R cut-score of 30 for psychopathy has proven useful for research and applied purposes. For convenience, we refer to individuals with scores this high as psychopaths. Other cut-scores may be used by other investigators and authors, depending on the purpose of the assessments and the context in which they are used. In each case, however, the term psychopath implies a heavy concentration of psychopathic features.
The PCL-R
Recent reviews of the development of the PCL-R and its psychometric and structural properties are
The PCL: SV
The PCL: SV consists of 12 items derived from the PCL-R, each scored on a 3-point scale (0, 1, 2) on the
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Axis II Disorders
Table 24.2 Items and Factors in the Hare PCL: SV Interpersonal

1. Supercial 2. Grandiose 3. Deceitful
Affective
4. Lacks remorse 5. Lacks empathy 6. Doesnt accept responsibility
Lifestyle
7. Impulsive 9. Lacks goals 10. Irresponsibility
Antisocial
8. Poor behavioral controls 11. Adolescent antisocial behavior 12. Adult antisocial behavior
Note: The items are from Hart, Cox, & Hare (1995). Copyright 1995 R. D. Hare and Multi-Health Systems, 3770 Victoria Park Avenue, Toronto, Ontario, M2H 3M6. All rights reserved. Reprinted by permission. Note that the item titles cannot be scored without reference to the formal criteria contained in the PCL: SV Manual. The Interpersonal and Affective factors comprise Part 1 described in the PCL: SV Manual. The Lifestyle and Antisocial factors comprise Part 2 described in the PCL: SV Manual.
Table 24.3 Items and Factors in the Hare PCL: YV Interpersonal

1. 2. 4. 5. Impression management Grandiose sense of self-worth Pathological lying Manipulation for personal gain
Affective
6. 7. 8. 16. Lack of remorse Shallow affect Callous/lack of empathy Will not accept responsibility
Behavioral
3. 9. 13. 14. 15. Need for stimulation Parasitic orientation Lack of goals Impulsivity Irresponsibility
Antisocial
10. 12. 18. 19. 20. Poor anger control Early behavioral problems Serious criminal behavior Serious violations of release Criminal versatility
Note: The items are from Forth, Kosson, & Hare (2003). Copyright 2003 R. D. Hare and Multi-Health Systems, 3770 Victoria Park Avenue, Toronto, Ontario, M2H 3M6. All rights reserved. Reprinted by permission. Note that the item titles cannot be scored without reference to the formal criteria contained in the PCL: YV Manual. Item 11, Impersonal sexual behavior, and Item 17, Unstable interpersonal relationships, contribute to the total PCL: YV score but do not load on any factors.
basis of interview and collateral information that is less extensive than that required for scoring the PCL-R. Total scores can vary from 0 to 24. It is conceptually and empirically related to the PCL-R (Cooke, Michie, Hart, & Hare, 1999; Guy & Douglas, 2006) and can be used as an effective screen for psychopathy in forensic populations (Guy & Douglas, 2006) or as a stand-alone instrument for research with noncriminals, including civil psychiatric patients (De Oliveira-Souza, Igncio, Moll, & Hare, 2008; Steadman et al., 2000). Its psychometric properties and 4-factor structure (see Table 24.2) are much the same as those of the PCL-R (Hill, Neumann, & Rogers, 2004; Vitacco, Neumann, &
Jackson, 2005). There is rapidly accumulating evidence for the construct validity of the PCL: SV, including its ability to predict aggression and violence in offenders and in forensic and civil psychiatric patients (see below). In this respect, the correlates of the PCL: SV are much the same as those of the PCL-R. A cut score of 18 is approximately equivalent to a PCL-R score of 30.
The PCL: YV
The PCL: YV (Forth et al., 2003) is an age-appropriate modication of the PCL-R intended for use
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Psychopathy with adolescents. Like the PCL-R, it consists of 20 items and four factors (Jones, Cauffman, Miller, & Mulvey, 2006; Neumann, Kosson, Forth, & Hare, 2006). The items and factors are presented in Table 24.3. It appears to have much the same psychometric properties and much the same correlates as its adult counterpart (see Book et al., 2006; Salekin, Neumann, Leistico, DiCiccio, & Duros, 2004; Vitacco, Neumann, Caldwell, Leistico, & Van Rybroek, 2006). Like the PCL-R, it appears to generalize well across ethnic groups and countries (e.g., Book et al., 2006; Dolan & Rennie, 2006; McCoy & Edens, 2006; Schrum & Salekin, 2006). Although there is little doubt about the reliability and validity of the PCL: YV, concerns arise with respect to its use in the criminal justice system. The main issues have to do with (1) the dangers of labeling an adolescent as a psychopath; (2) the implications of the PCL: YV for classication, sentencing, and treatment; (3) the possibility that some features measured by the PCL: YV are found in normally developing youth; and (4) the degree of stability of psychopathy related traits from late childhood to early adulthood. Extensive discussions of these issues are available elsewhere (e.g., Book et al., 2006; Forth & Book, 2007; Frick, 2007; Frick & Marsee, 2006; Lynam & Gudonis, 2005; Salekin, 2006; Vitacco & Vincent, 2006). Briey, although psychopathy and its features do not suddenly emerge in early adulthood, the PCL: YV nonetheless should not be used to diagnose someone as psychopathic. Although some adolescents may exhibit some features of psychopathy in certain contexts or for a limited time, a high score on the PCL: YV requires evidence that the traits and behaviors are extreme and that they are manifested across social contexts and over substantial time periods. Lynam and Gudonis (2005), following their review of the literature, commented that psychopathy in juveniles looks much like psychopathy in adults. The same traits characterize these individuals at different developmental time points. Additionally, juvenile psychopathy acts like adult psychopathy. Like their adult counterparts, psychopathic juveniles are serious and stable offenders. They are prone to externalizing disorders . . . . as far as has been observed, juvenile psychopathy appears quite stable across adolescence. All of these ndings replicate those observed in studies using psychopathic adults. (pp. 401402)
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The Antisocial Process Screening Device (APSD)

The APSD (Frick & Hare, 2001) is a teacher/parent rating scale for use with children from age 6 to 13 years. It consists of 20 scaled items that measure three dimensions of behavior thought to be precursors to psychopathic traits: callous/unemotional (CU), narcissistic, and impulsive. Research with the APSD is increasing rapidly, with considerable evidence that CU traits in particular are related to a variety of disruptive behaviors and are relatively stable over 3or 4-year periods (Dadds, Fraser, Frost, & Hawes, 2005; Frick & Marsee, 2006). An expanded version of the CU traits measured by the APSD is now available as The Inventory of Callous-Unemotional Traits (Essau, Sasagawa, & Frick, 2006).
ICD-10 and DSMIV

