Aggression and Violent Behavior 24 (2015) 941

Contents lists available at ScienceDirect

Aggression and Violent Behavior

Clarifying the heterogeneity in psychopathic samples: Towards a new

continuum of primary and secondary psychopathy
Bari O. Yildirim a,, Jan J.L. Derksen b,1
a
b

Department of Clinical Psychology, Radboud University Nijmegen, De Kluyskamp 1002, 6545 JD Nijmegen, The Netherlands
Department of Clinical Psychology, Radboud University Nijmegen, Room: A.07.04B, Montessorilaan 3, 6525 HR Nijmegen, The Netherlands

a r t i c l e

i n f o

Article history:
Received 22 May 2014
Received in revised form 5 May 2015
Accepted 5 May 2015
Available online 11 May 2015
Keywords:
History
Assessment
Subtypes
Etiology
Neurobiology
Endocrinology

a b s t r a c t
Psychopathic individuals identied through contemporary instruments vary considerably in personality and etiological background, which creates confusion in practice and inconsistency in data. The goal of this paper is to
clarify this heterogeneity and introduce a new typology to narrow down psychopathic subcategories. Towards
this end, we will discuss the conceptual history of psychopathy, compare the construct-validity of different psychopathy measures (DSM, PCL-R, PPI-R, and TriPM), and review cluster-analytic studies to identify more homogenous categories. In line with the existing literature, the psychopathic population is broadly divided into a
primary and secondary category which diverge crucially in personality (reward/punishment sensitivity, neuroticism, impulsivity, hostility) and etiology (genetic contributions, fronto-limbic circuitry, serotonergic functioning,
and testosterone/cortisol endocrinology). Secondary psychopathy may be situated on a continuum with the antisocial or borderline personality disorder because it represents a more severe but not qualitatively different form
of environment-contingent emotional disturbance (e.g., prefrontal cortex malfunctioning, serotonin deciency,
impaired predictive allostasis), whereas primary psychopathy is a unique condition that is strongly rooted in a
constitutionally dened emotional deciency (e.g., limbic hyporesponsivity, serotonin hyperstability, dampened
reactive allostasis). However, both primary and secondary psychopathic samples show high levels of withingroup heterogeneity and may be placed on their own continuum of, respectively, self-control and affect instability. Concluding, we will introduce a new continuum of primary psychopathy (controlled to disinhibited) and
secondary psychopathy (detached to unstable) and discuss how these subtypes may differ on a number of psychopathy measures, personality proles, and endophenotypic pathways. Finally, future directions for resolving
conceptual issues are discussed.
2015 Elsevier Ltd. All rights reserved.

Contents
1.
2.

3.

4.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Divergent conceptualizations of psychopathy throughout history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.
The early conceptual history of psychopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2.
Hervey Cleckley; The Mask of Sanity (1941) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3.
William and Joan McCord; The Psychopath (1964) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Divergent operationalizations of psychopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.
Diagnostic and Statistical Manual of Mental Disorders (DSM) (1952present) . . . . . . . . . . . . . . . . . . . .
3.2.
Psychopathy Checklist-Revised (PCL-R) and its derivatives (PCL-SV, PCL-YV) (1980present) . . . . . . . . . . . . . . .
3.3.
The Psychopathic Personality Inventory (PPI) (1996present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.4.
The Triarchic Psychopathy Measure (TriPM) (2009present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clarifying the heterogeneity; primary or secondary psychopathy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1.
Historical to contemporary differentiations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2.
Is the Levenson Self-Report Psychopathy Scale (LSRP) a valid tool for the assessment of primary and secondary psychopathy?

We declare no conict of interest. No grant was received for this work and there are no third funding parties.
Corresponding author. Tel.: +31 646 11 8681.
E-mail addresses: onur.yildirim@live.nl (B.O. Yildirim), j.derksen@psych.ru.nl (J.J.L. Derksen).
1
Tel.: +31 24 36 12666.

http://dx.doi.org/10.1016/j.avb.2015.05.001
1359-1789/ 2015 Elsevier Ltd. All rights reserved.

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B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

4.3.
Identifying primary and secondary psychopathy in youngsters through cluster-analysis . . . . .
4.4.
Identifying primary and secondary psychopathy in adult offenders through cluster analysis . . .
4.5.
Identifying primary and secondary psychopathy in community samples through cluster analysis
5.
Etiological mechanisms in primary and secondary psychopathy . . . . . . . . . . . . . . . . . . .
5.1.
Biobehavioral pathways to primary psychopathy . . . . . . . . . . . . . . . . . . . . . .
5.2.
Biosociopsychological pathways to secondary psychopathy . . . . . . . . . . . . . . . . . .
5.3.
Serotonergic mechanisms in primary versus secondary psychopathy . . . . . . . . . . . . .
5.4.
Neuroendocrinological interactions in primary versus secondary psychopathy . . . . . . . . .
5.4.1.
The hypothalamic pituitary gonadal-axis (HPG-axis) and psychopathy . . . . . . . . .
5.4.2.
The hypothalamic pituitary adrenal-axis (HPA-axis) and psychopathy . . . . . . . . .
5.4.3.
The testosterone-to-cortisol ratio in primary versus secondary psychopathy . . . . . .
6.
Conclusions and typology; the primary and secondary psychopathic continuum . . . . . . . . . . .
6.1.
The primary psychopathic continuum . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.2.
The secondary psychopathic continuum . . . . . . . . . . . . . . . . . . . . . . . . . .
7.
Future directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1. Introduction
Antisocial personality traits, such as callousness, selshness, manipulativeness, and irresponsibility, have presumably been present since
the ascent of man (Cleckley, 1941; Kiehl & Hoffman, 2011; Lykken,
1995; Mealey, 1995). Indeed, the existence of psychopathic individuals
in pre-industrialized cultures and indigenous tribes validates that psychopathy is not an artifact of modern civilization (Lykken, 1995;
Murphy, 1976). Around 0.61.2% of the community and 1530% of the
prison population in the Western world can be diagnosed as psychopathic according to current standards. However, this group commits a
disproportionate amount of crimes, commits a greater variety of crimes,
begins committing crimes at younger ages, and is more violent during
the act (Coid, Freestone, & Ullrich, 2012; Coid, Yang, Ullrich, Robert, &
Hare, 2009; Hare, 1993, 2003; McCuish, Corrado, Lussier, & Hart, 2014;
Porter, Birt, & Boer, 2001; Porter, Woodworth, Earle, Drugge, & Boer,
2003; Sullivan & Kosson, 2006; Vaughn, Howard, & DeLisi, 2008). In
fact, psychopaths commit more than 50% of all serious felonies in Western society, and, after release from incarceration, are three to four times
more likely to recidivate violently compared to non-psychopathic criminals (Douglas, Epstein, & Poythress, 2008; Douglas, Vincent, & Edens,
2006; Hare, 1993; Hemphill, Hare, & Wong, 1998; Porter et al., 2001).
In response to such convincing statistics, some scholars have advanced
that psychopathy is the purest and best explanation for antisocial behavior and have even argued that psychopathy is the unied theory
of crime (italics added, DeLisi, 2009). Paradoxically, despite their
heightened risk for criminality, violence, and recidivism, psychopaths
are highly skilled at impression management, and able to convince professionals of their treatment progress or persuade parole boards to receive early release from incarceration (Porter, ten Brinke, & Wilson,
2009; Seto & Barbaree, 1999). All in all, psychopathy is a serious problem for societal harmony.
However, despite its profound effect on society, there is still much
confusion and disagreement on how psychopathy should be operationalized. Although Hervey Cleckley sought to delimitate the psychopathy
construct back in the 1940's, and was quite successful in his endeavor
(Cleckley, 1941), in the decades thereafter, the construct has again
been convoluted and a number of divergent denitions have gained
ground. Indeed, psychopathy as identied through currently available
instruments represents a highly heterogeneous group of personalities
with divergent etiological backgrounds (Brinkley, Newman, Widiger,
& Lynam, 2004). Also, the relationship of psychopathy to external constructs or its differentiation into separate subtypes is a source of ongoing
debate and research (e.g., Skeem, Polaschek, Patrick, & Lilienfeld, 2011).
Since several divergent denitions have received empirical support,

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some scholars have suggested that the psychopathy construct should

be recognized as being multidimensional in nature, possibly including
multiple subtypes that differ substantially regarding personality and etiology (e.g., Blackburn, Logan, Donnelly, & Renwick, 2008; Skeem,
Johansson, Andershed, Kerr, & Louden, 2007; Skeem, Poythress, Edens,
Lilienfeld, & Cale, 2003).
Furthermore, this widespread inconsistency and disagreement on
what should be regarded as psychopathic has naturally compromised
research that aims to uncover its etiological underpinnings and thereby
also hindered the development of specialized treatments. For example,
some reviews argue that primary psychopathy is associated with a highly stable serotonergic functioning which engenders socio-emotional deciency, while secondary psychopathy (previously termed sociopathy
by the authors) is associated with reduced serotonergic functioning
which engenders neuroticism, detachment, and reactive aggression
(Yildirim & Derksen, 2013). In sharp contrast, others argue that it is
primary psychopathy which is associated with reduced serotonergic
functioning and reactive aggression while secondary psychopathy
is not (Fanning, Berman, Guillot, Marsic, & McCloskey, 2014). Indeed,
when one inspects these papers more closely, it becomes clear
that both use widely divergent operationalizations of primary psychopathy (fearlessness/socio-emotional deciency versus Machiavellian
egocentricity).
Therefore, before specic psychological and pharmacological treatments can be designed or pre-emptive measures taken to reduce the
impact of psychopathy on society, it is paramount that we rst reach
consensus on what psychopathy is, which personality styles comprise
this heterogeneous group, how these subtypes associate with external
correlates, and which etiological mechanisms play an important role
in their development. In this review and theoretical contribution, we
will try to provide a more coherent understanding of the heterogeneous
population generally identied as psychopathic. To this end, the paper
is started in Section 2 with a discussion of the different psychopathy
conceptualizations that have arisen throughout history, beginning in
the early 19th century and ending with a comparison of the inuential
operationalizations as set out by Cleckley and the McCords. Continuing
in Section 3, we will compare various psychopathy measures that have
emerged in the last decades, critically discuss their construct validity,
and examine how these instruments may contribute to the heterogeneity
observed in the literature (i.e., DSM-IV-TR, DSM-5, PCL-R, -SV, -YV, PPI,
and TriPM). Then, in Section 4, an attempt is made to disentangle the heterogeneous population identied through these instruments into more
homogeneous categories. It is discussed that the psychopathic population
may be broadly divided into a primary and secondary category. To determine the external correlates of primary and secondary psychopathy, we

B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

will not rely on data obtained with the Levenson Self-Report Psychopathy scale (LSRP) because of several issues regarding its construct
validity, especially the divergent validity of the primary psychopathy
scale. Instead, we will review cluster-analytic studies which have included additional measures of neuroticism and anxiety in order to differentiate primary and secondary variants and examine how these
conditions differ in psychology and behavior. Following this conceptual
dissociation, Section 5 delves deeper into the underlying etiological
mechanisms and discusses the corresponding biobehavioral and
biosociopsychological pathways and associated neurophysiological
proles (serotonin, testosterone, HPA-axis), pertaining to either
primary or secondary psychopathy. Here, it is also argued that both
primary and secondary psychopathy may show considerable withingroup heterogeneity and can be placed on their own continuum.
Synthesizing the foregoing discussion in Section 6, we will summarize
the deductions made in this review, provide a new continuum of primary psychopathy (i.e., controlled to disinhibited) and secondary psychopathy (i.e., detached to unstable), and discuss how these subtypes may
differ across a number of psychopathy measures (TriPM, PPI-R, PCL instruments), personality proles (narcissistic, antisocial, borderline),
and endophenotypic pathways (emotional processing, executive functioning, self-control, neuroticism). Finally, in Section 7, we will discuss
future directions to resolve conceptual issues.

11

liars and swindlers, and pseudoquerulants) (Kraeplin, 1912). Another

prominent theorist on psychopathy during these times was Kurt
Schneider. In his book, Die Psychopathischen Persnlichkeiten (The
Psychopathic Personalities) he wrote about personalities with distinct
criminal tendencies (Schneider, 1923). Schneider asserted that many
of these delinquents are incorrigible and constitutionally inclined to
progress into criminality from an early age on. Schneider's portrayal of
these devious and criminally inclined personalities, termed the active
affectionless bears close resemblance to contemporary views on
psychopathy;
We mean personalities with a marked emotional blunting mainly
but not exclusively in relation to their fellows. Their character is a
pitiless one and they lack capacity for shame, decency, remorse,
and conscienceThe social moral code is known, understood but
not felt and therefore personality is indifferent to it (cited in
Millon, 2011, pp. 430).
Furthermore, Schneider was also the rst to assert that not all these
constitutionally predisposed subjects actually progressed into a criminal lifestyle but that they could be found in all walks of life. As he described it, some of these psychopaths might even be surprisingly
successful in positions of either political or material power (Millon
et al., 1998).

2. Divergent conceptualizations of psychopathy throughout history

2.1. The early conceptual history of psychopathy
Throughout the rst 1800 years A.D., mind was equated with reason and only a disintegration of rational thinking and reasoning was
therefore judged as insanity (Millon, Simonsen, & Birket-Smith, 1998).
Due to their excellent cognitive capabilities and apparently normal appearance, psychopathic personalities were generally not considered insane or pathologically disturbed during these early times but rather
evil or demonic in a more spiritual sense. Then, beginning at the
end of the 18th century, paranormal and spiritual explanations for
deviant behavior slowly started to make place for more rational and
philosophical discussions on the nature of consciousness and free-will
(Millon et al., 1998).
At the dawn of the 19th century, the French psychiatrist Philippe
Pinel was the rst to propose that some individuals engaged foolhardily
in impulsive, aggressive, violent, and destructive acts despite an excellent intellectual understanding of the futility and counterproductivenes
of their behavior (Pinel, 1806). Pinel referred to these cases as exhibiting
manie sans dlire by which he meant that, contrary to popular belief
at the time, madness could exist without confusion/psychosis
(Pinel, 1806). Later during the 1830's, the English psychiatrist James
Crowley Prichard used the insights of Pinel to devise a broad category
of mental disorders marked by what he termed moral insanity or
moral imbecility (Prichard, 1835). These terms referred to a wide variety of personality disordered individuals and only overlap partly with
the construct of psychopathy as operationalized today (Millon, 2011).
The actual terms psychopathy and psychopathic were rst introduced by the German psychiatrist Julius Ludwig August Koch towards
the end of the 19th century. Koch's concept of psychopathic inferiority
largely replaced the term moral insanity in the literature (Koch, 1889).
However, similar to the concept of moral insanity, Koch's psychopathic
inferiorities included a wide range of personality disturbances of which
only a small portion would be considered psychopathic in the modern
sense of the concept.
At the beginning of the 20th century, the German psychiatrist,
Emil Kraeplin, published the seventh edition of his important work
Psychiatrie: Ein Lehrbuch (later translated to English in 1912; Psychiatry:
A Textbook) and contrary to Koch, used the term psychopathic personalities to refer specically to antisocial individuals rather than personality disorders in general (i.e., born criminals, unstable criminals, morbid

2.2. Hervey Cleckley; The Mask of Sanity (1941)

In 1941, the American neuropsychiatrist Hervey Cleckley released
his now seminal work The Mask of Sanity in which he sought to narrow
the concept of psychopathy (Cleckley, 1941). Cleckley provided the scientic and psychiatric community with lively and vivid descriptions of a
large number of psychopathic cases and elaborated his efforts with a list
of 16 personality traits that characterized this population more specically (see Table 1). First and foremost, Cleckley argued that psychopaths
make a persuasive and distinctly positive impression of robust mental
health upon rst sight, as though they are genuinely well-adjusted to
society, content with life, morally reputable in mind, and authentically
sincere in conduct. However, as the title of his book suggests, he described that beneath the veneer of apparent adjustment and sincerity,
the affective landscape of the psychopath is barren, unpassionate, uncaring, and indifferent. These inner workings are slowly but surely revealed over time when the psychopath's maladaptive, egocentric, and
irresponsible behaviors start to accumulate and the observer starts to
notice the profound abyss that lies between his own and the
psychopath's understanding of agreements, values, rules, norms, and
morality in general. However, no matter how many times he is
reprimanded for his misdemeanors, and no matter how difcult these
punishments make life (incarceration, institutionalization), the psychopathic subject is unable to change his maladaptive ways. Despite his
sound and rational reasoning, the psychopath fails miserably in gaining

Table 1
The 16 characteristics of the psychopathic personality by Hervey Cleckley (1941).
Cleckley's criteria
1) Supercial charm/good intelligence
2) Absence of psychotic symptoms
3) Absence of nervousness and
neurotic symptoms
4) Unreliability
5) Untruthfulness and insincerity
6) Lack of remorse or shame
7) Inadequately motivated antisocial behavior
8) Poverty in affective reactions

9) Pathological egocentricity
and incapacity for love
10) Poor judgment and failure to
learn by experience
11) Specic loss of insight
12) Interpersonal unresponsiveness
13) Fantastic and uninviting behavior
14) Suicide rarely carried out
15) Trivial and impersonal sex-life
16) Failure to follow any life-plan

12

B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

any form of deeper insight into his own condition, rarely seen in even
the most disordered neurotic and psychotic patients.
Cleckley introduced the term semantic aphasia to explain the profound loss of insight of psychopaths into their own emotional disability
despite their excellent intellectual understanding that their behavior
causes harm to everyone involved (Cleckley, 1941). Semantic aphasia
entails that although the faculties of language and the ability to speak
it remain unimpaired supercially, the ability to truly understand and
resonate with what one is saying is absent. According to Cleckley, patients with semantic aphasia can converse about moral and ethical constructs, but their words are neither connected to internalized principles
or values, nor do they automatically conjure up the appropriate affect,
thereby remaining hollow of real content. These patients can eloquently
speak the words of regret, guilt, and remorse, but do not know, or better
said, feel their deeper meaning.
2.3. William and Joan McCord; The Psychopath (1964)
Another inuential contribution on the concept of psychopathy was
made by the sociologist William McCord and his wife, the criminologist
Joan McCord. In their book The Psychopath; An Essay on the Criminal
Mind (1964), the McCords described psychopathy along a number of
pathological traits similar to Cleckley, but rather than 16, included
only ve traits to set such individuals apart from the ordinary man
and criminal (see Table 2). Furthermore, in contrast to Cleckley, who
worked in a psychiatric hospital, the McCords gained their insights
within the criminal justice system which might explain why their conceptualization of psychopathy portrays a more maladjusted, aggressive,
and impulsive pattern. Indeed, the McCords broadly dened the
psychopath as an asocial, aggressive, highly impulsive person who
feels little or no guilt and is unable to form lasting bonds of affection
with other human beings (italics added, pp. 3).
Comparable to Cleckley, who focused on affective deciencies
to explain the condition, the McCords dened lovelessness and
guiltlessness as being the main differentiating features that set psychopaths apart from ordinary criminals (McCord & McCord, 1964).
However, the psychopath is not described by the McCords as a peculiar
and separate class to ordinary criminals as Cleckley explained the condition, but as those criminals who, because of an earlier and more profound traumatization, rejection, and abuse in childhood, are simply
more severely disturbed in their affective development than are other
criminals. In accordance, apart from the core personality traits of
guiltlessness and lovelessness, the McCords focus largely on behavior
to dene psychopathy (McCord & McCord, 1964).
Important differences that set the McCord'ian operationalization of
psychopathy apart from the Cleckley'an, is the inclusion of uncontrollable desires (i.e., impulsivity) and aggression as being dening of the
construct while excluding adaptive features such as low neuroticism,
absence of psychotic symptoms, low inclination towards suicide, and
good intelligence. In contrast to Cleckley, who focused on neither impulsivity nor aggression to dene psychopathy, the McCords adamantly
contend that the psychopath's impulsivity and aggression go far and beyond that of the ordinary criminal and might be qualied as undifferentiated and explosive. They even go as far as to state that the
psychopath's asociality often expresses itself in brutal aggression
(p. 10, italics added). Thus, in the McCord'ian view, psychopaths are

Table 2
The ve features characterizing psychopathy by William and Joan McCord (1964).
William and Joan McCord's criteria
1) The psychopath is asocial.
2) The psychopath is driven by uncontrolled desires.
3) The psychopath is aggressive.
4) The psychopath feels little guilt.
5) The psychopath has a warped capacity for love.

overtly aggressive and dysfunctionally impulsive by denition whereas

only a small portion of Cleckley's case examples exhibited overt aggressive behaviors and some of his cases had even achieved professional
successes that would denitely require a degree of planning and selfcontrol (e.g., businessman, scientist, physician, psychiatrist).
3. Divergent operationalizations of psychopathy
3.1. Diagnostic and Statistical Manual of Mental Disorders (DSM)
(1952present)
Although the rst editions of the DSM stayed true to the personalitybased denition of psychopathy as put forth by Cleckley and the
McCords (e.g., egocentricity, absence of love or loyalty, emotional immaturity) (APA, 1952, 1968), the operationalization of psychopathy in
later editionsstarting with the DSM-IIIfocused largely on observable
behaviors, such as irresponsibility and criminality for classication,
while omitting latent personality traits. These later denitions were
chiey inuenced by the work of the American researcher Robins
(1966). In the 1960's, Robins examined the behavioral reports of delinquent and deviant children who had been admitted to a guidance clinic
three decades earlier and followed them up in their forties to assess
their adult personality patterns. The ndings from this single followup study were used as the prime foundation for the construction of a
new diagnostic category in the DSM-III. In line with the Zeitgeist of
the behavioristic era spanning the last decades of the 20th century,
the DSM-III task force decided that including latent personality traits
as criteria invites subjectivity and reduces the reliability of classication
and thus suggested to focus solely on observable behavior. Since Robins'
study adhered to a similar philosophy, and focused largely on the factual
observation of behaviors, it was considered the ideal study for this aim.
With its publication in 1980, the DSM-III introduced the new diagnostic category of antisocial personality disorder (abbreviated as
ASPD) (3rd ed.; DSM-III; American Psychiatric Association, 1980). To
the annoyance of many scientists and clinicians in the eld, this new
category conated psychopathic and non-psychopathic criminals into
one general diagnostic group of overtly impulsive, aggressive, deceitful,
criminal, and irresponsible individuals. This trend of focusing on specic
behaviors rather than personality in the diagnosis of ASPD continued in
subsequent versions of the DSM, up to the recent DSM-5 published in
2013 (see Table 3). When referring to ASPD, the DSM-IV-TR even
went as far as to state that this pattern has also been referred to as
psychopathy, sociopathy, or dyssocial personality disorder (pp. 702, 4th
ed., text rev; DSM-IV-TR; American Psychiatric Association, 2000),
which is a confusing and incorrect statement.
A large range of scholars including the American behavioral geneticist David Lykken opposed ercely to the narrow view of the DSM-IV.

Table 3
DSM-IV and DSM-IV-TR Axis II, and DSM 5 Section II criteria for the diagnosis of antisocial
personality disorder (APA, 1994, 2000, 2013).
Antisocial personality disorder (DSM-IV, DSM-IV-TR, DSM 5 Section 2)
A. There is a pervasive pattern of disregard for and violation of the rights of others
occurring since age 15 years, as indicated by three (or more) of the following:
(1) failure to conform to social norms with respect to lawful behaviors as indicated by
repeatedly performing acts that are grounds for arrest
(2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for
personal prot or pleasure
(3) impulsivity or failure to plan ahead
(4) irritability and aggressiveness, as indicated by repeated physical ghts or assaults
(5) reckless disregard for safety of self or others
(6) consistent irresponsibility, as indicated by repeated failure to sustain consistent
work behavior or honor nancial obligations
(7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt,
mistreated, or stolen from another
B. The individual is at least age 18 years.
C. There is evidence of Conduct Disorder with onset before age 15 years.

B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

Their main argument was that different psychological processes can result in similar patterns of behavior and, thus, the classication of people
based on their criminal and antisocial actions rather than their psychological dispositions and characteristics, even though this is preferable
and required in court, is much less attractive to psychiatry or science
(Lykken, 2006). The DSM-IV- and DSM-IV-TR diagnostic category of
ASPD has for these reasons never been attractive as a substitute for psychopathy. Moreover, the diagnostic criteria for personality disorders in
the DSM-IV (APA, 1994) and its revision DSM-IV-TR (APA, 2000) have
been repeatedly criticized for disproportionate diagnostic comorbidity,
instability of the disorders over time, excessive heterogeneity within diagnoses (e.g., 256 ways to diagnose borderline personality disorder),
lack of model variance, and poor convergent and discriminant validity
across personality disorders (Clark, 2007; Schmeck, Schlter-Mller,
Foelsch, & Doering, 2013; Skodol et al., 2011; Widiger & Trull, 2007).
Initially, it appeared that the DSM-5 was going to address many of
the substantiated critiques expressed at its predecessors. In response
to extensive research, different groups of scientists, clinicians, and
scholars suggested to improve the assessment of personality disorders
by using dimensional constructs (i.e., negative affectivity, antagonism,
detachment, psychoticism, disinhibition) to assess personality pathology rather than categorical models and by including additional diagnostic
items concerning more latent personality traits such as self-identity and
other-relatedness (Clark, 2007; Millon, 2011; Schmeck, Schlter-Mller,
Foelsch, & Doering, 2013; Widiger & Trull, 2007). In line with these suggestions, the DSM-5 personality disorders workgroup proposed an alternative system for the diagnosis of ASPD which includes many latent
personality traits in the criteria set (selshness, lovelessness, grandiosity, etc.) in addition to behavioral expressions (see Table 4).
However, the American Psychological Association (APA) Board of
Trustees decided at the last moment before publication that in order
to preserve continuity with current clinical practice, while also introducing a new approach that aims to address numerous shortcomings
of the current approach to personality disorders (pp.761, 5th ed.;
DSM-5; American Psychiatric Association, 2013), both models should
be retained. While the old model is now placed in the main section
meant for actual diagnosis (section II), the new approach is included
in a separate appendix-like section (section III) titled Alternative
DSM-5 Model for Personality Disorders (APA, 2013). This section is reserved for models and measures that are still emerging and need further research to merit replacement of the existing diagnostic criteria
(APA, 2013).
Preliminary ndings indicate that although DSM-5 section III criteria
for ASPD adequately capture the coldheartedness, impulsive antisociality,
meanness, and disinhibition domains of psychopathy and do a better job
at indexing core psychopathy traits compared to the DSM-IV-TR and

Table 4
DSM 5 Section III criteria for the diagnosis of antisocial personality disorder (APA, 2013).
Antisocial personality disorder (DSM 5 Section III)
A. Moderate or greater impairment in personality functioning, manifested by
characteristic difculties in two or more of the following four areas:
1. Identity: Egocentric
2. Self-direction: Goal setting based on personal gratication
3. Empathy: Lack of empathy
4. Intimacy: Incapacity for intimacy
B. Six or more of the following seven pathological personality traits:
1. Manipulativeness
2. Callousness
3. Deceitfulness
4. Hostility
5. Risk-taking
6. Impulsivity
7. Irresponsibility
Note. The individual is at least 18 years of age.
Specify if with psychopathic features:
Speciers: Low anxiousness, Low withdrawal, High attention seeking.

13

DSM-5 Section II criteria, they still fall short in assessing the boldness/
fearless dominance domain of psychopathy which is an integral part
of the Cleckley'an conceptualization (Anderson, Sellbom, Wygant,
Salekin, & Krueger, 2014; Crego & Widiger, 2014; Few, Lynam, Maples,
MacKillop, & Miller, 2015; Strickland, Drislane, Lucy, Krueger, &
Patrick, 2013). Apart from risk-taking and manipulativeness which are
both positively associated to the boldness/fearless dominance domain
of psychopathy (r 0.400.70), none of the other traits included in
the main criteria set correlate signicantly with these integral psychopathy facets and hostility even shows a small negative correlation
(r 0.15) (Anderson et al., 2014; Crego & Widiger, 2014;
Strickland et al., 2013). However, the items included in the DSM-5 as
psychopathy speciers, especially low anxiousness and low withdrawal, do show signicant correlations with boldness and fearless dominance scores (Anderson et al., 2014; Crego & Widiger, 2014; Few
et al., 2015). Nonetheless, the variance of fearless dominance and boldness scores explained by these speciers has been small (only low
anxiousness shows a consistent correlation) and it has been suggested
to include additional trait facets of the Personality Inventory for DSM5 (PID-5) as psychopathy speciers such as intimacy avoidance, restricted affectivity, grandiosity, and low submissiveness (Anderson
et al., 2014; Few et al., 2015; Strickland et al., 2013). In its current
form, the DSM-5 section III category of ASPD may pertain particularly
to the McCord'ian rather than Cleckley'an conceptualization and relate
more closely to secondary rather than primary variants of psychopathy.

3.2. Psychopathy Checklist-Revised (PCL-R) and its derivatives (PCL-SV,

PCL-YV) (1980present)
In the same year that the DSM-III task force introduced antisocial
personality disorder as a new diagnostic category, the Canadian psychologist and researcher Robert D. Hare rejuvenated the efforts of
Hervey Cleckley and developed the Psychopathy Checklist (PCL). The
PCL originally consisted of 22 items, but was later shortened to 20 in
the revised edition; PCL-R (see Table 5). Similar to the DSM, the PCL-R
is a clinician rating scale. However, since DSM criteria are more lenient
for classication purposes, the prevalence of ASPD is high among incarcerated criminals (5080%), whereas the prevalence of psychopathy as
diagnosed with the PCL-R is much lower (1525%) (Hare, 2003; Hare,
Hart, & Harpur, 1991; Hart & Hare, 1989; Widiger et al., 1996). In
other words, psychopathy as classied with the PCL-R is a more specic
and severe pattern of antisocial deviancy. Furthermore, in sharp
contrast to the DSM which exclusively includes observable behaviors
to increase reliability, the high inter-rater reliability of the PCL-R demonstrates that it is also possible to reliably assess latent personality traits
such as callousness, manipulativeness, and grandiosity (Hare, 2003;
Widiger et al., 1996). Nevertheless, some studies have recently
Table 5
PCL-R criteria for the diagnosis of psychopathy. Factor 1 is dened here as the Interpersonal
(In) and Affective (Af) facets combined and Factor 2 as the Antisocial (An) and Lifestyle (Li)
facets combined.
Psychopathy Checklist-Revised (PCL-R) items
Factor 1 (Interpersonal & affective facets)
1) Glib/supercial charm (In)
2) Grandiose sense of self-worth (In)
3) Pathological lying (In)
4) Conning/manipulative (In)
5) Shallow affect (Af)
6) Callous/Lack of empathy (Af)
7) Lack of remorse or guilt (Af)
8) Failure to accept responsibility (Af)
Independent items
19) Promiscuous sexual behavior
20) Many short-term relationships

Factor 2 (Antisocial & lifestyle facets)

9) Parasitic lifestyle (Li)
10) Needs stimulation/proneness to boredom (Li)
11) Irresponsibility (Li)
12) Impulsivity (Li)
13) Lack of realistic, long term goals (Li)
14) Revocation of conditional release (An)
15) Poor behavioral controls (An)
16) Juvenile delinquency (An)
17) Early behavioral problems (An)
18) Criminal versatility (An)

Note. Factor structure derived from Hare (2003).