The attributes measured by the PCL-R are similar in many respects to the diagnostic criteria for dissocial personality disorder listed in ICD-10 (Huchzenmeir et al., 2007; Ullrich & Marneros, 2004; Widiger et al., 1996). However, they differ in important ways from the criteria for antisocial personality disorder (ASPD) contained in DSMIV and DSMIVTR (APA, 2000). The diagnostic criteria for ASPD reect the assumptions that it is difcult for clinicians to assess personality traits reliably, and that earlyonset delinquency is a cardinal symptom of the disorder (Robins, 1978). These assumptions account for the heavy emphasis on delinquent and antisocial behavior in the criteria for ASPD (Hare, 2003; Hare & Neumann, 2006; Rogers, Salekin, Sewell, & Cruise, 2000; Widiger et al., 1996). In forensic populations the prevalence of ASPD is much higher than the prevalence of psychopathy, resulting in an asymmetric association between the PCL-R and ASPD. In this respect, it is noteworthy that ASPD is more strongly associated with the PCL-R Lifestyle and Antisocial than with the Interpersonal and Affective dimensions. Most psychopaths meet the criteria for ASPD, but most of the offenders with ASPD are not psychopaths. Yet DSMIV states that ASPD has also been referred to as psychopathy (p. 655), effectively equating the two constructs. The Associated Features and Disorders section for ASPD (in DSMIV and DSMIVTR) compounds the problem by suggesting that in forensic populations the diagnosis of ASPD may be facilitated by assessing
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626
Axis II Disorders does ASPD, either in males or in females (Warren & South, 2006). This matter is of more than academic interest. High scores on the PCL-R and its derivatives are predictive of institutional problems, recidivism, violence, and poor treatment outcome (see section on Psychopathy and Crime). It would be unfortunate if a forensic clinician equates ASPD with psychopathy and then uses the PCL-R literature to draw conclusions about the individuals treatability and risk for reoffending.
traits and behaviors imported (without attribution or scoring instructions) from the 10-item Psychopathy Criteria Set that Hare and his colleagues had derived from the PCL-R and PCL: SV for use in the DSMIV Field Trial for ASPD (Widiger et al., 1996). Had these imported traits been required for a diagnosis of ASPD, rather than being made optional in forensic contexts, the relation between psychopathy and ASPD would have been strengthened. Rogers et al., (2000) had this to say about the situation: As noted by Hare (1998), DSMIV does considerable disservice to diagnostic clarity in its equating of ASPD to psychopathy (pp. 236237). Or, as Lykken (2006) put it, Identifying someone as having ASPD is about as nonspecic and scientically unhelpful as diagnosing a sick patient as having a fever or an infectious or a neurological disorder (p. 4). Far from being identical with ASPD, the broader construct of psychopathy seems to emerge from the conuence of multiple domains from personality pathology. For example, two large-scale empirical studies (Livesley, Jang, & Vernon, 1998, Ulrich & Marneros, 2007) and a comprehensive review of personality disorder research (Trull & Durrett, 2005) all suggest that a superordinate factor reecting dissociality/psychopathy emerges when symptoms of all personality disorders are factor analyzed. A study by Livesley et al. (1998) is noteworthy in that use of a dimensional measure of personality disorder symptoms resulted in the same factor solution across large twin, clinical, and general population samples. The psychopathy factor was composed of the following personality disorder items: callousness, conduct problems, narcissism, rejection, and stimulus seeking. In an ICD-10 study by Ullrich and Marneros (2007), dimensionalized personality disorder symptoms resulted in a factor made up of the dissocial, paranoid, histrionic, and impulsive traits, and was the only ICD-10 PD factor (out of three) that was strongly correlated (r = .77) with the PCL: SV. Based on other ICD-10 research, Ullrich and Marneros (2004) concluded: Although suggestions to replace (ASPD) in DSMIV with the construct of psychopathy were previously rejected, its importance within forensic contexts is established. Against the background of our ndings, we conclude that specic dimensions of personality disorders are strongly interrelated and show remarkable similarities to the personality features constituting psychopathy (pp. 211212). A similar conclusion was drawn by Livesley and Schroeder (1991). The PCL-R and its derivatives do not measure the same construct as
Self-Report Measures
Self-report psychopathy scales are beginning to broaden the repertoire of available assessment tools, and show promise of helping us to understand better the construct they purport to measure. These include the Psychopathy Personality Inventory (PPI; Lilienfeld & Andrews, 1996); the Youth Psychopathic Traits Inventory (YPI; Andershed, Kerr, Stattin, & Levander, 2002); the Child Psychopathy Scale (CPS; Lynam, 1998; Lynam & Gudonis, 2005); and the experimental four-factor version of the Self-Report Psychopathy (SRP) Scale (Williams, Paulhus, & Hare, 2007). These scales are moderately correlated with the PCL instruments, and recent empirical research indicates they have moderate predictive validity with respect to recidivism (e.g., Boccaccini et al., 2007; Lilienfeld & Fowler, 2006). The SRP-III Scale is a signicant predictor of a variety of unethical and antisocial behaviors in college students (Nathanson, Paulhus, & Williams, 2006; Williams et al., 2007). Omnibus personality inventories, including the Multidimensional Personality Questionnaire (MPQ; Tellegen, in press) and the various instruments used in the Five-Factor Model (FFM) of personality (Costa & McCrae, 1992; Costa & Widiger, 2002; Lynam, 2002), also have played a useful role in research where investigators have attempted to apply general personality theory to the study of psychopathy. For example, the MPQ and FFM measures have been used to examine the strength of associations and theoretical links between normal-range personality traits and pathological traits reecting psychopathic personality (see below section on Normal-Range Personality and Psychopathy). There are several advantages and disadvantages to using specialized and general self-report scales for the study of psychopathy (Lilienfeld & Fowler, 2006; Westen & Weinberger, 2004). They make it
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Psychopathy possible to assess very large samples, in forensic and other populations, and to extend to the general population some of the research paradigms found useful in experimental/laboratory research with forensic populations. Further, by viewing psychopathy from different perspectives, including that of the individual under study (self-reports), these scales may lead to a more complete and accurate conceptualization of the construct when combined with other measures. And of course they also make the researchers task much easier because most of the assessment work is done by the study participants, who provide their own managed view of themselves. However, we should recognize that individuals with psychopathy are particularly prone to impression management (Cooper & Yuille, 2007). Further, they may nd it more difcult to provide accurate reports of specic personality than of overt behaviors (Jackson & Richards, 2007b). Recently, Neumann, Malterer, and Newman (2008) used the self-report PPI in a large sample of offenders and found that the Coldheartedness subscale bore little relation to the other PPI subscales (e.g., Impulsive nonconformity, Blame externalization). This nding suggests that it might be particularly difcult to provide accurate self-reports of affective experiences associated with psychopathic tendencies. Finally, investigators should also take pains to ensure that the putative construct measured by self-reports really is what we think it is. As Rutter (2005) put it in his commentary on a special journal issue on adolescent psychopathy, some of the core features of psychopathy may not be best represented by scores on personality dimensions that are designed to pick up rather different features (p. 500).
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Structural Models of the PCL-R