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questioned PCL-R inter-rater reliability and argued that it can differ

widely across different contexts (i.e., research vs. therapeutic), especially with regard to its personality features (Edens, Boccaccini, & Johnson,
2010).
In the last two decades, different PCL-R derivatives have been developed for the assessment of psychopathic traits in non-incarcerated samples (PCL-Screening Version = PCL-SV) and in children and adolescents
(PCL-Youth Version = PCL-YV). These later instruments are strongly
correlated with the PCL-R (r = 0.80), show similar external correlates,
and are thus suggested to capture the same construct (Hart, Cox, &
Hare, 1995; Neumann, Kosson, Forth, & Hare, 2006). Studies with the
various PCL instruments in different settings and populations have
consistently revealed a dominant two-factor-four-facet structure underlying their items (with both factors and four facets moderately correlated; r 0.50) (Benning, Patrick, Hicks, Blonigen, & Krueger, 2003;
Hare, 2003; Harpur, Hakistan, & Hare, 1988; Harpur, Hare, & Hakistan,
1989; Hill, Neumann, & Rogers, 2004; Kosson et al., 2013; Neumann
et al., 2006; Sevecke, Pukrop, Kosson, & Krischer, 2009). Factor 1,
consisting of the interpersonal and affective facet, is uniquely related
to emotional deciencies, instrumental/goal-directed aggression, narcissistic and histrionic personality disorders (NPD and HPD), and has
been associated with both adaptive and maladaptive behavioral patterns (e.g., competitive achievement orientation, emotional resilience
to stress and threat, high socioeconomic status, deliberate risk-taking,
professional success, corporate and political status, and social dominance). Conversely, factor 2, including the antisocial and lifestyle facets,
is uniquely related to a lack of behavioral controls, reactive/impulsive
aggression, ASPD and borderline personality disorder (BPD), and
has mainly been associated with maladaptive behavioral patterns
(e.g., institutional and authority care before the age of 16, violence,
expelled from school, impetuous risk-taking, run away from home, psychiatric admission, suicide attempts, being convicted and incarcerated,
homelessness, nancial problems) (Babiak & Hare, 2007; Babiak,
Neumann, & Hare, 2010; Blackburn, 2007; Blackburn et al., 2008; Blair,
2006a,b, 2010; Board & Fritzon, 2005; Coid, Freestone, & Ullrich, 2012;
Colledge & Blair, 2001; Fowles & Dindo, 2006; Hall & Benning, 2006;
Hall, Benning, & Patrick, 2004; Hare, 2003; Kennealy, Skeem, Walters,
& Camp, 2010; Nioche et al., 2010; Patrick, 2006; Poythress & Skeem,
2006; Reidy, Shelley-Tremblay, & Lilienfeld, 2011; Skeem, Poythress,
et al., 2003; Skeem et al., 2007; Verona, Patrick, & Joiner, 2001;
Woodworth & Porter, 2002).
Hare's operationalization of psychopathy as an unitary construct
(PCL-R total score) differs substantially from Cleckley's and in many
ways parallels the McCord'ian denition (aggression, criminality). One
important point of divergence between the PCL-R and the Cleckley'an
conceptualization is the source material from which these denitions
were originally extrapolated. Although many of Cleckley's patients
were convicted criminals admitted by the courts on the suspicion of
mental illness, his operationalization was also extrapolated from a
great number of psychopathic cases who were neither criminal nor violent, but were admitted by their hopeless families unable to deal with
their erratic, reckless, and unreliable behavior. In contrast, the PCL-R
items were extrapolated exclusively from incarcerated criminals
through statistical analysis rather than qualitative observation. Furthermore, since the PCL-R items were chosen to index psychopathy as an
unitary construct, and because the initial candidate pool included
more deviancy related items that assessed maladjustment, the positive
adjustment indicators did not show high internal consistency and
dropped out in the selection process (Patrick, 2006). As a consequence,
the PCL-R does index an uniform construct but this is not Cleckley'an
psychopathy. Rather, the PCL-R items are uniformly indicative of deviancy and maladjustment (Patrick, Fowles, & Krueger, 2009).
In accordance, different researchers and clinicians have criticized the
construct validity of the PCL-R in the assessment of psychopathy and
have asserted that it is mainly due to the inclusion of factor 2 items
that the PCL-R portrays a more deviant, criminal, and maladjusted

pattern than with Cleckley's criteria (Cooke & Michie, 2001; Cooke,
Michie, & Hart, 2006; Lilienfeld, 1994; Patrick, 2006; Skeem & Cooke,
2010a,b). Cooke and Michie (2001) were among the rst to contend
that the signicance of antisocial and socially deviant behavior in the diagnosis of psychopathy is unclear. Using structural equation modeling
they concluded that antisocial behavior is best viewed as a secondary
symptom or consequence of psychopathy rather than part of the inherent personality structure. It was determined that psychopathy could
best be captured through 13 of the 20 items included in the PCL-R.
These items were clustered into three overarching facets that were
conceptually distinct and nonredundant (Arrogant and Deceitful
Interpersonal Style, Decient Affective Experience, and Impulsive and
Irresponsible Behavioral Style). The remaining 7 items pertaining to
overt antisocial behavior were seen as secondary consequences that
might or might not develop out of the basic personality prole captured
by the three facets. Therefore, Cooke and Michie did not necessarily regard criminality as inherent to the psychopathy construct, but they did
include impulsive and irresponsible behavior as being central. Later
scholars have convincingly argued that psychopathy (especially primary variants) and impulsivity are independent constructs and that only
factor 1, namely the interpersonal and affective facets, indexes core
characteristics inherent to psychopathy (Poythress & Hall, 2011;
Skeem & Cooke, 2010a).
Nonetheless, despite that it is somewhat tacitly assumed that factor
1 is largely convergent with the Cleckley'an denition, there are some
important differences between both trait constellations. Most importantly, factor 1 includes different malicious traits as being central to
the psychopathic personality that are absent from Cleckley's list
(i.e., cunning manipulation, grandiose sense of self-worth). In doing
so, factor 1 indexes a more cold hearted and devious personality pattern
than Cleckley's criteria. For example, explaining the trait grandiose
sense of self-worth, Hare (1993) contends that psychopathic inmates
come over as arrogant, shameless braggarts - self-assured, opinionated,
domineering, and cocky (pp. 38). Cleckley did not put much of an
emphasis on this aspect of grandiosity and although he did notice that
psychopaths can be ignorantly boastful rather than domineeringly arrogant, he also emphasized that their interpersonal conduct is often characterized by a certain agreeableness, cordiality, and apparent sincerity.
In a similar vein, the wording of Cleckley's criteria differs substantially from that of the PCL-R, even with traits that are named similarly such
as supercial charm. When reading the corresponding text to the criterion of supercial charm, it can be identied that Cleckley intended
this item to be an indicator of positive psychological adjustment
(cordial, intelligent, outwardly sincere, likable, well-adjusted, happy,
and looks like the real thing) whereas the PCL-R wording conjures
up the image of a self-absorbed narcissistic individual (glib, insincere,
slick, boastful, macho, fake, and a too good to be true social presentation) (Patrick, 2006). Indeed, Cleckley coupled this criterion to good intelligence (see Table 1) thereby supporting the claim that this was
actually an indicator of positive adjustment. As discussed, during the development of the PCL-R, Hare removed indicators of positive adjustment because these items did not show high internal correlations to
the other items. Therefore, for the items to be included in the PCL-R,
such as supercial charm, the diagnostic text accompanying these traits
would have been written in such a way that they complemented an
overall deviant personality.
Furthermore, in removing indicators of positive adjustment, the
PCL-R tacitly approves that despite pronounced neurotic symptoms
such as anxiety, depression, and suicidal tendencies, a subject may still
be diagnosed as psychopathic as long as he meets most of the other
criteria. In accordance, PCL-R total scores show a weak positive relationship to neuroticism (r = 0.15), negative emotionality (r = 0.30), and
even suicide (Lynam & Derenko, 2006; Patrick, 2006; Verona et al.,
2001). Traits that are unanimously seen as being antithetical to the construct of primary psychopathy. The fact that the PCL-R does not include
any indicator of emotional stability, low neuroticism, good mental

B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

health, or fearlessness is considered by many researchers to impact its

construct validity in assessing primary psychopathy in particular
(Lilienfeld & Andrews, 1996; Schmitt & Newman, 1999; Skeem &
Cooke, 2010a; Skeem et al., 2007).
Finally, in response to these shortcomings, Skeem and Cooke
(2010a) and Skeem et al. (2011) have recently addressed concerns
about the PCL-R's monopoly in the eld of psychopathy assessment.
While there have been several endeavors to develop psychopathy measures over the years, none have emerged as major alternatives to the
PCL-R. Skeem et al. (2011) have expressed concerns that the measure
has, effectively, usurped the construct and contributed to monooperation bias - that is, the error of operationalizing a construct in
only one way (pp. 102). As a consequence of this conation of the measure with the construct, the scientic eld has learned a great deal about
the criminal psychopath as dened by the PCL-R and not necessarily
about the nature and boundaries of the psychopathy construct
(pp. 102). Instead of focusing so heavily on one instrument to dene
such a relevant clinical condition with so much impact on society, future
studies should also include other instruments and cross validate the correlations of these instruments with external constructs.
In short, although the specicity of the PCL-R is such that it differentiates psychopathic individuals from the larger and highly heterogeneous group of antisocial personality disorders diagnosed through
the DSM, there is still much heterogeneity in the PCL-R derived psychopathic population. Starting in Section 4, we will extensively discuss the
heterogeneity observed within samples diagnosed with the PCL instruments and make the crucial distinction between primary and secondary
forms of psychopathy.
3.3. The Psychopathic Personality Inventory (PPI) (1996present)
In pursuit of a reliable tool to assess psychopathic traits in nonincarcerated or community samples, different self-report measures
have been published in the decades following the release of the PCL-R
(see Lilienfeld and Fowler (2006)). However, these questionnaires, including the Hare Self Report Psychopathy Scale (SRP) and the Levenson
Primary and Secondary Psychopathy Scales (LPSP), index a more global
antisociality construct that is more closely associated with secondary
variants of psychopathy rather than primary psychopathy as conceptualized by Cleckley such as low neuroticism, fearlessness, and social potency (Lilienfeld & Fowler, 2006; Ross, Benning, Patrick, Thompson, &
Thurston, 2009).
In response to these issues of construct validity, Lilienfeld and
Andrews developed the Psychopathic Personality Inventory (PPI).
Since research with the PCL-R indicated that psychopathy is a multidimensional construct and that different types of psychopathy may exist
that are underpinned by divergent etiological pathways, the PPI was developed without assuming or requiring its items to cohere around an
unitary higher order construct. Applying an exploratory approach to
test construction, Lilienfeld and Andrews (1996) used preliminary
responses as a basis for further revisions, thus moving back and forth
between the construction and validation of the items.
The PPI initially included 187 items (Lilienfeld & Andrews, 1996),
but in order to lower its reading level and eliminate psychometrically
problematic or culturally specic items, 33 items have been removed
in the PPI revised version (PPI-R) (Lilienfeld & Widows, 2005). Overall,
PPI total scores show a moderate to high correlation to interviewer ratings of the degree of Cleckley'an psychopathy (r = 0.60), PCL-R total
scores (r = 0.390.58), DSM-IV ASPD scores (r = 0.57), and DSM-5
Section III ASPD scores (r = 0.490.79) (Anderson et al., 2014;
Berardino, Meloy, Sherman, & Jacobs, 2005; Lilienfeld & Andrews,
1996; Malterer, Lilienfeld, Neumann, & Newman, 2010; Poythress,
Edens, & Lilienfeld, 1998; Poythress, Lilienfeld, et al., 2010). When
factor-analyzed, the PPI item pool can be organized around eight replicable facets which can be clustered into three superordinate factors (see
Table 6) (Benning, Patrick, Salekin, & Leistico, 2005; Benning et al.,

15

2003). Interestingly, while the two PCL-R factors are moderately to

highly correlated, the overarching PPI factors of fearless dominance
(PPI-I) and impulsive antisociality (PPI-II) are found to be weakly correlated (Neumann, Uzieblo, Crombez, & Hare, 2013), with some studies
even reporting orthogonality (Benning et al., 2003; Marcus, Fulton, &
Edens, 2013).
Empirical studies with the PPI report that especially the fearless
dominance factor (PPI-I) parallels the Cleckley'an conceptualization of
psychopathy. In accordance with major theories on primary psychopathy, PPI-I is negatively correlated to measures of neuroticism, harmavoidance, and social sensitivity such as anxiety, hostility, negative urgency, nervousness, irritability, depression, emotional lability, empathy,
self-consciousness, vulnerability, social withdrawal, and behavioral inhibition (BIS), while showing positive correlations to measures of positive affectivity, reward sensitivity, and self-esteem such as narcissism,
pride, extraversion, excitement seeking, risk taking, assertiveness, gregariousness, motivational drive, fun-seeking, and behavioral activation
(BAS) (Anderson et al., 2014; Benning, Patrick, Blonigen, Hicks, &
Iacono, 2005; Benning, Patrick, & Iacono, 2005; Benning et al., 2003;
Blonigen, Hicks, Krueger, Patrick, & Iacono, 2005; Del Gaizo &
Falkenbach, 2008; Derenko & Lynam, 2006; Douglas et al., 2008;
Falkenbach, Stern, & Creevy, 2014; Maples et al., 2014; Patrick, Edens,
Poythress, Lilienfeld, & Benning, 2006; Ross et al., 2009). In addition,
PPI-I is also related to various indicators of positive adjustment such
as socio-economic status, conscientiousness, perseverance, achievement, well-being, and educational level (Benning et al., 2003; Maples
et al., 2014). This pattern of associations suggests that PPI-I indexes
the low fearfulness, reduced empathy, and high reward-seeking considered to exemplify primary psychopathy while also capturing some of
the more adaptive traits as related to the Cleckley'an conceptualization.

Table 6
The Psychopathic Personality Inventory facets, factors, and example items.
Psychopathic Personality Inventory (PPI)
Facets

Factor 1 Fearless dominance

Social potency

- Even when others are upset with me, I can usually

win them over with my charm.
- If I really wanted to, I could convince most people
of just about anything.
- I would nd the job of movie stunt person exciting.
- Looking down from a high place gives me the
jitters. (r)
- When I want to, I can usually put fears and
worries out of my mind.
- When I'm in a frightening situation, I can turn
off my fear almost at will.

Fearlessness

Stress immunity

Factor 2 Impulsive antisociality

Machiavellian egocentricity

Impulsive non-conformity

Blame externalization
Carefree nonplanfulness

- If I want to, I can inuence other people without

their realizing they are being manipulated.
- To be honest, how much I like someone depends a
lot on how useful that person is to me.
- I've never really cared much about society's so
called values of right and wrong.
- I get restless and disappointed if my life becomes
too routine.
- People have often criticized me unjustly (unfairly).
- I generally feel that life has treated me fairly. (r)
- I weigh the pros and cons of major decisions
carefully before making them. (r)
- I generally prefer to act rst and think later.
Factor 3 Callousness

Coldheartedness

- I am a guilt-prone person. (r)

- Seeing poor or homeless person walking the
streets at night could really break my heart. (r)

Note. r = reversed scoring. Factor structure derived from Benning et al. (2003).

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Interestingly, PPI-I displays inconsistent associations with

agreeableness; a personality trait that manifests itself through
behaviors that are perceived as kind, sympathetic, cooperative, warm
and considerate (Thompson, 2008). Some studies report a weak negative correlation (r = 0.13) (Benning, Patrick, Salekin, et al., 2005)
while others fail to nd a signicant relationship to agreeableness
(Maples et al., 2014; Ross et al., 2009). Furthermore, PPI-I is negatively
related to hostility or anger (r 0.11) and only shows a weak positive association with physical aggression (r = 0.12) (Anderson et al.,
2014; Falkenbach et al., 2014). These ndings suggest that individuals
who score high on PPI-I might show some narcissistic and dominant
traits but are largely neutral regarding interpersonal behavior, being
neither cooperative and altruistic nor necessarily hostile and alienated
in their social conduct, which is coherent with Cleckley's initial conceptualization. In fact, some researchers have found that PPI-I is associated
with altruistic heroism and argued in response that psychopaths may
indeed be more likely to behave both heroically and antisocially, dependent on the circumstances (Lykken, 1995; Smith, Lilienfeld, Coffey, &
Dabbs, 2013). Therefore, Hare's conceptualization of the core psychopathic personality, reected by the interpersonal/affective items (factor
1 PCL-R), captures a more malignant, callous, grandiose, and aggressive
pattern than PPI-I. More specically, PPI-I seems to relate modestly to
factor 1 of the PCL-R (r = 0.190.25) (Malterer et al., 2010; Poythress,
Lilienfeld, et al., 2010), which is mainly explained by the unique variance in the interpersonal facet of the PCL-R (r 0.3) while showing
no relationship to the more malevolently dened affective facet
(Benning, Patrick, Blonigen, et al., 2005).
Because PPI-I is closely associated with narcissism (r = 0.52), and
does not correlate with antisocial behavior or aggression, different
researchers have questioned its construct validity in assessing
core psychopathy traits and in differentiating psychopathic from
nonpsychopathic subjects (Lynam & Miller, 2012; Maples et al., 2014).
However, Maples et al. (2014) reported that compared to other questionnaires specically designed to index narcissism (i.e., narcissistic
personality inventory-16), PPI-I showed much stronger negative associations with neuroticism, sensitivity to punishment, and negative affect,
while also showing higher positive associations with extraversion,
openness, positive affect, and mental health, and equally strong positive
associations with reward sensitivity. Furthermore, as discussed above,
deviant personality traits, such as criminality and aggression, are not integral to primary psychopathy (Cleckley, 1941; Cooke & Michie, 2001;
Poythress & Hall, 2011; Skeem & Cooke, 2010a,b). Nonetheless, one
trait that is central to primary psychopathy, but which does not correlate to PPI-I, is moral utilitarianism (Gao & Tang, 2013). Despite this
shortcoming, PPI-I may be a valid self-report scale to assess primary
psychopathic features as introduced by Cleckley and differentiate such
individuals from secondary psychopaths and other personality disordered groups (narcissistic, ASPD) (see also Cox et al. (2013)).
Similar to the factor 2 of the PCL-R, the impulsive antisociality factor
(PPI-II) mainly comprises items that assess global maladjustment to society and behavioral deviancy. In accordance, PPI-II has been associated
with impulsivity, aggressiveness, deceitfulness, irresponsibility, anxiousness, criminality, substance abuse problems, suicidal ideation, and
high levels of both externalizing and internalizing symptomatology
(Anderson et al., 2014; Benning, Patrick, Blonigen, et al., 2005;
Benning et al., 2003; Blonigen et al., 2005; Derenko & Lynam, 2006;
Douglas et al., 2008; Patrick et al., 2006; Ross et al., 2009). However,
PPI-II adopts a personality based approach and does not directly assess
deviant or criminal behavior, but rather gages the presence of characteristic personality traits underlying such a lifestyle including impulsivity,
recklessness, rebelliousness, and selshness. Indeed, the PCL-R factor 2
is only modestly related to the PPI-II (r 0.300.40) (Benning,
Patrick, Blonigen, et al., 2005; Malterer et al., 2010; Poythress,
Lilienfeld, et al., 2010). PPI-II may index personality features that are
more closely related to secondary variants of psychopathy (Cox et al.,
2013; Hicks et al., 2012).

Finally, the third factor consists of the independent facet of

Coldheartedness (unsentimentality and a lack of imaginative capacity)
which was meant to index callousness, lovelessness, and absence of
empathy (Benning, Patrick, Salekin, et al., 2005; Benning et al., 2003).
However, it has been hypothesized that because nearly all items of the
Coldheartedness scale are reverse keyed, the item content reects sentimentality, imaginativeness, and affective responsivity more so than
callousness or cruelty (Benning et al., 2003).
3.4. The Triarchic Psychopathy Measure (TriPM) (2009present)
In response to the checkered history of psychopathy, Patrick et al.
(2009) recently provided a basis for reconciling and accommodating
alternative conceptualizations. According to their Triarchic Model,
psychopathy is best assessed through distinct phenotypic domains
rather than as an unitary construct. In addition, since there is still
much uncertainty on the development of psychopathy and its expression in children, future investigations into its etiology may benet by
conceptualizing psychopathy in terms of more elemental phenotypic
constructs with clear psychobiological and neurobiological referents
(p. 914).
In an attempt to integrate historical conceptualizations with modern
operationalizations, Patrick et al. (2009) identied three recurring
themes in the literature; boldness, meanness, and disinhibition (see
Fig. 1). These three constructs, although interrelated, can be measured
and understood separately as they reect separate developmental processes and are phenotypically distinct. Thus, these phenotypic traits are
proposed not as pertaining to a unitary higher order construct, but as
congural building blocks expressed in varying degrees by different
psychopathic individuals (Skeem et al., 2011). To operationalize these
three phenotypical constructs, Patrick (2010) developed The Triarchic
Psychopathy Measure (TriPM) which is a 58-item self-report inventory.
Boldness is described by Patrick et al. (2009) as a benign and pure
phenotypic expression of genotypic fearlessness and dened as the
nexus of fearless dominance, low anxiety, and thrill/adventure seeking
(Skeem et al., 2011). Boldness may be expressed through adaptive features, such as emotional stability, low internalizing symptomatology,
leadership/authority, social poise, assertiveness, persuasiveness, bravery, and venturesomeness, but also through less adaptive proclivities
such as narcissism, low BIS, manipulativeness, risk-taking, and thrill
seeking (Anderson et al., 2014; Patrick et al., 2009; Sellbom & Phillips,
2013; Stanley, Wygant, & Sellbom, 2013; Strickland et al., 2013).
Boldness is further described as integral to the Cleckley'an conceptualization of primary psychopathy and is largely parallel with the
fearless dominance factor of the PPI-R (PPI-I) (Patrick et al., 2009;
Skeem et al., 2011). Indeed, boldness is most strongly related to PPI-I
(r = 0.610.77) while showing no signicant associations to PPI-II or
the separate facet of coldheartedness (Anderson et al., 2014; Sellbom
& Phillips, 2013). In other words, boldness is phenotypically distinct
from disinhibition, impulsivity, or callousness and emergent from

Fig. 1. The Triarchic model of psychopathy (Patrick et al., 2009).

B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

different etiological mechanisms (i.e., fearlessness in boldness, disafliation in callousness, and low self-control in disinhibition) (Anderson
et al., 2014; Patrick et al., 2009).
However, it must be noted that the construct validity of boldness as
operationalized by the TriPM is not entirely clear and it may be
questioned whether this scale is uniquely related to primary psychopathy. Since most items on the boldness scale are to some degree indicative of admirable personal traits such as resilience (I am well
equipped to deal with stress) and self-condence (I don't think of
myself as talentedreverse keyed), but also admirable social traits
such as persuasiveness (I have a knack for inuencing people), poise
(it's easy to embarrass mereverse keyed), and leadership (I'm a
born leader), it is imaginable that narcissistic individuals would also
show high scores on this dimension while not necessarily being psychopathic. Indeed, the boldness scale has been associated quite substantially with narcissism (r = 0.64) (Sellbom & Phillips, 2013). This is
somewhat expected since psychopaths are by denition narcissistic
due to a profound cognitive and affective egocentrism (Hare, 1993).
However, the opposite is not true and although narcissists like to view
themselves as fearless, resilient, revolutionary, and inuential, their
self-condence is often not based in reality. In sharp contrast with primary psychopathy, narcissists can be quite neurotic, are unable to handle criticism, desperately seek for attention, and have an obsessive need
to validate their self-worth (Miller, Gentile, Wilson, & Campbell, 2013;
Vaknin & Rangelovska, 2013; Wright et al., 2013). It is thus paramount
that future studies examine to what degree boldness is able to separate
narcissistic from primary psychopathic individuals.
Meanness is dened as being similar to boldness regarding underlying genotypic dispositions of fearlessness, but arises when this temperament is additionally met with genotypic disafliation or an abusive
and neglectful environment which may push genotypic fearlessness
in the direction of phenotypic meanness (p. 932, Patrick et al., 2009).
Characteristic behavioral manifestations of meanness include arrogance
and verbal derisiveness, deance of authority, lack of close personal relationships, aggressive competitiveness, physical cruelty to animals and
people, instrumental aggression, strategic exploitation of others for
gain, and thrill seeking through destruction (Patrick et al., 2009;
Skeem et al., 2011). For example, both boldness and meanness are
associated with low BIS scores but meanness is additionally related
to a more severe lack of empathy, Machiavellianism, and higher
levels of antisociality (Sellbom & Phillips, 2013; Stanley et al., 2013).
Furthermore, empathy or empathetic concern show a weak negative
but non-signicant association to boldness (r 0.15) but are signicantly related to meanness (r 0.60) (Sellbom & Phillips, 2013;
Stanley et al., 2013). Also, contrary to boldness, meanness is related to
the coldheartedness (r = 0.67) and the impulsive antisociality factor
(PPI-II) of the PPI-R (r 0.60), callousness as measured through different questionnaires (r 0.60), and the affective and antisocial facets of
the PCL-R (r 0.20) (Patrick, 2010; Sellbom & Phillips, 2013; Stanley
et al., 2013).
Therefore, whereas boldness was constructed to assess core psychopathy features as dened by Cleckley, meanness is intimately
connected to antisocial attitudes and behavior and more closely related to conceptualizations of psychopathy derived from criminal offender samples such as those by Hare and the McCords (Patrick et al.,
2009).
As discussed, due to the fact that the PCL-R was extrapolated from offender samples, it is uniformly indicative of maladjustment and antisocial
deviancy. Thus, factor 1 of the PCL-R naturally indexes a more malignant
phenotypic expression of genotypic fearlessness (e.g., callousness,
cunning, and lovelessness) that is intimately linked to an antisocial lifestyle (factor 2) and more closely related to meanness rather than boldness. More specically, when factor 1 is subdivided into its facets, the
interpersonal facet shows the strongest associations with boldness
(r = 0.27) whereas the affective facet shows the highest correlations to
meanness (r = 0.25) (Patrick, 2010).

17

However, meanness is not exclusive to primary psychopathy and may

also arise in neurotic and irritable individuals if exposed to sufcient
levels of adversity, abuse, and trauma (e.g., secondary psychopathy).
Indeed, meanness has been positively associated with hostility, anhedonia, depressivity, social withdrawal, and suspiciousness (Strickland et al.,
2013). Constructs that are intimately connected to emotionality. Related
to this suggestion, Patrick et al. (2009) assert that phenotypic meanness
can manifest as a predatory and unemotional pursuit of self-serving
goals in the context of a fearless temperament (primary psychopathy)
but can also manifest as hostility, anger, and reactive aggression in the
context of an irritable temperament (secondary psychopathy). Therefore,
similar to boldness, the meanness scale may not pertain uniquely to primary psychopathy and a variety of personality styles, including secondary
psychopaths, may show high scores on this dimension.
Disinhibition is dened by Patrick et al. (2009) as the nexus of impulsivity and negative affectivity (p. 925, italics added). Disinhibition
is originally described through behaviors that are closely related to neuroticism such as irritability, oppositionality, substance abuse, emotional
dysregulation, anger, and hostility. Accordingly, it is positively related to
neuroticism (r = 0.32) (Stanley et al., 2013). It is thus unclear how this
dimension relates to primary psychopathy which is characterized by
fearlessness and low neuroticism rather than to secondary psychopathy
more specically. Patrick et al. (2009) assert themselves that contemporary researchers in the eld would generally not view disinhibition
or externalizing as equivalent to psychopathy and it is when externalizing tendencies are coupled with dispositional boldness or meanness
that a diagnosis of psychopathy would be considered applicable
(p. 926).
Reviewing the Triarchic Model, Skeem et al. (2011) also assert
that disinhibition occurring in the context of psychopathy may have a
distinctive appearance and perhaps arise from different sources,
compared to disinhibition per se (p. 106). Indeed, because strong
emotional reactions can fuel impulsive and aggressive behaviors,
disinhibition in the context of primary psychopathy may be predominantly related to cognitive and motivational risk endophenotypes that
impair self-control and result in impetuous risk-taking behaviors
(i.e., hypersensitivity to anticipated rewards, need for excitement/
novelty, inability to inhibit dominant behavioral tendencies, frustration
intolerance, hyposensitivity for potential punishment, and inability to
plan ahead) (Buckholtz et al., 2010; Gao & Raine, 2010; Gao, Raine, &
Schug, 2011; Hartzler & Fromme, 2003; Ishikawa, Raine, Lencz, Bihrle,
& LaCasse, 2001; Snowden & Gray, 2010; Swogger, Walsh, Lejuez, &
Kosson, 2010).
Unfortunately, these risk factors are insufciently reected in the
TriPM and, thus, similar to the boldness and meanness scales, the construct validity of the disinhibition scale when applied as a measure of
primary psychopathy is unclear. For example, nearly all items of the
TriPM disinhibition scale are ambiguous and index short-sighted behavior that can arise due to negative urgency and hostile impulsivity
(more closely associated with secondary psychopathy and neuroticism)
as well as reward hyperfocus and impetuous risk-taking (associated
with both primary and secondary psychopathy). Some items even
have an emotional connotation such as people often abuse my trust.
In accordance, the disinhibition scale has been equally strongly associated to anxiousness, emotional lability, separation insecurity, anhedonia, and depressivity (all r 0.300.40), as to risk-taking (r 0.35)
(Anderson et al., 2014; Strickland et al., 2013). It has been demonstrated
that psychopathy is mainly associated with risk-taking, even in the face
of punishment, but not so much with impulsivity or an inability to appraise future consequences (Takahashi, Takagishi, Nishinaka, Makino,
& Fukui, 2014). It would thus have been more appropriate to include
items such as when I focus on something I want, I lose track of the potential risks involved or I cannot let go of a goal once I have set my
mind on it, regardless of whether I hurt other people in the process
or sometimes I like to stir up some chaos just for the sake of sensation,
in order to specically assess the disinhibition as related to primary

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B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

psychopathy rather than disinhibition more generally related to neuroticism and secondary psychopathy.