The study of any psychological construct relies on a clear delineation of its underlying dimensionality. Understanding its dimensionality helps to interpret scores on a measure of the construct and the pattern of correlations between the dimensions and relevant external variables. Structural equation modeling (SEM) provides a powerful multivariate statistical approach for testing hypotheses about the underlying dimensionality of latent psychological constructs (Barnes, Murray, Patton, Bentler, & Anderson, 2000; Bollen, 2002; Borsboom, Mellenbergh, & van Heerden, 2003). A special case of SEM is conrmatory factor analysis (CFA).
Prior to the development of rigorous statistical approaches such as SEM, early exploratory factor analysis (EFA) indicated that two correlated dimensions underpinned the 22-item PCL scale that preceded the PCL-R (Harpur, Hare, & Hakstian, 1989) and the 20-item PCL-R (Hare et al., 1990; see Hare, 2003). In this two-factor model of the PCL-R, one factor consisted of the eight interpersonal and affective items listed in Table 24.1, whereas the other factor consisted of nine of the lifestyle and antisocial items (i.e., all but Item 20) listed in Table 24.1. Three items (11, 17, and 20 in Table 24.1) did not load on either factor. Although this factor structure has been replicated several times and is currently used by several investigators, a review of the EFA studies (Cooke & Michie, 2001; Neumann, Kosson, & Salekin, 2007) suggested that a more ne-grained parsing of the twofactor PCL model is possible. Investigators recently have opted to use CFA and other multivariate statistical tools to provide rigorous tests of new structural models of psychopathy. Using a variety of statistical analyses (including CFA) and subjective decisions, Cooke and Michie (2001) developed a three-factor model of psychopathy consisting of 13 selected PCL-R items constituting the Interpersonal, Affective, and Lifestyle factors in Table 24.1. They stated that the retained items lie within the realm of personality and form the core of psychopathy, whereas the excluded items reect antisociality. But the retained items (e.g., pathological lying, irresponsibility) do not seem any less antisocial than items excluded (e.g., early behavior problems, poor behavioral controls). In-depth critiques of the conceptual, empirical, and statistical problems with the three-factor model are available elsewhere (Hare & Neumann, 2008; Neumann & Hare, 2007). Cooke, Michie, Hart, and Clark (2004) also proposed a causal model of psychopathythat is, that certain traits measured by the PCL-R (e.g., lack of remorse or guilt, pathological lying) caused other psychopathic traits (e.g., impulsivity, poor behavioral controls)based on use of cross-sectional data. As we have pointed out (Neumann, Vitacco, Hare, & Wupperman, 2005), such a model is problematic. In addition, current behavior genetic and longitudinal research reveals that there are fundamental empirical relations among psychopathic features reecting, for example, affective and antisocial tendencies. More specically, there is an increasing number of studies indicating that broad genetic fac-
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628
Axis II Disorders ning the condition (Frick & Marsee, 2006; G. T. Harris & Rice, 2006; Robins, 1966). From an evolutionary psychology perspective, for example (G. T. Harris & Rice, 2006; Mealey, 1995), psychopathy is a heritable adaptive life strategy in which a central feature is the early emergence of antisocial behavior, including aggressive sexuality. Clearly, the view that major dimensions of personality reect trait dispositions and characteristic adaptations to the environment (Zuckerman, 1991) is consistent with twin studies on the heritability of antisocial behavior (Slutske, 2001) and on the trait and action features of psychopathy in children, adolescents, and adults (Blonigen, Hicks, Krueger, Patrick, & Iacono, 2005; Larsson et al., 2007; Viding et al., 2007).
tors account for a substantial portion of the variance and covariance of diverse sets of psychopathy traits. Independent studies have reported bivariate analyses that suggest that there are genetic inuences on the covariance of psychopathy scales reecting emotional detachment and antisocial tendencies (Taylor, Loney, Bobadilla, Iacono, & McGue, 2003; Viding, Blair, Moftt, & Plomin, 2005). Similarly, based on a large sample of 9- to 10-year-old twins, Baker, Jacobson, Raine, Lozano, and Bezdjian (2007) found that a common antisocial behavior factor (comprising child psychopathy traits, aggression, and delinquency, assessed across informants) was strongly heritable. Recently, Viding, Frick, and Plomin (2007) reported that a common genetic component accounted for the covariation between callous-unemotional traits and antisocial tendencies in children. Finally, based on a large adolescent twin sample, Larsson et al. (2007) reported that interpersonal, affective, impulsive, behavioral, and antisocial features of psychopathy all loaded onto a single genetic factor for males and females. In terms of longitudinal research, there is clear evidence that earlier antisocial tendencies covary with and predict the stability of other psychopathy traits (Frick, Kimonis, Dandreaux, & Farell, 2003; Larsson et al., 2007). The behavior genetic and longitudinal studies in particular, as well as the structural nding presented below, indicate that in personality theory and psychopathology it is problematic to make simple distinctions between so-called basic traits and characteristic adaptations. The problem is exacerbated by the likelihood that traits and their behavioral components are linked to some of the same underlying psychobiological processes, with the pathways to the latter being more complex than those to the former. Indeed, the different features of psychopathic personality appear to reect a functional system. As suggested by Livesley et al. (1998), Since the components of personality are parts of an integrated system, disturbance in one system is likely to affect the whole system (p. 944). In this sense, antisocial tendencies are fundamentally tied to other psychopathy dimensions. It is unclear how we could measure psychopathic traits directly, without reference to behavioral manifestations, except perhaps in some abstract, philosophical manner. Additionally, there are cogent arguments that, like other personality disorders, an integral part of psychopathy is the emergence of an early and persistent pattern of problematic behaviors, and that these behaviors are important in de-
A Four-Factor Model
Consistent with the empirical ndings discussed previously, Hare (2003) proposed that at least four latent variable dimensions are needed to represent the PCL-R construct of psychopathy: those in the three-factor model plus an Antisocial dimension (see Table 24.1). Several recent studies, based on latent variable analyses of each of the PCL instruments, provide considerable support for the four-factor model of psychopathy across diverse and primarily very large samples of male and female offenders (Hare & Neumann, 2006, Neumann, Kosson, et al., 2007), forensic and civil psychiatric patients (Hill et al., 2004; Jackson, Neumann, & Vitacco, 2007; Neumann, Hare, & Newman, 2007; Vitacco et al., 2005), youth offenders (Jones et al., 2006; Neumann et al., 2006; Salekin, Brannen, Zalot, Leistico, & Neumann, 2006; Vitacco et al., 2006), as well as individuals from the general community (Hare & Neumann 2006; Neumann & Hare, in press). Figure 24.1 illustrates the form and content of the model for the PCL-R, as well as standardized item-discrimination parameters, based on a megasample analysis of 6929 male and female adult offenders and male forensic psychiatric patients. Consistent with a number of studies, model t of the four-factor model in Figure 24.1 is excellent. Also, the four factors are comprehensively explained by a cohesive superordinate factor (Neumann & Hare, in press; Neumann, Hare, et al., 2007; Neumann et al., 2006). The model has also shown structural invariance across North American and U.K. samples of
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Psychopathy
glib/ superficial .73 grandiose self-worth pathological lying conning manipulative .73 .70 .71
629
lack remorse or guilt .80 .65 shallow affect callous lack empathy fail to accept responsibility
Interpersonal
Affective
.82
.66 .42 .55
.59
.50 stimulation seeking .73 impulsivity .71 .60 irresponsible .58 parasitic orientation .60 lack of realistic goals
.51 poor behavior controls .65 .70 early behavior problems juvenile delinquency revocation of cond. release criminal versatility
Lifestyle
.73
Antisocial
.67 .54 .64
Figure 24.1 Four-factor PCL-R item-based model of psychopathy (N = 6,929). Reprinted from Neumann & Hare (2007) with permission of Guilford Press. Item titles are based on The Hare Psychopathy Checklist-Revised (PCL-R; Hare, 2003) and are used with permission of R. D. Hare and Multi-Health Systems, Inc., 3770 Victoria Park Avenue, Toronto, Ontario, Canada M2H 3M6. Note that the items cannot be scored without reference to the formal criteria contained in the PCL-R Manual.
adolescent offenders (Neumann et al., 2006), and adult male African American and White civil psychiatric patients (Jackson et al., 2007; see also Bolt, Hare, & Newman, 2007; Bolt, Hare, Vitale, & Newman, 2004). Although the PCL-R and its derivatives cannot be equated with the construct of psychopathy (Neumann et al., 2005), the robustness of the four-factor model across such a diverse set of samples suggests that the measure is highly compatible with traditional-clinical and modernempirical conceptualizations of psychopathy. The results show that the PCL-based psychopathic personality dimensions reect a broadly antisocial and undercontrolled personality disposition, involving deceptiveness, pathological lying, absence of empathy, remorse and guilt, as well as irresponsible, impulsive, and versatile antisocial tendencies. These studies indicate clearly that in offender populations antisocial behavior is an important component of psychopathy, as measured by the PCL
Scales. Based on a CFA of PCL: SV data from the MacArthur Risk Assessment Study, Vitacco et al. (2005) found that the four-factor model also applies to civil psychiatric patients. To determine if the model applies to the general population, Neumann and Hare (in press) conducted a CFA on the PCL: SV scores from the community sample in the MacArthur Risk Assessment Study. Consistent with previous studies, model t for the four-factor model using the community data was excellent. The items on the Antisocial factor had substantial factor loadings and correlated signicantly with the other three psychopathy factors, highlighting the critical nature of antisocial behavior in the psychopathy construct. Moreover, it arguable that the other psychopathy dimensions reecting deceptive, callous, and impulsive features take on the necessary avor of dissociality, given their strong covariation with the fourth Antisocial tendencies factor (Neumann, Hare, et al., 2007).
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630
Axis II Disorders PCL: SV (but not in the PCL: YV) is consistent with the presence of two broad factors, one consisting of the eight items that constitute the Interpersonal and Affective factors, and the other consisting of the 10 items that constitute the Lifestyle and Antisocial factors (Figure 24.2). These broad factors are the same as those in the original two-factor model of the PCL-R but with the addition of Item 20 to the second factor (see Hare & Neumann, 2008). An interesting application of the four-factor model is in the identication of subtypes of psychopathy. An extensive historical account of clinically derived subtypes was provided by Herv (2007b). Terms used to describe clinically derived subtypes have included idiopathic/pseudopsychopathic, primary/ secondary, and aggressive/parasitic. Millon and Davis (1998) suggested that 10 subtypes of psychopath could be identied: unprincipled, disingenuous, risk taking, covetous, spineless, explosive, abrasive, malevolent, tyrannical, and malignant. Herv (2007b) suggested that clinically derived subtypes, including those described by Millon and Davis (1998), can be subsumed under three main categories: classic, manipulative, and explosive. Support for this suggestion was provided by cluster analyses of proles based on the four PCL-R factors (see Table 24.1). He reported that the proles of male and female offenders and forensic psychiatric patients with PCL-R scores of 27 and above fell into three clusters, labeled classic (high score on each factor), manipulative (high score on the Interpersonal and Affective factors, lower scores on the Lifestyle and Antisocial factors), and explosive (low score on the Interpersonal factor and high scores on the other factors). Each of these three groups had a very high score on the Affective factor. Interestingly, a fourth group emerged from the analyses, one with low scores on the Interpersonal and Affective factors and high scores on the Lifestyle and Antisocial factors. This group was labeled pseudopsychopathic because its behavioral features, but not its interpersonal/affective features, were similar to those of the other groups. The term sociopathic might also apply here.
Hill et al. (2004) found that the four-factor model, relative to the three-factor model, accounts for greater variance in maximum security patients aggression at 6-month follow-up. Similar results were obtained by Vitacco et al. (2005) for psychiatric patients community violence at 10-week follow-up. In these longitudinal studies, the Interpersonal, Affective, and Antisocial factors were signicant predictors of future aggression and violence. Interestingly, there is some evidence that the psychopathy factors are differentially linked to certain forms of violence. Specically, Vitacco et al. (2006) found that the Interpersonal factor positively predicted and Antisocial factor negatively predicted instrumental violence in a sample of severe youth offenders. Last, Walsh, Swogger, and Kosson (2003) found that the Antisocial factor of the PCL-R contributed uniquely to postdicting blind ratings of instrumentality of violence. In sum, the current ndings provide strong evidence that the four-factor model has incremental validity over the three-factor model in predicting important external correlates of psychopathy. A signicant strength of the four-factor model is that it can be used in longitudinal research to study the relations between the emergence of early antisocial tendencies and development of other psychopathic personality features. For instance, psychopathic traits (callousness, impulsivity) are predictors of future antisocial behavior (Frick et al., 2003; Vitacco, Neumann, Robertson, & Durrant, 2002). At the same time. prior antisocial behavior is associated with higher levels of callousness and other psychopathic traits (Dowson, Sussams, Grounds, & Taylor, 2001; Lynam, 1998). Also, early antisocial tendencies are an important predictor of stability of other psychopathic traits (Frick et al., 2003), and antecedent antisocial behaviors covary signicantly with subsequent interpersonal and affective psychopathy traits (Larsson et al., 2007). Similarly, Knight and Sims-Knight (2003) found good t for an SEM that hypothesized that physical and/or verbal abuse produced callousness and/or lack of emotionality. Such ndings are consistent with the fact that repeated exposure to antisocial acts desensitizes individuals negative emotional responses to such behavior (Anderson et al., 2003), suggesting that exposure toor engagement inantisocial behavior can precede development of callousness or other psychopathy traits. Of particular note, the pattern of correlations among the four factors in the PCL-R and the
Latent Growth Models

A relatively new longitudinal approach in research on psychopathy involves latent growth models (LGMs). This approach has the advantage of separating the level of some phenomenon (violence) at
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Psychopathy
glib/ superficial .73 grandiose self-worth pathological lying conning manipulative .73 .71
631
lack remorse or guilt .80 .65 shallow affect callous lack empathy fail to accept responsibility
Interpersonal
.77 .66 .90
Affective
.82
.59
F1
.68
stimulation seeking .73 impulsivity .71 .60 irresponsible .58 parasitic orientation .60 lack of realistic goals .91
F2
.65 .81 .70
poor behavior controls early behavior problems juvenile delinquency revocation of cond. release criminal versatility
Lifestyle
Antisocial
.67 .54
.64
Figure 24.2 Two-factor PCL-R higher order representation of the four correlated factors model (N = 6,929). From Hare, R. D., & Neumann, C. S. (2008). Psychopathy as a Clinical and Empirical Construct. Annual Review of Clinical Psychology, 4, 217246. Reprinted with permission of Annual Reviews.
any given time from the rate of change or growth of the phenomenon over time (Muthen & Muthen, 2001). Neumann and Vitacco (2004) recently used a LGM to examine how the four psychopathy factors and a psychotic symptom factor predicted growth in violence in psychiatric outpatients. Model t for the LGM was good, and the four psychopathy factors and the psychotic symptom factor differentially predicted latent intercept and slope violence factors. Specically, the absolute level of violence at any given follow-up time was primarily explained by the Antisocial psychopathy factor and the psychotic symptom factor. In terms of growth in violent behavior, the Interpersonal psychopathy factor predicted an increased slope or rate of change in violent acts with time. This model accounted for 65% and 18% of the variance, respectively, in the level of and growth in violent acts during a 30-week follow-up.
Although psychopathy is well known as a potent risk factor for violence (Leistico, Salekin, DeCoster, & Rogers, 2008), most research has been concerned with predicting a single event, usually the rst violent act after release from custody. However, it is well recognized in psychology that predicting a single event is particularly challenging, given that the variables that predict an event at Time 1 may not be the same variables that predict events at later times, and that it is often necessary to aggregate information across time. As such, use of an LGM approach will allow investigators to test models that attempt to elucidate, for example, the dynamic temporal relations between specic personality traits and future violent behavior. Clearly, additional research using LGMs for understanding the development and consequences of psychopathy and other critical variables during multiple periods is warranted.
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Axis II Disorders answer to this question will require much larger samples than typically available to researchers.
Other Statistical Approaches

Several other advanced statistical approaches also have added to our understanding of the structure of psychopathy. These include item response theory (IRT) and taxometric analysis (see reviews of these and other analytic methods by Hare & Neumann, 2005, 2008). Briey, IRT provides information about the extent to which item and total test scores have the same meaning, with respect to a latent construct, in different groups and populations. IRT analyses of the PCL instruments indicate that the items, dimensions (especially the Interpersonal and Affective), and total scores have considerable cross-cultural generalizability (Bolt et al., 2004; Bolt et al., 2007; Cooke, Kosson, & Michie, 2001). Taxometric analysis address the issue of whether psychopathy can better be represented as a categorical, discrete category (taxon) or as a continuously distributed dimensional construct. There now is strong evidence that the structure of psychopathy is dimensional, whether measured via structured diagnostic interview (Edens, Marcus, Lilienfeld, & Poythress, 2006; Guay, Ruscio, Knight, & Hare, 2007; Murrie et al., 2007; Walters, Duncan, & Mitchell-Perez, 2007; Walters, Gray, et al., 2007), or via self-report (Guay & Knight, 2003; Marcus, John, & Edens, 2004; Murrie et al., 2007). One interpretation of these ndings, consistent with the FFM research (Lynam, 2002; Lynam & Widiger, 2007, is that psychopathy reects, or emerges from, a combination of extreme variants of normal-range personality processes (see below), many of which are antisocial in nature (Lynam & Widiger, 2007). These combinations of extreme traits could be taxonic. Ruscio (2007) noted that the structure of psychopathy may contain both taxonic and dimensional features: Within a nonpsychopathic group, a set of dimensions may capture individual differences on psychopathy-relevant traits, but hardcore psychopaths deviate substantially on multiple dimensions and form their own group (p. 1589). Certainly, it is common for researchers and clinicians to describe those with very high PCL-R scores as different from other individuals. Although psychopathy appears to be dimensional at the measurement level, it is possible that there is discontinuity (suggestive of taxonicity) at the psychobiological level. For example, as scores on the PCL-R increase do certain anomalies (e.g., information processing, autonomic, electrocortical, neuroimaging, etc.) begin to appear only at a relatively high score? The
Implications of Structural Models

The structural properties of the PCL scales are of more than academic interest. Among other things, they help to delineate and elucidate the latent variables that make up the psychopathy construct. The four-factor model indicates that, contrary to some arguments, the presence of early and persistent antisocial behavior is an important feature of the construct. In line with the structural ndings are those from behavior genetic (e.g., Larsson et al., 2007; Viding et al., 2007) and longitudinal (Frick et al., 2003; Loney, Taylor, Butler, & Iacono, 2007; Lynam, Caspi, Moftt, Loeber, & Stouthamer-Loeber, 2007) studies. The PCL four-factor latent variable model also becomes important in accounting for the associations between the components of psychopathy and a variety of external correlates, including risk for violence, treatment options, and psychobiological processes. Although factor analysis identies four dimensions underpinning assessments of psychopathy made with the PCL scales, multidimensional scaling suggests that more dimensions may be required to fully account for the construct (Bishopp & Hare, 2008). The nature of the causal relationship between early antisocial tendencies and other psychopathic traits is of considerable importance, but largely unexplored. It strikes us as too simplistic (Neumann et al., 2005) to assume that antisocial tendencies are merely consequences of other psychopathic features (Cooke et al., 2004). An equally plausible model is that antisocial features inuence the nature and development of other psychopathic features (Frick & Marsee, 2006; Neumann et al., 2005). For example, basic longitudinal research indicates that the imitative behavior of toddlers plays an important role in their development of moral conscience (Forman, Aksan, & Kochanska, 2004). Similarly, negative parenting appears to play an important role in decreasing the level of a childs prosocial behavior (Knafo, & Plomin, 2006). Thus, exposure to, and engagement in, antisocial acts may play a role in the development of callous, manipulative, and impulsive psychopathic traits, which may then lead to further antisocial behavior. Given that that the modeling results described above indicate a mod-
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Psychopathy erate to strong covariation of four dimensions of psychopathy (Interpersonal, Affective, Lifestyle, and Antisocial), it would be prudent to assume that the longitudinal relations among these dimensions are interactive and reciprocal.
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Normal-Range Personality and Psychopathy