4. Clarifying the heterogeneity; primary or secondary psychopathy?

4.1. Historical to contemporary differentiations
In the same year that Cleckley published his important work on the
psychopathic personality, the American psychiatrist Karpman (1941)
came to another major insight on psychopathy. He recognized that phenotypical similarities, such as egocentrism, callousness, deviousness,
and antisociality, can arise due to differing etiological pathways, mediated in varying degrees by constitutional or social inuences. Karpman
coined the term idiopathic psychopathy to refer specically to individuals with a heritable affective defect which had hindered conscience
formation and resulted in a fearless and predatory character, characterized by the instinctive emotional organization of a subhuman animal
(p. 533). Conversely, he used the term symptomatic psychopathy to
refer to those who had become psychopathic due to an environmentally
acquired affective disturbance which had skewed conscience formation
and resulted in deep-seated neurotic conicts (Karpman, 1941).
Karpman viewed the callousness and hostility observed in symptomatic
psychopathy as an emotional adaptation to parental rejection and
abuse, and therefore as more amenable for treatment.
To test Karpman's hypothesis empirically, the British psychologist
Ronald Blackburn subjected the personality proles (assessed with
the Minnesota Multiphasic Personality Inventory MMPI) of nonpsychotic male offenders to cluster analysis (Blackburn, 1975). In accordance with Karpman, he identied two subtypes of psychopathy that
resembled the idiopathic and symptomatic groups and who showed
equally pronounced psychopathic traits. However, these groups differed
on a number of personality measures, with the most notable differences
being found regarding neuroticism. The psychopathic group with low
levels of neuroticism was labeled by Blackburn as exhibiting primary
psychopathy and the other group with high levels of anxiety and depression as secondary psychopathy (Blackburn, 1975; Blackburn
et al., 2008; Lykken, 1995; Skeem, Poythress, et al., 2003; Skeem et al.,
2007).
In the years following Blackburn's empirical identication, both
Fowles (1980) and Lykken (1995) elaborated on the concepts of primary and secondary psychopathy and focused on the etiological mechanisms underpinning each disorder. Their insights are based on the
biopsychological theory of personality proposed by Gray (1987).This
theory posits that humans have two opposing motivational inuences
that mediate behavioral reactions to environmental cues and a ghtight-freeze system responsible for organizing behavior in response
to unconditioned stimuli of salience. One inuence is the behavioral
inhibition system (BIS) which serves to increase arousal to cues of
punishment or non-reward and inhibit behavior to such contingencies
(i.e., passive avoidance). The other system is termed the behavioral
activation system (BAS) and serves to increase arousal to rewardanticipatory cues thereby initiating behavioral approach modules
(i.e., incentive motivation).
According to Lykken (1995) and Fowles (1980), primary psychopathy arises mainly due to an hyporesponsive ght-ight system
(low fear) and low levels of BIS (low anxiety), thereby resulting in
attenuated appraisal and low avoidance of danger, risk, novelty, and
otherwise aversive events. In contrast, secondary psychopathy evolves
primarily out of an unusually active BAS thereby increasing the risk of
impulsive responding to reward-anticipatory cues. Lykken (1995) further proposed that both a low BIS but normal BAS as well as a normal
BIS but high BAS can lead to troubles in avoiding potential punishment.
However, the primary psychopath, due to his low BIS, would be expected to additionally show a low stress and anxiety sensitivity, whereas the
secondary psychopath would be expected to show high scores on

neuroticism and anxiety because the lure of temptation would be likely

to cause him to select a stressful and disquieting lifestyle (p. 122).
Other scholars have focused on evolutionary mechanisms when
explaining the etiology of primary and secondary psychopathy. For example, the evolutionary psychologist Mealey (1995) argued that the
human tendency towards cooperation has enabled the emergence of a
niche of cheaters; the psychopaths of human society. That is, as long
as the majority of people are trustworthy and cooperating, there will
always be a small group of individuals who take advantage of this
human tendency through cheating. Both groups would always remain
of equal size so that a persistent equilibrium can exist between cheaters
and cooperators (Mealey, 1995). Mealey (1995) further argued that the
tendency to acquire a life-strategy of cheating can evolve out of
divergent etiological pathways. This behavior can come about either
(1) as a genetically based, individual difference in the use of a cheating
strategy (termed primary sociopathy by Mealey), or (2) as an
environmentally-contingent strategy, leading to cheating when the individual is evolutionary disadvantaged to overcome obstacles towards
survival and reproduction any other way (e.g., low intelligence, low
SES, less resources, less social abilities) (termed secondary sociopathy).
Apart from their evolutionary relevant backgrounds, both groups were
described by Mealey as being largely similar in behavior.
The forensic psychologist Porter (1996) also developed an explanatory theory about how secondary psychopathy may come about and in
what aspects it can differ from primary fundamental types. In his
essay Without Conscience or Without Active Conscience, he argued that
two distinct etiological pathways, one primarily constitutional and one
primarily environmental, can culminate phenotypically as a psychopathic personality (p. 180). Porter's proposition is that the fundamental psychopath is born without the capacity for strong affect. However,
rather than focusing on imbalanced motivational processes or neuroticism, Porter described secondary psychopathy as a form of dissociative
disorder rather than a personality disorder. He hypothesized that secondary psychopaths have experienced a de-activation or dissociation
of affect. In response to repeated rejection and abuse, he argued, the
youngster learns to de-activate his basal inborn capacity towards love,
empathy, and attachment in order to protect himself from further
pain. This brings about a dissociation of cognition and affect and
skews the development of conscience. Whereas most scholars argued
that psychopathic subtypes are likely to differ regarding neuroticism
and impulsivity, Porter sees the fundamental and secondary psychopath
as phenotypical twins that differ mainly in etiological background
(constitutional and environmental). Rather than showing a propensity
towards neuroticism, Porter argues that due to the dissociation of emotion and cognition, the secondary psychopath is also affectionless.
4.2. Is the Levenson Self-Report Psychopathy Scale (LSRP) a valid tool for
the assessment of primary and secondary psychopathy?
To assess primary and secondary forms of psychopathy, Levenson,
Kiehl, and Fitzpatrick (1995) developed the Levenson Self-Report
Psychopathy Scale (LSRP) which is a 26-item self-report measure designed to assess psychopathic traits in community samples. The LSRP
has gained much popularity in the differential diagnosis of primary
and secondary psychopathy and is commonly used for such purposes.
However, there are some notable issues with the construct validity of
this instrument, especially with regard to its primary psychopathy
scale (PP scale).
First, rather than assessing emotional deciencies or social potency,
the PP scale indexes a egocentric, callous, and manipulative mindset
more globally (i.e., Machiavellianism), which is related to both primary
and secondary psychopathy (Ali, Amorim, & Chamorro-Premuzic, 2009;
Karpman, 1941; McHoskey, Worzel & Szyarto, 1998; Ross et al., 2009;
Seibert, Miller, Few, Zeichner, & Lynam, 2011; Sellbom, 2011; Skeem,
Poythress, et al., 2003). Furthermore, the PP scale has been positively associated with traits that are antithetical to primary psychopathy such as

B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

stress reaction (r = 0.09), anxiety (r = 0.16), trait neuroticism (r =

0.17), attachment anxiety-avoidance (r = 0.18), BPD traits (r = 0.27),
cluster C personality traits (r = 0.16), and emotional dysregulation
(r = 0.23) (Burns, Roberts, Egan, & Kane, 2014; Levenson et al., 1995;
Miller, Gaughan, & Pryor, 2008; Salekin, Chen, Sellbom, Lester, &
MacDougall, 2014). In addition, the PP scale is also associated with an
aggressive humor style, reactive aggression, angry hostility, and feeling
socially excludedall indicating a particular bitterness and neurotic antagonism towards others (Fanning et al., 2014; Masui, Fujiwara, & Ura,
2013; Miller et al., 2008; Seibert et al., 2011). Finally, PP is more strongly
related to factor 2 and facets of PPI-II (especially Machiavellian egocentricity) rather than factor 1 and facets of PPI-I (Brinkley, Schmitt, Smith,
& Newman, 2001; Lilienfeld, Skeem, & Poythress, 2004; Ross et al., 2009;
Seibert et al., 2011; Sellbom, 2011). These results suggest that the PP
scale might index secondary psychopathic traits more generally and
Machiavellian egocentricity more specically, rather than primary
psychopathy. Indeed, the PP scale was associated with reduced serotonergic functioning, which is related to neuroticism and reactive aggression and specically characterizes secondary psychopathy (Fanning
et al., 2014; Yildirim & Derksen, 2013). Nevertheless, primary psychopaths, especially those who are more disinhibited, disafliated, or violent, are likely to also show high scores on the PP scale.
Conversely, the secondary psychopathy scale (SP) assesses a selfdefeating, impulsive, and disillusioned mentality more generally and
has been closely associated with BPD (r = 0.44), emotional dysregulation (r = 0.70), trait anxiety (r = 0.69), state anxiety (r = 0.28), and
neuroticism (r = 0.43) (Ali et al., 2009; Burns et al., 2014; Miller et al.,
2008; Ridings & Lutz-Zois, 2014). Making matters more confusing, the
SP scale has also been closely related to Machiavellianism (Ali et al.,
2009; Jakobwitz & Egan, 2006; McHoskey et al., 1998; Seibert et al.,
2011), and shows similar associations with criminality and violence as
the PP scale (Brinkley et al., 2004), which calls into question the discriminant validity between the SP and the PP scale.
One possibility is that the SP scale indexes a more fearful and dysregulated subtype of secondary psychopathy which is mainly associated
with BPD and ASPD pathology and high anxiety, whereas the PP scale
captures both disinhibited subtypes of primary psychopathy as well as
a more detached subtype of secondary psychopathy which is mainly related to NPD and ASPD pathology and normal anxiety (see Section 7 for
typology). Therefore, we will not rely on data with the LSRP to infer the
external correlations of primary and secondary psychopathy. Instead, to
validly identify primary and secondary psychopathic subtypes, we will
focus below on cluster-analytic studies which have included additional
measures of neuroticism and anxiety to differentiate these conditions.
4.3. Identifying primary and secondary psychopathy in youngsters through
cluster-analysis
Cluster analytic studies with the PCL-YV in youngsters has revealed
that distinct psychopathic subtypes may be crucially differentiated. A
sample of adolescent offenders (N = 116) with similar PCL-YV scores
(mean score 30) and equal levels of premeditated instrumental aggression could be clustered into a primary and secondary group
(Kimonis, Skeem, Cauffman, & Dmitrieva, 2011). Secondary psychopathic youth reported higher levels of neuroticism overall (i.e., physiological
anxiety, worrying, hostility, depression, social concerns, and global psychological distress), psychosocial immaturity, impulsive aggression, and
lower levels of self-control and responsibility. In addition, secondary
psychopathic youngsters showed higher levels of emotional and attentional problems and were more attentive to emotionally distressing pictures during neuropsychological testing, suggesting more sensitive
emotional processing (Kimonis, Frick, Cauffman, Goldweber, & Skeem,
2012).
Despite that Vincent, Vitacco, Grisso, and Corrado (2003) also
parsed subtypes of psychopathy in a sample of incarcerated adolescents
(N = 259), the group that scored high on all facets, named the

19

psychopathy cluster (mean PCL-YV score 30), was treated by the

authors as a homogeneous group. Since Vincent et al. (2003) did not differentiate the psychopathy cluster into separate subtypes based on external constructs such as anxiety, neuroticism, or self-esteem, they
may have failed to properly distinguish between primary and secondary
psychopathy (see Kimonis et al. (2011, 2012)). Nonetheless, an interesting nding that should be highlighted here is that Vincent et al. (2003)
reported a separate cluster who exclusively showed heightened factor 1
scores on the PCL-YV (termed callous/deceitful cluster) and accordingly displayed the lowest rate of behavioral problems, violent offenses,
drug use, recidivism, and prior convictions, and the highest age at rst
conviction compared to the other clusters. This callous/deceitful group
may thus have represented a more controlled subtype of primary
psychopathy.
Other studies in children and adolescents have used the callous and
unemotional scales of The Antisocial Process Screening Device (Frick &
Hare, 2001) or the Inventory of CallousUnemotional Traits (Frick,
2004) to assess psychopathic traits. Callousunemotional traits are
largely convergent with affective facet of the PCL-YV (Lee, Vincent,
Hart, & Corrado, 2003). Beginning with the youngest sample studied,
Humayun, Kahn, Frick, and Viding (2014) reported that children who
showed high levels of anxiety in addition to callous-unemotional traits
(secondary psychopathy) (N = 119) had more adjustment problems
at age seven (peer problems, antisocial behavior) than youth who
displayed elevated scores on callous-unemotional traits exclusively
(N = 627). Another study by Fanti, Demetriou, and Kimonis (2013),
in a large sample of non-institutionalized adolescents (N = 2306),
also reported two variants of psychopathy among youth high in
callousunemotional traits and conduct problems; secondary highanxious variants and primary low-anxious variants. Both groups
were more likely to be male and showed equally high levels of callous
unemotional traits, impulsivity, and sensation seeking. However,
primary psychopathic adolescents showed lower levels of anxiety,
narcissism, and conduct problems, and higher levels of self-esteem
compared to the secondary group.
The most recent study by Docherty, Boxer, Huesmann, O'Brien, and
Bushman (in press) identied three variants of psychopathy with the
primary subtypes showing the lowest levels of psychopathology overall,
including both internalizing and externalizing pathology, and the secondary subtypes showing the highest levels. A third cluster, possibly a
variant of the secondary psychopath, was called the fearful cluster and
scored in between the other two categories on most domains of psychological functioning.
In conclusion, cluster-analytic studies with youngsters demonstrate
that primary and secondary forms of psychopathy may be differentiated
as young as childhood and adolescence. In this context, primary psychopathic youngsters, regardless of legal status (incarcerated, institutionalized, or community), are more emotionally stable, fearless, and selfassured while secondary variants are more impetuous, neurotic, and
generally show more severe psychopathology and externalizing
symptomatology.
4.4. Identifying primary and secondary psychopathy in adult offenders
through cluster analysis
In response to comprehensive review, Skeem, Poythress, et al.
(2003) concluded that two psychopathic subtypes exist who show
equally pronounced PCL-R traits, but differ regarding etiological antecedents and levels of dysregulatory and neurotic psychopathology.
While the primary psychopathic group consistently shows high scores
on factor 1 of the PCL-R and a strong genetic component, the secondary
group mainly displays high scores on factor 2 and a stronger relationship with childhood abuse (Skeem, Poythress, et al., 2003). The
authors further argue that these subtypes would likely differ regarding
several facets of personality. First, these subtypes are suggested to differ
on levels of impulsivity and neuroticism with secondary variants

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B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

displaying a more pronounced lack of behavioral controls, higher levels

of reactive aggression, and higher levels of both trait-anxiety and mood
disorders. Previous studies have accordingly indicated that secondary
psychopaths exhibited higher scores on both objective measures of
emotionality such as autonomic arousal as well as on subjective measures such as ratings of anger and aggression (Blackburn & Lee-Evans,
1985). Second, Skeem, Poythress, et al. (2003) argue that secondary
psychopathy is associated with higher levels of BPD traits as reected
by their increased propensity towards neuroticism, anxiety, and affect
instability. Finally, the authors contend that narcissism may also be particularly useful in distinguishing between primary and secondary psychopathy and argue that the primary variant is more closely related to
overt forms of narcissism (i.e., grandiose narcissism) characterized by
social poise, assertiveness, fearless dominance, and self-assurance,
while the secondary variant may be more closely related to covert
forms of narcissism (i.e., vulnerable narcissism) characterized by neurotic conicts, high levels of stress vulnerability, narcissistic fury (violence), and discontentedness with life in general (Skeem, Poythress,
et al., 2003). Different studies in adult incarcerated male samples have
largely supported these theoretical differentiations by Skeem and colleagues. The conclusions from this review and the results of others
(Blackburn, 2007; Blackburn et al., 2008; Ishikawa et al., 2001) with regard to personality pathology in primary and secondary psychopathy is
schematized in Fig. 2.
Using model-based cluster-analysis, Hicks, Markon, Patrick, Krueger,
and Newman (2004) identied two groups of imprisoned criminals that
could be diagnosed as being psychopathic using the PCL-R (mean PCL-R
score of the whole sample = 32, N = 96). One cluster, termed the
emotionally stable psychopaths (primary variants) were characterized by high levels of agency (social potency, well-being, achievement)
and low levels of stress vulnerability, whereas the second group, termed
aggressive psychopaths (secondary variants) were characterized by
high negative emotionality, low constraint, and high levels of social detachment. A year later, Newman, MacGoon, Vaughn, and Sadeh (2005)
reported that primary psychopathy, which was dened as PCL-R N30
and low anxiety, was primarily associated with a weak BIS but unrelated
to BAS, whereas secondary psychopathy, dened as PCL-R N30 and high
anxiety, showed the opposite; high BAS with an average BIS. These ndings accord with earlier theories which stated that primary psychopaths
are less fearful of threat and avoidant of punishment whereas secondary
psychopaths are more impulsive, hedonistic, and short-sighted (Lykken,
1995). Although not specically analyzed, BIS scores were more variable
in the secondary psychopathy group (SD = 0.97 vs. 0.83) while
BAS scores were more variable in the primary psychopathy group

Fig. 2. Primary and secondary psychopathy as relating to the antisocial, narcissistic, and
borderline personality (ASPD, NPD, BPD). Both primary and secondary psychopathic individuals are characterized by strong NPD traits (although the specic variant of narcissism
may vary) (Skeem, Edens, et al., 2003; Skeem et al., 2007), whereas ASPD is more closely
related to secondary variants. The core features associated with primary psychopathy are
mainly related to NPD disturbances and can thus also come to expression in controlled individuals (Blackburn, 2007; Blackburn et al., 2008; Gao & Raine, 2010; Ishikawa et al.,
2001; Poythress & Hall, 2011). Furthermore, a substantial part of the secondary psychopathic group is additionally characterized by the presence of BPD traits (Skeem, Edens,
et al., 2003; Skeem et al., 2007). Note; since the studies in female samples are scarce this
schematization applies mainly to males.

(SD = 0.98 vs. 0.84) indicating that primary and secondary groups
may vary regarding BAS and BIS scores respectively (Newman et al.,
2005).
A comprehensive cluster-analysis by Skeem et al. (2007), conducted
in a male prison sample (N = 367), further validated these putative differences between primary and secondary psychopathy (PCL-R average
of 34 versus 32 respectively). Secondary psychopathic inmates manifested signicantly more pathological personality traits (borderline,
dependent, and avoidant), higher levels of neuroticism and social
withdrawal (higher levels of irritability, stress susceptibility, lack of assertiveness), and a poorer clinical functioning (substantially higher
levels of major mental illnesses). There were also some positive
outcomes associated with secondary psychopathy (although nonsignicant) such as higher response rates to therapeutic interventions.
Contrary to expectations, however, primary and secondary psychopathic
inmates did not differ regarding impulsivity or NPD traits.
Swogger and Kosson (2007) also identied two psychopathic clusters in incarcerated offenders (N = 258) who showed high PCL-R scores
but could be distinguished regarding levels of anxiety (total PCL-R =
28.65 and 25.27 respectively). In line with previous studies they reported that the secondary group showed higher levels of psychopathology
including more pronounced drug dependency, negative affectivity,
and lower levels of social poise or assertiveness. Also interesting to
note is that Swogger and Kosson (2007) identied a third cluster who
showed high levels of factor 1 traits and the lowest levels of anxiety of
all groups but who did not show the life-course persistent impulsivity,
irresponsibility, and short-sightedness that characterized the other
clusters. This particular group of low psychopathology criminals
may have represented a more controlled class of primary psychopaths
(comparable to the Vincent et al., 2003 category of callous/deceitful
youngsters).
In the following year, Blackburn et al. (2008) used cluster-analysis in
a violent forensic male sample (N = 79) with equally high PCL-R scores
(PCL-R 26) and identied four clusters. One group presented with
particularly high scores on factor 1 exclusively (termed controlled psychopathy by the authors), and three clusters presented with high
scores on both factors (termed primary, secondary, and inhibited
psychopathy). Both the primary and controlled subgroups showed
low levels of internalizing pathology and social withdrawal, low prevalence of paranoid, avoidant, dependent, and BPD traits, and low levels of
childhood sexual and physical abuse, whereas the secondary and
inhibited subgroups exhibited high scores on all these variables. In accordance with the ndings of Vincent et al. (2003) and Swogger and
Kosson (2007), the controlled psychopathic cluster showed the lowest
levels of criminal convictions, highest age at rst conviction, and lowest
rate of total violence convictions but showed the highest scores on factor 1 and highest prevalence of sexual convictions (e.g., rape, pedophilia) (Blackburn et al., 2008). Controlled primary psychopaths may thus
be at heightened risk for sexual deviancy more specically.
A more recent study by Poythress, Edens, et al. (2010) examined BIS/
BAS functioning in different PCL-R clusters but found slightly different
results from that of Newman et al. (2005). They identied three clusters
with a PCL-R score above 30 (a primary, secondary, and a fearful
cluster) in a pre-selected sample of 691 subjects (from 1413 inmates)
who met the DSM-IV-TR criteria for ASPD. Similar to Newman's ndings, the primary cluster showed the lowest levels of anxiety and
harm avoidance, and the highest number of commission errors on a passive avoidance taskall indicative of a low BIS. However, contrasting the
earlier ndings, primary psychopathy was also related to the highest
BAS scores, thereby indicating that subsamples of primary psychopaths
may parallel and even surpass secondary samples in BAS scores. Nonetheless, the secondary cluster showed the highest levels of externalizing
symptomatology, impulsivity, aggressive disciplinary problems, and a
trend towards higher levels of violent recidivism. In other words, the
BAS elevations in secondary psychopaths may be of a more pathological
nature and more likely to result in dysfunctional forms of impulsivity.

B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

Finally, the fearful cluster was nearly similar to the secondary cluster
but differed in that they showed higher levels of harm avoidance and
lower levels of child abuse and trauma, thus indicating a fearful and
neurotic temperament.
To replicate the ndings by Poythress, Edens, et al. (2010) and examine whether similar clusters could be identied using less timeconsuming self-report measures, Cox et al. (2013) cluster-analyzed a
large sample of inmates with the PPI (N = 691 pre-selected from
1143 inmates based on the presence of ASPD). In line with Poythress,
they identied three clusters termed primary, secondary, and
fearful psychopathy. In accordance with previous results, the secondary cluster scored higher on measures of internalizing symptomatology
and impulsivity, while showing a lower score on interpersonal dominance compared to the primary cluster. Similarly, primary psychopathy
was related to the lowest scores on Carefree Nonplanfulness and highest
on Fearlessness, Social Potency, Machiavellian Egocentricity, and Stressimmunity facets of the PPI, suggesting a less emotional and more
egocentric, calculated, manipulative, and deliberate approach to life.
Unexpectedly, however, primary psychopathy showed the highest
level of externalizing symptomatology and were more prone to recidivism compared to all other groups. Therefore, cluster-analyzing the
PPI may bring forth primary subtypes that are more prone to problematic, externalizing behavior than secondary subtypes whereas an opposite pattern may be found when cluster-analyzing the PCL-R. Finally, it is
also interesting to note that the fearful cluster showed near identical
pattern of scores compared to the secondary cluster but differed exclusively in levels of Fearlessness on the PPI. As discussed below in
Section 6, the fearful cluster may constitute a specic group of highly
neurotic secondary psychopaths.
Summarizing, cluster-analytic studies in adult prison or forensic
samples have repeatedly and consistently reported that regardless of
similarities on different psychopathy measures such as the PCL-R or
PPI, primary and secondary psychopaths can be differentiated on several psychological and behavioral traits. Secondary psychopathy is generally related to more severe social maladjustment and higher levels of
both internalizing and externalizing psychopathology. For example, reactive aggression, impulsivity, and violent criminality are more closely
related to secondary psychopathy, whereas primary psychopathy may
also manifest in more controlled individuals (e.g., Blackburn et al.,
2008; Swogger & Kosson, 2007).
4.5. Identifying primary and secondary psychopathy in community samples
through cluster analysis
In contrast to these investigations in forensic or prison samples,
three recent studies have examined the existence of subtypes in community samples. Coid et al. (2012) were the rst to cluster-analyze
PCL-SV scores in a large pre-selected community sample (624 subjects
selected from a sample of 8.886 community individuals). In agreement
with incarcerated samples (e.g., Blackburn et al., 2008), the authors
reported two groups resembling primary psychopathy who showed
equally high scores on the factor 1, but differed regarding factor 2
scores (criminal psychopathy and successful psychopathy), and
one group resembling secondary psychopathy who showed high
levels of antisocial, lifestyle, and affective but not interpersonal traits
(non-psychopathic criminals). However, as identied through
cluster-analysis by both Blackburn et al. (2008) and Poythress, Edens,
et al. (2010), some violent individuals attain high scores on all four
facets of the PCL-R, including interpersonal traits (and would, therefore,
be clustered into the criminal psychopathy subcategory of the Coid
study), but present with high levels of neuroticism and harm avoidance.
Indeed, Coid et al. (2012) found that a very large proportion of the
criminal psychopathy cluster displayed affective or anxiety disorders
(90.9%, p b 0.01 and 63.6%, p b 0.01, respectively). This study may therefore have unintentionally lumped the primary and secondary psychopathic subjects into the criminal psychopathy group since they did

21

not separate subtypes based on external constructs such as traitanxiety or internalizing symptomatology.
Second, Drislane et al. (2014) used model-based cluster analysis in
men who scored 95th percentile on the Triarchic Psychopathy Measure (N = 193) (Patrick et al., 2009). These subjects were selected
from a larger community sample of over 4000 males who were evaluated for service in the Finnish military. Similar to incarcerated samples,
the best tting model identied two clusters resembling primary and
secondary variants. Secondary psychopathic subjects reported high
levels of internalizing problems including anxiousness, depression,
and somatization, and scored higher on the disinhibition facet of
the TriPM, whereas primary psychopathic individuals showed
higher rates of violent crimes and particularly high scores on the
boldness facet.
Finally, Falkenbach et al. (2014) conducted a cluster-analytic study
with the PPI-R in a large sample of college students (N = 418).
Compared to the secondary cluster, the primary cluster showed higher
scores on the PPI-I, overt narcissism, and positive affectivity, while
displaying lower scores on the PPI-II, anxiety, anger, aggression, BIS,
negative affectivity, and BPD traits. However, both groups were equal
regarding BAS scores indicating that while primary psychopathy is consistently related to a lower BIS as Fowles (1980) and Lykken (1995) hypothesized, it does not necessarily relate to lower levels of BAS
compared to secondary variants. The authors conclude that the existence of theory-driven subtypes in community samples, or those at
the lower ends of the criminality spectrum, provides empirical support
for the dimensionality of the construct as a whole (p. 16, Falkenbach
et al., 2014).
In summary, similar to incarcerated samples, community samples
with adults also provide evidence for the existence of primary and secondary psychopathic clusters who diverge regarding internalizing
symptomatology, fearlessness, disinhibition, aggression, and violence.
See Table 7 for a nal overview of the putative scoring proles and emotional, behavioral and psychopathological differences between primary
and secondary psychopathy.
5. Etiological mechanisms in primary and secondary psychopathy
Although both primary and secondary variants of psychopathy show
substantial heritability (Hicks et al., 2012) these genetic components
play different roles in their etiology (Blackburn et al., 2008; Cook,
2010; Hicks et al., 2012; Kimonis et al., 2012; Mealey, 1995; Skeem,
Poythress, et al., 2003; Skeem et al., 2007).
For example, empirical research in the last decade has indicated that
plasticity genotypes which are associated with endophenotypes integral to secondary psychopathy, such as emotional lability, approach
motivation/reward-sensitivity, and irritability, only result in antisocial
development when additionally exposed to abusive and stressful
environments, whereas the same genotypes can also increase propensity towards prosocial and socially adapted behavior in positive environments (Bakermans-Kranenburg & Van IJzendoorn, 2006; BakermansKranenburg, Van IJzendoorn, Pijlman, Mesman, & Juffer, 2008; Belsky
& Beaver, 2011; Belsky et al., 2009; Cicchetti, Rogosch, & Thibodeau,
2012; Munaf, Yalcin, Willis-Owen, & Flint, 2008; Propper, Willoughby,
Halpern, Carbone, & Cox, 2007; Reif et al., 2007; Sheese, Voelker,
Rothbart, & Posner, 2007). Indeed, except for Lykken (1995), who suggested a strong genetic component, most scholars have argued that despite some temperamental abnormalities, the etiology of secondary
psychopathy is mainly explained by destructive social experiences
that have disturbed emotional development (Blackburn et al., 2008;
Karpman, 1941; Mealey, 1995; Porter, 1996).
Contrastingly, the emotional deciency and corresponding fearlessness that underpin the development of primary psychopathy are
strongly rooted in constitution (Baker et al., 2009; Beaver, Rowland,
Schwartz, & Nedelec, 2011; Blair, 2006a,b; Hicks et al., 2012; Karpman,
1941; Porter, 1996; Ribeiro da Silva, Rijo, & Salekin, 2012; Skeem,

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B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

Table 7
Emotional, behavioral, and psychopathological differentiations between primary and secondary psychopathy and their respective scoring proles on the LSRP, PCL-R, PPI, and
TriPM. PP scale = Primary Psychopathy scale, SP scale = secondary psychopathy scale,
F1 = factor 1 (interpersonal/affective), F2 = factor 2 (antisocial lifestyle), PPI-I = Fearless
Dominance, PPI-II = Impulsive Antisociality.
Domains

Primary
psychopathy

Secondary psychopathy

LSRP prole

Elevated on PP Scale
Low on SP Scale
F1 biased prole
Heterogeneity on F2
PPI-I biased prole
Heterogeneity on PPI-II
Boldness
Meanness
Heterogeneity on;
Disinhibition

High on PP Scale
Normative to high on SP scale
F2 biased prole
Heterogeneity on F1
PPI-II dominated prole
Heterogeneity on PPI-I
Disinhibition
Meanness
Heterogeneity on;
Boldness

Emotional
Threat sensitivity (fear)
Anxiety
Anhedonia
Hostility

Low
Low
Low
Low

Normative to high
Normative to high
High
High

Behavioral
BAS
BIS
Harm avoidance
Impulsiveness

Normative to high
Low
Low
Normative to high

High
Normative to high
Normative to high
High

Psychopathology
Internalizing
Externalizing
Reactive aggression
Instrumental aggression
Criminal behavior
Narcissism

Low
Normative to high
Normative to high
High
Primarily goal-driven
Overt grandiose forms

Drug abuse

Heterogeneity

Normative to high
High
High
Normative to high
Primarily impulse-driven
Overt grandiose and covert
vulnerable forms
High