Research on normal-range personality traits is informative for understanding psychopathic traits, but the precise link between these two trait domains remains an important area for future research. Although psychopathic personality may be viewed as a maladaptive variant of common personality traits, it is not yet clear whether normal range (i.e., nonpathological) personality traits form the elemental basis of the pathological traits seen in psychopathic individuals. Lynam and Widiger (2007) have outlined how the FFM can be used to study the elements of psychopathy. Their proposal is based on the assumption that the 30 facets of the FFM are relatively more distinct than the PCL-R items (p. 165). For instance, based on their previous translational research (e.g., Widiger & Lynam 1998), Lynam and Widiger (2007) suggested that the PCL-R items might be seen as blends of several FFM facet domains, and therefore the former may be less elemental than the latter. However, large-sample factor analysis of the lower-order NEO facets (Costa & McCrae, 1992) that make up the ve higherorder FFM domains reveals that a number of facets show substantial factor cross-loadings among different FFM domains (cf. Aluja, Garca, Garca, & Seisdedos, 2005). That certain PCL-R items can be translated to t under several FFM facets may stem from the fact that the FFM facets themselves demonstrate empirical overlap across FFM domains. Thus, one might question whether the FFM facet domains are indeed more distinct, or elemental, than the PCL-R items (and by extension, PCL factors). In addition, Digmans (1997) meta-analytic factor analytic results clearly demonstrate higherorder alpha and beta factors that explain the signicant covariation among the lower-order FFM domains. Similar results have been reported in other large-sample factor analytic research (DeYoung, Peterson, & Higgins, 2001, Musek, 2007). Thus, whether the FFM domains represent distinct elements of personality that can explain psychopathic
personality remains an open area of investigation. Nevertheless, despite such questions and considerations, we support the line of FFM psychopathy research being pursued by a number of investigators and believe such endeavors not only complement research on the PCL instruments, but also represent important avenues of investigation. Moreover, using self-report instruments such as the FFM in conjunction with the interview-based PCL instruments might provide excellent opportunities to conduct hetero-method studies, which may provide additional coverage of the psychopathy construct as well as the opportunity to model method effects (e.g., multitrait, multimethod CFA). If normal-range personality traits are not synonymous with, or more elemental than, psychopathy traits, then an important avenue for research concerns the nature of the association between nonpathological and pathological personality trait domains. There is no doubt that normal-range personality traits are correlated with psychopathy traits. For instance, aggregate data can be obtained using the results reported in Table 24.1 of Lynam and Widiger (2007, p. 168), which displays the correlations between the FFM facets and the PPI and Hare SRP based on a combined sample of 560 young adults. The average (absolute) correlation is approximately r = 0.22 between the FFM facets and the two self-report psychopathy scales. If one uses only the highly prototypic FFM facets, then the aggregate correlation (derived from Table 24.1 in Lynam & Widiger, 2007) between the FFM facets and the PPI or Hare SRP scales is r = 0.27. Interestingly, similar results are obtained with offender populations, based on a hetero-method approach. For example, modest MPQ/PCL-R correlations have been reported for a sample of 218 male offenders (Benning, Patrick, Blonigen, Hicks, & Iacono, 2005). Similar modest associations were found between the MPQ and the PCL-R facets in a sample of 157 male offenders (Wupperman, Neumann, & Newman, 2008). Generally similar ndings of modest correlations have been reported in a meta-analysis by Lynam and Derenko (2006). They used both mono-method and hetero-method studies of either adult or youth samples to gauge the strength of the association between normal-range personality and psychopathy. They reported that the majority of normal-range personality dimensions was modestly, at best, related to psychopathy traits. Most important, the normal range dimension of agreeableness tended to display a moderately strong (negative) associa-
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634
Axis II Disorders order levels linked to more specic, residual genetic factors (Livesley, 2005, Livesley et al., 1998). Similarly, as Little, Cunningham, Shahar, and Widaman (2002) discussed, it is often necessary to mathematically represent constructs like personality in terms of a broad array of indicators. For example, Baker et al. (2007) reported that a broad set of items reecting antisocial behavior, aggression, delinquency, and psychopathic traits all formed a single cohesive factor, which had signicant genetic effects across child, caregiver, and teacher ratings. The strength of measures such as the PCL instruments (Hare & Neumann, 2006), the YPI (Andershed et al., 2002), the APSD (Vitacco, Rogers, & Neumann, 2003), and the SRP-III (Williams et al., 2007) is that the item-to-factor relations have been clearly worked out, and each of these measures can be precisely represented in terms of lower-order as well as cohesive higher-order latent variable models. Once the latent structure of a measure is known, it is then possible to determine if the same structure can be revealed with biometric data (e.g., Livesley et al., 1998).
tion with psychopathy. Lynam and Derenko (2006) suggested that low agreeableness reects individuals who are suspicious, deceptive, exploitive, aggressive, arrogant, and tough minded. Thus, the relation between low agreeableness and psychopathy may reect overlap in broad antisocial tendencies. Taken together, the results of these studies suggest that the empirical link between normal-range personality traits and psychopathic personality traits is modest at the measurement level, though the association may be stronger at the latent level. Unfortunately, research in this area has only relied upon total psychopathy scores and not examined the associations among normal-range personality and the four psychopathy factors. Also, besides examination of cross-sectional bivariate relations, future research might examine the longitudinal relations between normal-range personality and psychopathic traits in forensic and nonforensic populations. Despite the link between normal-range and psychopathic personality traits, Livesley (2007) suggested that a strength of dimensional models of personality disorder (PD) is that they are based on clinical descriptions of PDs, and also that it is difcult to explain how extreme positions on dimensions such as agreeableness, sociability, or conscientiousness are necessarily pathological (p. 203). At the same time, there appears to be a fair degree of convergence between models of normal-range traits and PD traits (Widiger & Simonsen, 2005). Thus, continued research on the integration of pathological and nonpathological trait domains is necessary. For instance, do the same genetic factors pertain to normal-range and pathological personality traits (Livesley et al., 1998)? If so, perhaps pathological traits are simply maladaptive expressions of normal-range personality traits. However, an alternative empirical relation might be that normalrange traits are reciprocally related to pathological personality traits. If this assumption is correct, then normal-range traits may contribute to the development of PD traits, but additional factors, such as pathological interactions with parents or peers (e.g., Frick et al., 2003, Pardini, Lochman, & Powell, 2007), may be necessary for the development of PD traits, including those that dene psychopathy. Based on our discussion of lower-order and higher-order personality domains, it appears that the level of analysis for mathematically representing psychopathy-related traits is an important consideration. For instance, higher-order levels may be linked to broad general genetic factors, and lower-
Behavior Genetics of Psychopathic Traits

As mentioned above, there is increasing evidence that broad genetic factors may account for a substantial portion of the variance and covariance of diverse sets of psychopathy traits. Investigators have reported that there are genetic inuences on the covariance of psychopathy scales reecting emotional detachment and antisocial tendencies (Taylor et al., 2003, Viding et al., 2005). Relatedly, MPQ dimensions that are conceptually and emprically linked to psychopathy (fearless-dominance and impulsiveantisociality) show genetic covariation with externalizing psychopathology in men (Blonigen et al., 2005). In a large sample of 9- to 10-year-old twins, Baker et al. (2007) found that a common antisocial behavior factor (composed of child psychopathy traits, aggression, and delinquency) across informants was strongly heritable. Recently, Viding et al. (2007) found a common genetic component to the covariation between callous-unemotional traits and antisocial tendencies in children. Finally, based on a large adolescent twin sample, Larsson et al. (2007) described four factors similar to those in the PCL four-factor model of psychopathy (e.g., Hare & Neumann, 2006, Neumann et al., 2006, Vitacco et al., 2005). The authors reported that these four
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Psychopathy factors all loaded onto a single genetic factor. The variance in the male psychopathic traits in each factor accounted for by the common genetic factor was 25% for grandiose/manipulative, 20% for callous/ unemotional, 42% for impulsive/irresponsible, 19% for antisocial behavior (ages 13 to 14), and 30% for antisocial behavior (ages 16 to 17). For females, the variance accounted for by the common genetic factor was 37% for grandiose/manipulative, 22% for callous/unemotional, 45% for impulsive/irresponsible, 21% for antisocial behavior (ages 13 to 14), and 41% for antisocial behavior (ages 16 to 17). Notably, in both sexes the impulsive/irresponsible and antisocial facets showed some of the strongest genetic components, consistent with the very early conceptions of psychopathy. Taken together, the behavior genetic research on psychopathy ts with the structural research discussed previously. The results reported by Livesley et al. (1998) may be the most informative, given that the same latent psychopathy factor resulted when using either phenotypic or genotypic PD symptom data. Thus, consistent with the observations of Eley (1997), the behavioral genetic evidence suggests that genetic factors might be acting as general inuences (i.e., general genes) in the manifestation of covarying psychopathic traits, with environmental factors inuencing the form of specic psychopathic traits (pp. 9091). At the same time, as discussed by Livesley (2005), lower-order specic residual genetic effects may also be important for understanding personality disorders such as psychopathy. For example, Larsson et al. (2007) found this type of residual genetic effect for the grandiose/manipulative scale of the YPI in girls.
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Longitudinal Nature of Psychopathic Traits