PCL-R prole
PPI prole
TriPM prole

Poythress, et al., 2003; Skeem et al., 2007; Yildirim & Derksen, 2013).
Studies which have assessed primary psychopathic traits (e.g., low neuroticism, fearlessness, insouciance, callous/unemotional traits) reported
that shared and nonshared environmental factors, including those
found within the family (parental permissiveness, attachment, socialization), were either unrelated or marginally related to between-twin
differences in such personality attributes (e.g., Beaver, Vaughn, & DeLisi,
2013; Viding, Blair, Moftt, & Plomin, 2005; Viding, Jones, Frick, Moftt,
& Plomin, 2008; Viding & Larson, 2010; Waldman & Rhee, 2006). In accordance, socialization seems to have a much larger effect on different risks
for antisocial behavior found in secondary psychopaths such as neuroticism, impulsivity, and hostility, rather than those found in primary psychopaths such as fearlessness, likely because the neural mechanism
through which these latter risks are mediated is more strongly determined by constitution and less susceptible to environmental inuences
(Blair, 2006a, 2010; Hall et al., 2004; Hare, 1993; Harpur et al., 1989;
Lykken, 1995; Reidy et al., 2011; Viding et al., 2005, 2008).
Nevertheless, it must be noted that neither primary nor secondary
variants are entirely related to genetics or environment. More specically, secondary psychopathy and the associated impulsive antisociality
have been related to childhood abuse/trauma and low socioeconomic
status, whereas primary psychopathy and the associated interpersonal/affective traits have been associated with parental neglect, maternal
disengagement, and low maternal care (Beaver, Vaughn, DeLisi,
Barnes, & Boutwell, 2012; Blackburn et al., 2008; Coid et al., 2012;
Cook, 2010; Graham, Kimonis, Wasserman, & Kline, 2012; Hicks et al.,
2012; Ishikawa et al., 2001; Kimonis, Cross, Howard, & Donoghue,
2013; Kimonis, Fanti, Isoma, & Donoghue, 2013; Kimonis et al., 2012;
Poythress, Edens, et al., 2010; Poythress, Skeem, & Lilienfeld, 2006;
Ribeiro da Silva et al., 2012; Skeem, Poythress, et al., 2003). For example,
incarcerated youth with secondary psychopathy were more often characterized by sexual abuse, whereas those with primary psychopathy

were more likely to have been neglected (Kimonis, Fanti, et al., 2013).
In a similar vein, the only environmental variable that showed an effect
on primary psychopathic features was maternal disengagement (Beaver
et al., 2012).
It might, therefore, be more adequate to say that the emotional deciency associated with primary psychopathy and strongly rooted in
temperament is more naturally related to antisocial behavior when
the absence of protective factors such as maternal warmth and engagement, rewarding social network, and undivided parental attention, do
not counterbalance such tendencies (e.g., Lykken, 1995), whereas the
temperamental irritability, neuroticism, and reward responsivity, as
associated with secondary psychopathy, may only result in antisocial
development in the presence of risk factors that increase social stress
levels to non-optimal heights such as trauma, rejection, and abuse
(e.g., Porter, 1996; Yildirim & Derksen, 2013).
5.1. Biobehavioral pathways to primary psychopathy
As shortly described above, the etiology of primary psychopathy is
predominantly rooted in genetic contributions that dampen spontaneous emotional responses to social cues or immediate threat and thereby
attenuate the natural aversion to risk, punishment, and novelty
(emotional deciency), impede emotional empathy or the development
of self-conscious moral emotions (guilt/shame), and eventually
preclude the proper integration of affect into a developing model of morality (decient conscience) (see Blair (1995, 2006a,b); Fowles and
Kochanska (2000); Kochanska (1991, 1993); Larsson, Andershed, and
Lichtenstein (2006); Lykken (1995); Meffert, Gazzola, den Boer,
Bartels, and Keysers (2013); Ribeiro da Silva et al. (2012); Viding et al.
(2005, 2008); Yildirim and Derksen (2013)).
Core characteristics that are common to all primary psychopaths can
be summarized as; (1) lower levels of psychological and physiological
stress/fear responsiveness (fearlessness), (2) dampened empathyrelated neural and physiological responses to, and reduced recognition
and psychological appraisal of, socio-affective stimuli (callous insouciance), (3) less emotional interference during moral judgments and
decision-making (moral utilitarianism), and (4) a particular talent at
manipulating, deceiving, and persuading others (social potency)
(Blair, 2006a,b, 2010; Blair, Colledge, Murray, & Mitchell, 2001; Blair
et al., 2002, 2003; Carr, Hyde, Neumann, Viding, & Hariri, 2013; Cima,
Smeets, & Jelicic, 2008; Cima, Tonnaer, & Hauser, 2010; ContrerasRodrguez et al., 2014; Deeley et al., 2006; Gao & Tang, 2013; Glenn,
2011a,b; Glenn, Raine, & Schug, 2009; Gordon, Baird, & End, 2004;
Hare, 1993; Harenski, Edwards, Harenski, & Kiehl, 2014; Harenski,
Harenski, & Kiehl, 2014; Harenski, Harenski, Shane, & Kiehl, 2010;
Harenski, Kim, & Hamann, 2009; Hicks et al., 2004; Iria & Barbosa,
2009; Jones, Laurens, Herba, Barker, & Viding, 2009; Justus & Finn,
2007; Kiehl et al., 2001; Koenigs, Kruepke, Zeier, & Newman, 2011;
Kosson, Suchy, Mayer, & Libby, 2002; Mahmut, Homewood, & Stevenson, 2008; Marsh & Cardinale, 2012; Marsh & Cardinale, 2014; Marsh
et al., 2011; Montagne et al., 2005; Patrick, Bradley, & Lang, 1993; Porter
et al., 2009; Seto & Barbaree, 1999; Sobhani & Bechara, 2011;
Sprengelmeyer et al., 1999; Stadler et al., 2011; Tassy, Deruelle, Mancini,
Leistedt, & Wicker, 2013; Vanman, Mejia, Dawson, Schell, & Raine,
2003; Viding et al., 2012; Young, Koenigs, Kruepke, & Newman, 2012).
Contrary to these emotional patterns that operate below consciousness,
conscious cognitive appraisals of what is considered morally wrong or
right are consistently found to be intact, and sometimes even enhanced,
in psychopathy (Aharoni, Sinnott-Armstrong, & Kiehl, 2012; Cima et al.,
2010; Link, Sherer, & Byrne, 1977; Tassy et al., 2013). As the title of one
of these studies aptly states, psychopaths know right from wrong but
do not care (Cima et al., 2010).
The neural signature of this emotional deciency has been ascribed to
a genetically determined attenuation of amygdalar reactivity (e.g., Blair,
2006a,b; Blair, Mitchell, & Blair, 2005). Longitudinal studies have, indeed,
provided support for extremes of temperamental emotionality and

B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

fearfulness based on amygdalar reactivity, namely the low- and highresponsive temperament, which show high stability from infancy to
adulthood (see Kagan and Snidman (2004); Kagan, Snidman, Kahn, and
Towsley (2007); Schwartz, Wright, Shin, Kagan, and Rauch (2003)).
Furthermore, low-responsive children and adolescents display a leftward bias in resting brain activity, which is associated with behavioral
approach and reduced anxiety, whereas high-responsive youngsters
show a right-ward bias, which has been associated with behavioral inhibition and increased anxiety (Balconi & Mazza, 2009, 2010; Coan & Allen,
2003; Fox et al., 1995; Harmon-Jones & Allen, 1997; Hecht, 2011; Kagan &
Snidman, 2004). Similarly, adolescents with callousunemotional traits
and adults who score high on core psychopathy features especially display right-hemisphere fronto-amygdalar structural abnormalities and
hyporeactivity to aversive stimuli or when processing moral emotions
(Carr et al., 2013; Fairchild et al., 2013; Glenn et al., 2009; Gordon
et al., 2004; Harenski, Edwards, et al., 2014; Harenski, Harenski, et al.,
2014; Harenski et al., 2009, 2010; Jones et al., 2009; Kiehl et al., 2001;
Kosson et al., 2002; Marsh & Cardinale, 2014; Marsh et al., 2011; Mller
et al., 2008; Tiihonen et al., 2000; Viding et al., 2012; Yang, Raine,
Colletti, Toga, & Narr, 2010). Interestingly, Marsh et al. (2014b) recently
reported that extraordinarily altruistic individuals (those who donated a
kidney to a complete stranger) displayed an enlargement and enhanced
responsivity of specically the right-hemisphere amygdala, which is the
exact opposite of what is found in primary psychopathy.
In a similar vein, Hecht (2011) concludes that prosocial behavior,
as well as feelings of empathy, guilt, and fear are mediated predominantly by regions within the right hemisphere, whereas impulsivity,
stimulation-seeking, aggression, and risk-taking are tightly linked to
left hemisphere activity. Therefore, while the core features of primary
psychopathy have been repeatedly and consistently associated to
right hemisphere hyporesponsivity, the antisocial and impulsive traits
have been mainly related to left hemisphere hyperactivity (see Hecht
(2011)).
The right fronto-amygdalar circuitry is involved in the initial, fast,
and possibly intuitive detection of peripheral and affectively salient or
otherwise relevant stimuli and results in somatic arousal in response
to these stimuli, followed by a more detailed, prolonged, and cognitive
evaluation of the stimulus by the left fronto-amygdalar complex after
it is brought within the central eld of attention (Costafreda,
Brammer, David, & Fu, 2008; Hardee, Thompson, & Puce, 2008; Morris,
deBonis, & Dolan, 2002; Morris, Ohman, & Dolan, 1999; Morris et al.,
1996; Sergerie, Chochol, & Armony, 2008; Skuse, Morris, & Dolan,
2005; Wright et al., 2001). Coherent with this inter-hemispheric lateralization of fronto-limbic functionality, primary psychopaths are mainly
impaired in spontaneous emotional reactions to (peripheral) aversive
stimuli. That is, when they are verbally instructed to consciously direct
attention or to deliberately induce the appropriate emotion (thereby
soliciting left-hemisphere capacities) their initial hyporesponsivity
and insensitivity is no longer observed (Meffert et al., 2013; Newman,
Curtin, Bertsch, & Baskin-Sommers, 2010).
In short, without the parallel uctuations of the right amygdalaprefrontal circuitry, left-lateralized goal-directed motivation and decision making may be devoid of socio-emotional considerations and depend solely on predicted instrumental outcomes and ongoing reward
feedback (trial-and-error learning). This neurophysiological prole
could then contribute to social insensitivity, egocentrism, risk-taking,
boldness, and an assertive pursuit of reward.
However, this emotional deciency and associated core psychopathic traits do not automatically lead to disinhibition or antisocial behavior
and might result in a variety of possible phenotypes dependent on other
biological and environmental factors (Cooke & Michie, 2001; Lykken,
1995; Patrick et al., 2009; Poythress & Hall, 2011; Skeem & Cooke,
2010a,b; Smith et al., 2013). It has been argued and empirically supported that temperamental characteristics, such as fearlessness and stressimmunity, may hold adaptive value in fast-paced and competitive
environments, especially in the context of other protective factors

23

such as a rm but authorative socialization, good executive functioning,

and high intelligence (Babiak & Hare, 2007; Dutton, 2012; Gao & Raine,
2010; Gao et al., 2011; Lilienfeld et al., 2012; Lykken, 1995; Poythress &
Hall, 2011; Stout, 2006). Furthermore, core psychopathic traits assessed
with the interpersonal facet (PCL instruments) and fearless dominance
factor (PPI-I) are either unrelated or positively related to general
intelligenceespecially verbal abilitieswhereas the affective, antisocial, and lifestyle facets (PCL instruments) and impulsive antisociality
(PPI-II) consistently show negative correlations to such cognitive abilities (Benning et al., 2003; De Tribolet-Hardy, Vohs, Mokros, &
Habermeyer, 2014; DeLisi, Vaughn, Beaver, & Wright, 2010; Neumann
& Hare, 2006; Salekin, Neumann, Leistico, & Zalot, 2004; Vitacco, Neumann, & Jackson, 2005; Vitacco, Neumann, & Wodushek, 2008). In accordance, high scores on the interpersonal facet or PPI-I are also
observed in community samples and in career-wise successful individuals who occupy respectable and high ranking jobs such as psychiatrists, physicians, lawyers, scientists, politicians, surgeons, managers,
CEO's, and even U.S. presidents (Babiak et al., 2010; Board & Fritzon,
2005; Cleckley, 1941; Coid et al., 2012; Dutton, 2012; Fanti et al.,
2013; Hall & Benning, 2006; Lilienfeld et al., 2012; Lykken, 1995).
In response to careful review of the types and levels of impulsivity in
psychopathic subsamples, Poythress and Hall (2011) conclude that the
blunt assertion that psychopaths are impulsive is no longer defensible (abstract). Instead, they argue that a signicant portion of primary
psychopathic individuals exhibit adequate self-control, foresight, and
planning ability, allowing them to refrain from serious antisocial behavior and to function relatively well in society, even attain success. In support of this hypothesis, different cluster-analytic studies in both
community and incarcerated samples and in both juveniles and adults
provide support a dual categorization of primary psychopathic subjects
(i.e., low neuroticism and fear) into a deceitful, controlled, and low
psychopathology group (controlled successful variants) and a more
aggressive, impulsive, and criminal group (disinhibited criminal
variants) (see Blackburn et al. (2008); Swogger and Kosson (2007);
Vincent et al. (2003)).
Regarding neurobiological factors that may contribute to this heterogeneity, primary psychopathic individuals have been found to differ
substantially regarding the functionality and structural integrity of neural regions involved in self-control, planning, organization, and instrumental learning. First, it has been found that primary psychopathic
individuals with high levels of antisocial and impulsive behavior are
characterized by both a lower stability and lower exibility of PFC mediated executive processes during goal directed behavior (Dolan, 2012;
Gao et al., 2011; Ishikawa et al., 2001; Lapierre, Braun, & Hodgins,
1995; Mitchell, Colledge, Leonard, & Blair, 2002; Molt, Poy, Segarra,
Pastor, & Montas, 2007; Poythress & Hall, 2011). This PFC processing
prole could underlie the automatic hyperfocus on immediate and
strong reinforcements (insufcient stability to engage in longer term
endeavors; easily bored) and the impaired behavioral adaptations to
non-reward, punishment, or peripheral warning cues (impaired response modulation; inability to learn from experience) as observed in
disinhibited and criminal subtypes of primary psychopathy (Blair
et al., 2005; Newman & Lorenz, 2003). Conversely, more controlled
and well-adjusted primary psychopathic individuals show higher levels
of PFC mediated cognitive stability and exibility during goal-directed
behaviors and thus engage more adaptively in long-term pursuits
(higher persistence and conscientiousness) and adjust behavioral strategies more sensitively when confronted with error/punishment or
when peripheral cues signal such a possibility (better response modulation) (Gao et al., 2011; Ishikawa et al., 2001; Mullins-Sweatt, Glover,
Derenko, Miller, & Widiger, 2010). Therefore, although controlled primary psychopaths may be equally likely to display a particular tendency
to take risks and persist towards coveted rewards, their intact PFC processes and higher levels of cognitive exibility may enable them to do so
in a more strategic, deliberate, and calculated manner (deliberate gainoriented risk-taking/functional impulsivity) (Gao & Raine, 2010;

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B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