Several recent longitudinal studies have provided good evidence that psychopathic traits are at least moderately stable across development. For instance, Frick et al. (2003) found that the APSD trait dimensions were stable over a 4-year period in a sample of nonreferred children in the third, fourth, sixth, and seventh grades at rst assessment. In this study, baseline antisocial behavior, socioeconomic status (SES), and quality of parenting were signicant predictors of stability. Using a large sample of inner-city boys assessed annually from ages 8 to 16 and items from a child behavior checklist
to model interpersonal-callousness, Obradovic, Pardini, Long, and Loeber (2007) found evidence of signicant stability across a 9-year period, as well as longitudinal invariance. The latter nding is important because it suggests that the same construct was being modeled across time. In related research, Burke, Loeber, and Lahey (2007) reported that the same behavior checklist-based interpersonalcallousness measure signicantly predicted PCL-R scores at age 19 in a clinic-referred sample of boys assessed at ages 7 to 12. Loney et al. (2007) used a large sample of twins and found that emotional detachment and antisocial tendencies showed good stability across six years. Lynam et al. (2007) also found moderate stability from ages 13 to 24, respectively, using the Child Psychopathy Scale (Lynam 1997) and the PCL: SV. This latter study is notable for its use of a hetero-method approach. Also, Lynam et al. (2007) found that in addition to Child Psychopathy Scale scores, family structure and SES also predicted PCL: SV scores, consistent with the Frick et al. (2003) ndings. Blonigen et al. (2005) reported greater genetic than environmental contributions to the stability of the MPQ factors (fearless-dominance, impulsive-antisociality) from late adolescence to young adulthood, but that nonshared environmental factors contributed more to their change over time. Importantly, across many of these studies there appear to be fundamental longitudinal relations between the antisocial-tendencies component of psychopathy and other psychopathic traits, in line with the behavior genetic and structural research ndings discussed above. Similarly, Larsson et al. (2007) found that prior (ages 13 to 14) antisocial tendencies were signicantly positively associated with later (ages 16 to 17) interpersonal, affective, and impulsive lifestyle psychopathic traits via cross-twin cross-trait biometric data. In sum, across a diverse set of psychopathy or psychopathyrelated instruments and samples, there is good evidence for the stability of psychopathic traits from childhood and adolescence into adulthood. At the same time, family factors, SES, and unique environmental factors also play important roles in the stability and change of psychopathic traits over time.
Biological and Cognitive Features of Psychopathy

Much of the research literature on psychopathy has to do with its clinical and forensic implications and
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636
Axis II Disorders chopathy can better be understood in terms of complex interactions among various regions and functions (e.g., Kiehl, 2006), perhaps as part of more general models related to, for example, externalizing psychopathology (e.g., Markon & Krueger, 2005), affective processing (Kiehl, 2006), and moral behavior (e.g., Moll, Zahn, de Oliveira-Souza, Krueger, & Grafman, 2005; Raine & Yang, 2006). With respect to the latter, an imaging study of civil psychiatric patients with high PCL: SV scores (De OliveiraSouza et al., 2008) found evidence of volumetric reductions in several brain regions implicated in a model (Moll et al., 2005) of moral sensibility and behavior. Interestingly, these reductions were related to the interpersonal/affective features of psychopathy but not to the lifestyle/antisocial features. Research of this sort reects a notable trend for neuroscientists to use psychopathy as a vehicle for evaluating their own models of behavior, personality, and brain function. The result ultimately may be an integration of psychopathy theory and research with more general psychobiological, behavioral genetic, developmental, and personality models. Meanwhile, the rapid increase in neuriomaging research presents some potentially difcult issues for the justice system, particularly those associated with psychopathy. For example, to what extent will evidence of anomalies in brain structure or function be taken as a mitigating factor in determining criminal culpability? The MacArthur Foundation has established the Law and Neuroscience Project (www.lawandneuroscienceproject.org) to investigate this and related issues. The ndings and reports are bound to be highly contentious, raising the ironic and disturbing possibility that some of societys most callous, manipulative, and aggressive individuals may not be held as accountable for their actions as are others.
applications. However, an equally robust literature aims at understanding the basic nature of the disorder. We discussed some of this literature in preceding sections on behavioral genetics, developmental psychopathology, and general personality theory. Here we refer to empirical research into the biological and cognitive mechanisms of psychopathy, beginning many decades ago with theories and methodologies derived from the then new eld of psychophysiology (e.g., Hare, 1968; Lykken, 1957) and continuing today with the active collaboration of scientists in a variety of disciplines, including biochemistry, neuroanatomy, and cognitive/affective neuroscience (e.g., see Blair, Mitchell, & Blair, 2005; Kiehl, 2006; Newman, Brinkley, Lorenz, Hiatt, & MacCoon, 2007; Patrick, 2006; Raine & Yang, 2006). Space limitations do not allow for a review of this literature, but a few notable trends can be mentioned. Early psychophysiological research had indicated that during anticipation of an unpleasant event the skin conductance responses (an autonomic measure of sympathetic nervous system arousal) were smaller in psychopathic individuals than in others. This nding was viewed as support for the view that psychopaths have difculty in avoiding punishment and other negative consequences because they do not sufciently fear these consequences. These and other aspects of psychopathy have been interpreted by Newman and his colleagues (e.g., Newman et al., 2007) as a failure to process the cues necessary for the guidance of prosocial behavior. Recently, there has been a surge in neuroimaging research on the structural and functional correlates of psychopathy. Most of this research uses the PCL-R or one of its derivatives, with results that generally are consistent with the view that psychopathy is characterized by anomalies in cognitive and affective processes. There is increasing evidence that some clinical and behavioral features of psychopathy, such as impulsivity, poor response inhibition, and difculty in processing emotional material, are mirrored in brain function and perhaps in brain structure. In most studies, it is the total PCL-R or PCL: SV score that is important, but in some tasks the psychopathy dimensions are differentiallyand meaningfully related to brain function (e.g., Blair et al., 2005; Kiehl, 2006). Although early investigations implicated relatively localized brain regions (e.g., amygdala, hippocampus, frontal cortex) in psychopathy, more recent theory and research takes the view that psy-
Psychopathy and Crime

In the past few years there has been a dramatic change in the perceived and actual role played by psychopathy in the criminal justice system. Formerly, a prevailing view was that clinical diagnoses such as psychopathy were of little value in understanding and predicting criminal behaviors. More recently, the importance of psychopathy, particularly as measured by the PCL-R and its derivatives, is widely recognized by forensic clinicians (e.g., Archer, Bufngton-Vollum, Stredny, & Handel, 2006) and
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Psychopathy by the courts (e.g., Walsh & Walsh, 2006). This is not surprising, given that many of the characteristics important for inhibiting antisocial and violent behaviorempathy, close emotional bonds, fear of punishment, guiltare lacking or seriously decient in psychopaths. Moreover, their egocentricity, grandiosity, sense of entitlement, impulsivity, general lack of behavioral inhibitions, and need for power and control constitute what might be described as the perfect prescription for the commission of antisocial and criminal acts (e.g., Porter & Porter, 2007). This would help to explain why psychopaths make up only about 1% of the general population but as much as one fourth of our prison populations. It also would explain why they nd it so easy to victimize the vulnerable and to use intimidation and violence as tools to achieve power and control over others. Their impulsivity and poor behavioral controls may result in reactive: forms of aggression of violence, but other features (e.g., lack of empathy, shallow emotions) also make it relatively easy for them to engage in aggression and violence that is more predatory, premeditated, instrumental or cold-blooded in nature (e.g., Porter & Woodworth, 2006).
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Assessment of Risk
Extensive discussions of the theories and methodologies of risk assessment are provided elsewhere (e.g., Quinsey, Harris, Rice, & Cormier, 2006). The latest generation of risk assessment instruments largely has dispelled the belief that useful predictions cannot be made about criminal behavior (see G. T. Harris & Rice, 2007; Monahan et al., 2001). Much of the recent debate is concerned with the relative effectiveness of actuarial instruments and structured clinical assessments. The former are empirically derived sets of static (primarily criminal history, demographic) risk factors, and include the Violent Risk Appraisal Guide (VRAG; Quinsey, Harris, et al., 2006), the Sex Offender Risk Appraisal Guide (SORAG; Quinsey, Rice, & Harris, 1995), and the Domestic Risk Appraisal Guide (DRAG; Hilton, Harris, Rice, Houghton, & Eke, 2008), instruments that improve considerably on unstructured clinical judgments or impressions. However, procedures that include structured clinical decisions based on specic criteria, are proving to be useful. For example, the HCR-20: Assessing Risk for Violence (Webster, Douglas, Eaves, & Hart, 1997) assesses 10 historical (H) variables, ve clinical (C) variables and ve risk management (R) vari-
ables. Because of its importance in the assessment of risk, psychopathy, as measured by the PCL-R or the PCL: SV, is included in the VRAG, SORAG, DRAG, and HCR-20, as well as in the Sexual Violence Risk-20 (SVR-20; Boer, Hart, Kropp, & Webster, 1997). We note that the PCL-R and its derivatives reect static risk factors and that they properly are used as supplements to more general risk evaluations. In addition to the instruments described above, there is increasing interest in the role of dynamic (changeable) risk factors in risk assessment (e.g., Quinsey, Jones, Book, & Barr, 2006). A detailed account of psychopathy as a risk for recidivism and violence is beyond the scope of this chapter (see Hemphill, 2007). However, its signicance as a robust risk factor for institutional problems, for recidivism in general, and for violence in particular, is now well established (see the largescale meta-analysis by Leistico et al., 2008). The predictive value of psychopathy applies not only to adult male offenders but also to adult female offenders (e.g., Jackson & Richards, 2007a), adolescent offenders (e.g., Forth et al., 2003), forensic psychiatric patients, including those with Axis I disorders (e.g., Lincoln & Hodgins, 2008), and offenders with intellectual difculties (Gray, Fitzgerald, Taylor, MacCulloch, & Snowden, 2007). Psychopathy also is increasingly being seen as an important factor in explaining domestic violence, with the PCL-R being included in the DRAG (Hilton et al., 2008). Many investigators use receiver operating characteristic (ROC) analyses to determine the predictive ability of instruments (e.g., Quinsey, Harris, et al., 2006). An ROC curve is a plot of true positives (sensitivity) against false positives (1 minus specicity), with respect to an outcome variable, at different PCL-R (or other) scores. If the outcome variable is recidivism, for example, the area under the curve (AUC) represents the probability that a randomly selected recidivist will have a higher PCL-R score than will a randomly selected nonrecidivist. AUCs for the PCL-R and PCL: SV in North American samples of offenders and forensic psychiatric patients typically fall between .70 and .80, and frequently are not signicantly different from the AUCs obtained with purpose-built risk tools, such as the VRAG and the HCR-20, that include one of these measures of psychopathy (e.g., Douglas, Yeomans, & Boer, 2005). Similar results have been obtained with the PCL-R or PCL: SV in studies of offenders and forensic psychiatric patients in Europe and the
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Axis II Disorders Cooke, & Hart, 1999; Ochberg et al., 2003; Stone, 1998). In their PCL-R study of murderers, Porter et al. (2003) concluded that not only are psychopathic offenders disproportionately more likely to engage in sexual homicide (than are other murderers), but, when they do, they use signicantly more gratuitous and sadistic violence (p. 467). Psychopathy, as measured by the PCL-R, is commonly used in preventative detention proceedings for sex offenders (Jackson & Hess, 2007; Mercado & Ogloff, 2007). At the same time, there is evidence that psychopathic sex offenders are more likely to obtain early release from prison than are other sex offenders, presumably because they adept at impression management (Porter et al., in press).
United Kingdom, including violent recidivism by Dutch forensic psychiatric patients (de Vogel, de Ruiter, Hildebrand, Bos, & van de Ven, 2004); violent recidivism by German prison inmates and forensic psychiatric patients (Stadtland, Kleindienst, Krner, Eidt, & Nedopil, 2005); general and violent recidivism by German prison inmates (Dahle, 2006); violent recidivism by Swedish rapists (Sjstedt & Lngstrm, 2002); violent recidivism by Belgium prison inmates and forensic psychiatric patients (Pham, Ducro, Maghem, & Rveillre, 2005); violent recidivism by Swedish violent offenders (Tengstrm, 2001); and physical violence and institutional aggression by English forensic patients with schizophrenia (Dolan & Davies, 2006). There is some evidence that the predictive validity of the PCL-R and the HCR-20 among criminals (also see next section) can be improved by using them as part of a classication tree analysis (e.g., Dahle, 2006).
Deadly Combination
One of the most potent combinations to emerge from the recent research on sex offenders is psychopathy coupled with evidence of deviant sexual arousal. Rice and Harris (1997) reported that sexual recidivism was strongly predicted by a combination of a high PCL-R score and deviant sexual arousal, dened by phallometric evidence of a preference for deviant stimuli, such as children, rape cues, or nonsexual violence cues. Several studies indicate that psychopathy and behavioral or structured clinical evidence of deviant sexual arousal also is a strong predictor of sexual violence (A. J. R. Harris & Hanson, 1998; Hildebrand, de Ruiter, & de Vogel, 2004; Serin, Mailloux, & Malcolm, 2001). Gretton, McBride, Hare, OShaughnessy, and Kumka (2001) found that this combination was highly predictive of general and violent reoffending in adolescent sex offenders. Recently, G. T. Harris and colleagues (2003) reported that in a large-sample study involving four sites the psychopathysexual deviance combination was predictive of violent recidivism in general, sexual and nonsexual. The authors commented, Because of the robustness of this (psychopathy sexual deviance) interaction and its prognostic signicance, its inclusion in the next generation of actuarial instruments for sex offenders should increase predictive accuracy (p. 421) of general violent recidivism.
Sexual Violence
The last few years have seen a sharp increase in public and professional attention paid to sex offenders, particularly those who commit a new offense following release from a treatment program or prison. It has long been recognized that psychopathic sex offenders present special problems for therapists and the criminal justice system (Meloy, 2002). In general, the prevalence of psychopathy, as measured by the PCL-R, is lower in child molesters than in rapists or mixed offenders, although child molesters with high PCL-R scores are at high risk for sexual reoffending (Porter, ten Brink, & Wilson, in press). Quinsey et al. (1995) concluded from their extensive research that psychopathy functions as a general predictor of sexual and violent recidivism. Although psychopathy appears to be more predictive of general violence than sexual violence (Hare, 2003; Porter et al., in press), its relationship with the latter may be underestimated because many sexually motivated violent offences are ofcially recorded as nonsexual violent offences (Rice, Harris, Lang, & Cormier, 2007). Not only are the offenses of psychopathic sex offenders likely to be more violent than those of other sex offenders, they tend to be more sadistic (G. T. Harris et al., 2003; Porter, Woodworth, Earle, Drugge, & Bower, 2003). In extreme casesfor example, among serial killerscomorbidity of psychopathy and sadistic personality is very high (Hare,
Civil Psychiatric Patients

The predictive validity of psychopathy is not conned to forensic populations (Douglas, Ogloff, & Nicholls, 1997; Steadman et al., 2000). The article by Steadman and colleagues (2000) was a report of
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Psychopathy the MacArthur Foundations ndings on risk for violence in civil psychiatric patients. The most extensive and thorough study of its sort ever conducted, it evaluated 134 potential predictors of violence in 939 patients following discharge from a civil psychiatric facility. In presenting their results, the authors used a classication tree approach in which a hierarchy of decisions is made about the risk posed by a given patient. The single best predictor was the PCL: SV, developed for use in the study. In this scheme, the rst decision is whether or not the patient has a PCL: SV score of 13 or more. Silver, Mulvey, and Monahan (1999) used a subsample of these patients to investigate the impact that neighborhood factors have on individual risk factors for violence in discharged patients. Again, the single best predictor of violence was the PCL: SV. Although patients discharged into neighborhoods with concentrated poverty generally were at higher risk for violence than were those discharged into neighborhoods with less poverty, this did not apply to patients with high PCL: SV scores. That is, their risk of the latter patients was independent of the neighborhood into which they were discharged. In a recent reanalysis of the MacArthur data, Vitacco et al. (2005) found that when using the three-factor model only the Affective factor signicantly predicted violence at 20 weeks. However, when the four-factor model was used the predictive power of the Affective factor increased and the Antisocial factor was a strong predictor. A similar result was obtained by Vitacco et al. (2006) in their analysis of the association between the PCL: YV and instrumental aggression. They reported that the association of the PCL: YV factors with instrumental aggression in the three-factor model changed with the addition of the Antisocial factor. G. T. Harris, Rice, and Camilleri (2004) applied a modied 10-item version of the VRAG to the MacArthur data and reported that its predictive validity was almost as high as that of the classication tree approach used by Steadman and colleagues (2000). Of the items in this version of the VRAG, the PCL: SV was by far the best predictor. G. T. Harris and colleagues (2004) commented that even if the base rate of psychopathy or psychopathic features in a population is relatively low, the personality traits associated with psychopathy are among the most important causes of aggression (p. 1070). Indeed, a reanalysis of the G. T. Harris et al. (2004) data by Edens, Skeem, and Douglas (2006) showed that the predictive power of the
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modied, 10-item version of the VRAG was entirely due to the PCL: SV.
Some Cautions
Although the research evidence for the reliability and validity of the PCL-R and its derivatives is extensive, this does not ensure that an individual clinical or forensic assessment will be reliable or valid. In a research context misuse of these instruments will have few negative consequences for the individual. However, when the scores are used in clinical and criminal justice contexts the implications of misuse are potentially very serious, especially if the scores are used to guide treatment or adjudication decisions (Edens, 2001; Hare, 1998, 2003). In addition, it is important when conducting an assessment to use all information available to provide a complete picture of the person. In each case the PCL-R must be used properly and in accordance with the highest ethical and professional standards. The items must be scored in accordance with the criteria listed in the manual, or not scored at all. Clinicians who use the PCL-R or its derivatives must be prepared to outline the information used to score the items and to explain and justify the manner in which they scored the items. They must take into account measurement error (Hare, 2003) and the probabilistic nature of risk assessments. They also should be aware of the fact that many prosecutors and defense attorneys are familiar with the PCL-R, its uses, and its limitations (see Book et al., 2006).
Treatment
Unlike most other offenders, psychopaths appear to suffer little personal distress, see little wrong with their attitudes and behavior, and seek treatment only when it is in their best interests to do so, such as when seeking probation or parole. They derive little benet from traditional prison programs, particularly those aimed at the development of empathy, conscience, and interpersonal skills (G. T. Harris & Rice, 2006, 2007; Richards, Casey, & Lucente, 2003; Thornton & Blud, 2007; Wong & Hare, 2005). Indeed, there have been reports that some programs designed to modify the behavior of psychopathic offenders resulted in an increase in postrelease criminal behavior (Hare, Clark, Grann, & Thornton, 2000; Rice, Harris & Cormier, 1992). These were group therapy and insight-oriented pro-
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Axis II Disorders ment programs that have little chance of success and that fool them and others into thinking that the exercise is worthwhile and of practical benet to them? Rather than being discouraged, we should mount a concerted effort to develop innovative procedures designed specically for psychopathic offenders. Lsel (1998), Thornton and Blud (2007), and Wong and Hare (2005) have discussed the issues involved in the treatment and management of psychopathic and other offenders and have outlined in some detail the requirements for an effective program. Thornton and Blud (2007) discussed the implications of the four-factor model of psychopathy for working with offenders. An extensive set of program guidelines for development of a program specically designed for psychopaths is now available (Wong & Hare, 2005). In brief, we propose that relapse-prevention techniques and risk/needs/responsivity principles (Andrews & Bonta, 2003) should be integrated with elements of the best available cognitive-behavioral correctional programs. The program is less concerned with developing empathy and conscience or effecting changes in personality than with convincing participants that they alone are responsible for their behavior, and that they can learn more prosocial ways of using their strengths and abilities to satisfy their needs and wants. It involves use of relapse prevention and risk/needs/responsivity principles (Andrews & Bonta, 2003), tight control and supervision, in the institution and following release into the community, and comparisons with carefully selected groups of untreated offenders or offenders treated in standard correctional programs. The program would permit empirical evaluation of its treatment and intervention modules (what works and what doesnt work for particular individuals). That is, some modules or components might be effective with psychopaths but not with other offenders, and vice versa. Because correctional programs are constantly in danger of erosion because of changing institutional priorities, community concerns, and political pressures, we proposed stringent safeguards for maintaining the integrity of the program. A key element of any program that hopes to be effective with psychopathic offenders and patients is the availability of a highly trained staff and cooperation of all levels of administration. A recent study by Wong, Witte, Gordon, Gu, and Lewis (2006) offers some promise that such a program may have a benecial effect on psychopathic offenders. Wong et al. (2006) found that although completion of
grams that unintentionally may have helped psychopaths to develop better ways of manipulating, deceiving, and using people but do little to help them to understand themselves. Programs that do not take into account the nature of psychopathic offenders are unlikely to be effective. Hobson, Shine, and Roberts (2000) found that offenders with high PCL-R Interpersonal/Affective scores obtained on admission to a well-developed prison therapeutic community program engaged in a variety of counterproductive behaviors during later therapy sessions. Their behaviors included manipulation of the system to satisfy a personal need for power, control and prestige, playing head games with other inmates and staff, continually testing the boundaries, exploitation of other patients, and a lack of genuine interest in changing their own attitudes and behaviors. Nevertheless, they managed to manipulate and fool some staff into thinking their efforts were sincere and that they were making good progress. Interestingly, Factor 1 also was predictive of treatment progress in offenders with intellectual disability (Morrissey, Mooney, Hogue, Lindsay, & Taylor, 2007). There is some evidence that psychopathic sex offenders are able to manipulate skilled therapists into concluding that they have made good progress (Looman, Abracen, Serin, & Marquis, 2005). However, earlier reports of the unusually high sexual reoffense rate of sex offenders with elevated PCL-R scores who had been rated as having made good progress in therapy have not been replicated (Barbaree, 2005). Langton, Barbaree, Harkins, and Peacock (2006) reported that among treated sex offenders it is psychopathy, not ratings of treatment success, that is a signicant predictor of postrelease sexual behavior. Further, they reported that psychopathic offenders with poor treatment ratings reoffended faster than did other offenders. This does not mean that the attitudes and behaviors of psychopathic offenders and patients are immutable or that nothing works (DSilva, Duggan, & McCarthy, 2004; Wong & Burt, 2007; Wong & Hare, 2005). But it is clear that traditional programs, particularly those that are emotion or insight oriented, are ineffective and that the task of bringing the behaviors of psychopathic individuals into line with societal expectations is a formidable one (Wong & Hare, 2005). What then? Do we simply keep them in prison until they are old enough to pose little risk to society? Do we ask psychopaths to participate in treat-
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Psychopathy the program did not reduce the recidivism rate or time to reoffense of psychopathic offenders, it appeared to reduce the seriousness of the offenses committed, as reected in the average length of the sentence for a new offense.
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Conclusions
There is a substantial amount of empirical evidence that psychopathy, as measured by the PCL-R and its derivatives, is a predictor of recidivism and violence in prison, forensic psychiatric, and civil psychiatric populations. Indeed, the PCL-R is one of the most generalizable of the risk factors identied thus far, and for this reason it is included in a variety of actuarial and structured-clinical risk assessment procedures. Although psychopathy is not the only risk factor for recidivism and violence, it is unusually pervasive and too important to ignore, particularly with respect to violence. Treatment and management are difcult, time-consuming, and expensive, but new initiatives based on current theory and research on psychopathy and the most effective correctional philosophies may help to reduce the harm done by psychopaths. Acknowledgment This chapter draws on material presented in Hare (2007) and Hare & Neumann (2008, in press). We thank Kylie Neufeld for her help in updating the material and in preparing the manuscript. References Acheson, S. K. (2005). Review of the Hare Psychopathy Checklist-Revised, 2nd edition. In R. A. Spies & B. S. Plake (Eds.), The sixteenth mental measurements yearbook (pp. 429431). Lincoln, NE: Buros Institute of Mental Measurements. Aluja, A., Garca, O., Garca, L. F., & Seisdedos, N. (2005). Invariance of the NEO-PI-R factor structure across exploratory and conrmatory factor analyses. Personality and Individual Differences, 38, 18791889. Andershed, H., Kerr, M., Stattin, H., & Levander, S. (2002). Psychopathic traits in non-referred youths: A new assessment tool. In E. Blauw & L. Sheridan (Eds.), Psychopaths: Current international perspectives (pp. 131158). The Hague, The Netherlands: Elsevier. Anderson, C. A., Berkowitz, L., Donnerstein, E., Huesmann, L. R., Johnson, J. D., Linz, D.,
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Hare &amp; Neumann Oxford Textbook 2009

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Psychopathy

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Table 24.2 Items and Factors in the Hare PCL: SV Interpersonal

Table 24.3 Items and Factors in the Hare PCL: YV Interpersonal

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The Antisocial Process Screening Device (APSD)

ICD-10 and DSMIV

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Structural Models of the PCL-R

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.66 .42 .55

.67 .54 .64

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Latent Growth Models

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Other Statistical Approaches

Implications of Structural Models

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Normal-Range Personality and Psychopathy

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Behavior Genetics of Psychopathic Traits

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Longitudinal Nature of Psychopathic Traits

Biological and Cognitive Features of Psychopathy

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Psychopathy and Crime

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Civil Psychiatric Patients

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Hare & Neumann Oxford Textbook 2009

Hare & Neumann Oxford Textbook 2009