Poythress & Hall, 2011). Second, violent, incarcerated, or convicted primary psychopaths show lower amygdala volumes bilaterally (right:
20%, left: 17% reduction), reduction of PFC grey matter (up to 22%),
and hippocampal abnormalities such as an R N L asymmetry (both
smaller left and greater right hippocampal volumes) when compared
to controls or non-convicted/non-incarcerated psychopathic subjects
(Gao & Raine, 2010; Laakso et al., 2001; Raine et al., 2004; Yang, Raine,
Lencz, LaCasse, & Colleti, 2005; Yang, Raine, Narr, Colletti, & Toga, 2009).
Interestingly, a lower hippocampal volume and dysfunctional PFCmediated regulation of goal-directed behavior have both been related
to more pronounced and dysregulated mesolimbic dopamine-driven
reward processes (Grace, 2010; Lisman et al., 2008; Lodge, 2011;
Lodge & Grace, 2006, 2011). In accordance with the interhemispheric
imbalances as associated with primary psychopathy (Hecht, 2011),
dopamine-driven reward processes are predominantly lateralized to
the left-hemisphere (see Tomer et al. (2014); Weiland et al. (2014)).
In other words, disinhibited and criminal variants of primary psychopathy may display a more hyperactive or dysregulated mesolimbic dopaminergic circuitry compared to controlled variants (Bjork, Chen, &
Hommer, 2012; Buckholtz et al., 2010; Soderstrom, Blennow,
Manhem, & Forsman, 2001; Soderstrom, Blennow, Sjodin, & Forsman,
2003), especially in the left hemisphere.
5.2. Biosociopsychological pathways to secondary psychopathy
Secondary psychopathic individuals also display a temperamental peculiarity that predisposes them to antisocial behavior (e.g., irritability, executive dysfunctionality, reward-sensitivity) but their socio-affective
detachment is primarily an adaptation and their aggression a retaliation
to traumatic, abusive, and painful social experiences that have instilled a
paranoid and hostile worldview (disturbed conscience) (Karpman,
1941; Lykken, 1995; Porter, 1996; Yildirim & Derksen, 2013). Instead of
emotional deciency, the core pathology associated with secondary psychopathy is the disturbed regulation, reduced awareness, undervaluation,
and outward projection of one's emotional processes, collectively termed
as emotional disturbance (Burns et al., 2014; Long, Felton, Lilienfeld, &
Lejuez, 2014; Yildirim & Derksen, 2013).
Therefore, despite a normal or high-responsive temperament, destructive social experiences such as trauma and abuse could disturb
neural and socio-emotional development and result in phenotypically
similar traits as found in primary psychopathy. Alternative pathways
to antisocial behaviors, as related to secondary psychopathy, may depend less on the amygdala, but instead arise due to the neural
dysfunctioning of cortical structures that mediate the cognitive appraisal and top-down regulation of socio-affective signals, and of which the
healthy maturation is dependent on sensitive and responsive social experiences early in life (Anderson, Bechara, Damasio, Tranel, & Damasio,
1999; Blair, 2007, 2008; Blair & Cipolotti, 2000; Blair et al., 2005;
Buckholtz & Meyer-Lindenberg, 2008; Burgess & Wood, 1990; Burns
et al., 2014; Damasio, Tranel, & Damasio, 1990; Decety & Chaminade,
2003; Eslinger, 1998; Kolb et al., 2012; Shore, 2001a,b; Weber, Habel,
Amunts, & Schneider, 2008; Yildirim & Derksen, 2013).
One specic neurobiological mechanism through which the relationship between social experience and secondary psychopathy could be mediated is through the maturation and functionality of the ventromedial
prefrontal cortex, abbreviated as vmPFC. The vmPFC includes a medial division; the medial prefrontal cortex (abbreviated as mPFC and including
the dorsal anterior cingulate; area 32, the subgenual cingulate; area 25,
the ventral anterior cingulate; area 24, and the frontopolar prefrontal cortex; area 10), and a ventral part; the orbitofrontal cortex (abbreviated as
OFC and including the medial OFC; area 11 and 12, and the lateral OFC;
area 47) (see Fig. 3; areas correspond to Brodmann's numerical categorization of the cerebral cortex). The healthy maturation of in particular the
right vmPFC is essential for affective skills such as self-regulation, emotional appraisal, and affective decision making, behavioral skills such as
self-control, cognitive skills such as foresight, learning from experience,

and social cognition, and interpersonal skills such as self-awareness, empathy, identication with others, and intersubjective processes more generally (Anderson et al., 1999; Bechara, Damasio, & Damasio, 2000;
Bechara, Damasio, Damasio, & Lee, 1999; Bechara, Tranel, & Damasio,
2000; Damasio et al., 1990; Decety & Chaminade, 2003; Eslinger, 1998;
Fuster, 2008; Grattan, Bloomer, Archambault, & Eslinger, 1994;
Molnar-Szakacs, Uddin, & Iacoboni, 2005; Shore, 2001a,b).
Indeed, vmPFC dysfunctioning has been consistently related to both
factors of the PCL-R and its healthy maturation is strongly dependent on
the balanced interaction between biological factors such as genes, gender, and gonadal hormones, social experiences such as attachment, and
other environmental factors such as substance abuse (Alia-Klein et al.,
2011; Blair, 2008; Blair et al., 2005; Chugani et al., 2001; Dannlowski
et al., 2012; De Brito et al., 2012; Edmiston et al., 2011; Franklin et al.,
2002; Hanson et al., 2010; Kates et al., 2006; Koenigs, 2012; Lombardo
et al., 2012; Minagawa-Kawai et al., 2009; Shore, 2001a,b; Thomaes
et al., 2010; Yang et al., 2005). It is especially the maturation the right
vmPFC cortex that is inuenced by the early attachment relationship
and affects many affective and emotional capacities throughout life
(Minagawa-Kawai et al., 2009; Shore, 2001a,b). These results indicate
that vmPFC dysfunctioning can arise out of an interaction between constitutional biology and destructive environmental inuences and predispose to the whole range of psychopathic traits, making it the ideal
candidate for the explanation of secondary psychopathy.
First, the autoregulatory tone of the medial prefrontal cortex (mPFC)
on subcortical reactivity, facilitated by optimal levels of baseline serotonin functioning, provides an intuitive counterbalancing mechanisms to
threat-related amygdalar and corresponding HPA-axis reactivity through
feedforward inhibition, thereby attenuating emotional uctuations and
stabilizing the homeostatic state (Akirav & Maroun, 2007; Banks, Eddy,
Angstadt, Nathan, & Phan, 2007; Fisher et al., 2009, 2011; Pezawas
et al., 2005; Posner, Rothbart, Sheese, & Tang, 2007; Quirk, Likhtik,
Pelletier, & Par, 2003). However, when confronted with salient events
that violate our expectancies and that require a shifting of attention to
new future contingencies, catecholamine-driven processes temporarily
override this autoregulatory tone and sensitize subcortical input into
prefrontal modules (i.e., predictive allostatic regulation) thereby improving action monitoring, sensitizing emotional responsivity, increasing
awareness of emotional states, enhancing operant conditioning, and decreasing impulsive decision-making (Drabant et al., 2006; Laviolette,
Lipski, & Grace, 2005; Pardey, Kumar, Goodchild, & Cornish, 2012;
Prez de la Mora, Gallegos-Cari, Arizmendi-Garca, Marcellino, & Fuxe,
2010; Posner et al., 2007; Schultz, 1998; Shah, Sjovold, & Treit, 2004;
Stahl, 2008; Van Noordt & Segalowitz, 2012; Winstanley, Theobald,
Dalley, Cardinal, & Robbins, 2006).
When this top-down autoregulatory tone is compromised
(e.g., genetic liabilities, prolonged stress), catecholaminergic activations
have a more pronounced effect on physiology and behavior which can
result in sensitized neural processing of, and impetuous behavioral
responding to unexpected/salient events. In the context of rewards or
cues signaling their potential presence, inhibiting mPFC-driven topdown autoregulation would induce a certain reward hyperfocus at
the expense of peripheral warning cues or information regarding
more optimal choices, thereby impairing response modulation and
leading to impulsivity (e.g., Harrison, Everitt, & Robbins, 1997;
Newman & Lorenz, 2003; Wallace & Newman, 2008; Winstanley,
Dalley, Theobald, & Robbins, 2003, 2004; Winstanley et al., 2006). In
the context of conict, punishment, and social rejection/exclusion, this
reduced top-down autoregulation may also amplify the salience of
these events and induce an over-evaluative hypervigilance and paranoia (i.e., the induction of a hypervigilant state to stay prepared for
dreaded future events) that can lead to anticipatory anxieties, aggression, worrying, nervousness, and fear (e.g., Stahl, 2008; Stein,
Newman, Savitz, & Ramesar, 2006).
Second, for adaptive regulation of behavior according learned rules
of reinforcement, the OFC comes online when an unexpected but salient

B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

25

Fig. 3. Different subcortical and cortical brain regions implicated in the etiology of primary and secondary psychopathy. Cortical regions are numbered according corresponding
Brodmann Area.

future possibility is activated and serves in the online maintenance of its

representation (Frank & Fossella, 2011; Grace, Floresco, Goto, & Lodge,
2007; Lodge, 2011). During the online maintenance of these wanted
or feared possibilities, the dorsolateral prefrontal cortex (dlPFC) constructs different action-plans that lead to the completion of the current
goal (whether obtaining rewards or avoiding threats) and the OFC continuously activates associational networks of reinforcement schedules
representing the relative outcome values of these various action-plans.
In a Darwinian-like competition of neural signals, action-plans with
the highest pay-off and least aversive neural traces or that signal the
least chance of error of punishment, are least inhibited and the corresponding reverberation between the OFC and dlPFC increases the
chance of them being carried out (Blair et al., 2005; Fuster, 2008;
Gottfried, O'Doherty, & Dolan, 2003; Padoa-Schioppa & Assad, 2006;
Schoenbaum, Chiba, & Gallagher, 1998; Tremblay & Schultz, 1999).
Without the OFC as a relay station temporarily holding representations about future outcomes active and deciding which signals to reverberate and which to inhibit, as is the case when lesioned, all internal
motivations, emotions, and behavioral tendencies (the Id) that are normally inhibited by the OFC (the Superego), may become plausible and
immediate possibilities and thus acted upon without adequate consideration of their consequence, adequateness, appropriateness, or relevance (Fuster, 2008). Serotonin functioning in the OFC is crucially
involved in this inhibitory function and its dysregulation thus strongly
affects optimal OFC functioning (Fuster, 2008; Homberg, 2012;
Walker, Robbins, & Roberts, 2009; Yildirim & Derksen, 2013).
In line with these vmPFC functions, individuals with vmPFC damage
due to blunt force head trauma show secondary psychopathic features
after the incident (termed acquired sociopathy) such as an inability to
use socio-affective and moral information to guide behavior, impulsivity, reward-hyperfocus, emotional numbing, HPA-axis dysfunctioning,
socio-emotional detachment, and reactive aggression (Anderson et al.,
1999; Blair & Cipolotti, 2000; Buchanan et al., 2010; Burgess & Wood,
1990; Damasio et al., 1990; Eslinger, 1998; Grattan et al., 1994;
Pennington & Bennetto, 1993). Nonetheless, in contrast to primary psychopathy, individuals with vmPFC dysfunctioning still display heightened physiological responsivity after discovering that they made a bad
decision, which is more characteristic of impulsivity and an inability to

adequately appraise emotional information or regulate behavioral tendencies beforehand (i.e., impaired appraisal/regulation) rather than a
properly dampened emotional response to the punishment of making
a bad decision (i.e., attenuated reactivity) as related to primary psychopathy (Bechara, Damasio, et al., 2000; Bechara, Tranel, et al., 2000;
Bechara et al., 1999; Blair, 2006a,b). In other words, patients with acquired lesions of the vmPFC show key differences in presentation compared to primary psychopathy.
Furthermore, altered vmPFC functioning is observed in many different clinical conditions marked by emotional disturbances such as panic
disorder, bipolar disorder, substance abuse, and major depressive disorder (Alia-Klein et al., 2011; Altshuler et al., 2008; Lacerda et al., 2004;
Roppongi et al., 2010; Tanabe et al., 2009). Therefore, vmPFC
dysfunctionality is not unique to secondary psychopathy but could be
the neural substrate through which the comorbidity between a variety
of clinical conditions marked by emotional dysregulation can be explained. Emotional disturbances may specically lead to antisocial development and secondary psychopathy in response to neglectful and
abusive experiences or rejection that result in socio-emotional disafliation or frustrating/anger-inducing social experiences that increase the
risk of hostile attributional biases (Dodge, 2003; Porter, 1996).
Finally, similar to primary psychopathic samples, there is also a great
deal of heterogeneity within the secondary psychopathic population
and different variants may be crucially differentiated. For example,
Porter's dissociative secondary psychopath is described as affectionless, mentally alienated, insensitive to social cues, and its etiology is explained through dissociative coping mechanisms in response to
relational trauma and rejection (reduced emotional appraisal), whereas
Blackburn's borderline or Karpman's symptomatic secondary psychopath is described as fearful, harm avoidant, and stress sensitive
and its development is primarily explained through neurotic disturbances and the maldevelopment of self-control or -regulation mechanisms (reduced emotional regulation) (Blackburn, 1975; Karpman,
1941; Porter, 1996; Shore, 2001b; Yildirim & Derksen, 2013).
Accordingly, some relationally traumatized youth with normally
functioning emotional systems might acquire callousness and
unemotionality through the mechanism of emotional numbing
(dissociation of cognition and affect) resulting in an affectionless,

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B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

interpersonally alienated, cognitively detached, and hedonisticimpulsive phenotype (i.e., reduced appraisal) (Kerig, Bennett, Thompson, &
Becker, 2012; Orsillo, Theodore-Oklata, Luterek, & Plumb, 2007; Porter,
1996), whereas others who are more emotionally reactive, hyperactive,
and irritable may additionally react with a dysregulation of affect and
motivation resulting in emotional instability, anxiety, interpersonal
hostility, and reactive aggression (i.e., reduced regulation/control)
(Burns et al., 2014; Davidson, Putnam, & Larson, 2000; Putnam & Silk,
2005; Scott, Stepp, & Pilkonis, 2014; Shore, 2001b; Sprague, Javdani,
Sadeh, Newman, & Verona, 2012; Yildirim & Derksen, 2013). Intriguingly, just like two broad clusters of primary psychopathic individuals can
be identied who diverge regarding behavioral self-control and (mal)adaptive behavioral patterns (Blackburn et al., 2008; Coid et al., 2012;
Vincent et al., 2003), cluster analytic studies in incarcerated samples
have also identied different types of secondary psychopathic offenders
who show similar PCL-R and PPI scoring proles but diverge regarding
measures of neuroticism, extraversion, harm avoidance, impulsivity,
and borderline personality traits (Blackburn et al., 2008; Cox et al.,
2013; Docherty et al., in press; Poythress, Edens, et al., 2010). Compare
the secondary and inhibited groups of Blackburn et al. (2008) or the
secondary and fearful groups of Poythress, Edens, et al. (2010), Cox
et al. (2013), and Docherty et al. (in press).
Also, the borderline (BPD) and antisocial personality disorder
(ASPD) have both been related to the entire spectrum of PCL-R traits
and it has been repeatedly argued that a continuum of severity might
be observed within the ASPD and BPD population with more severe variants gradually merging into a psychopathic phenotype (Cale &
Lilienfeld, 2002; Coid & Ullrich, 2010; Sprague et al., 2012; Verona,
Sprague, & Javdani, 2012; Yildirim & Derksen, 2013). When extrapolating potential secondary psychopathic subtypes from the BPD and ASPD
groups, it might be predicted that the detached ASPD types would
more strongly express the decits in affective appraisal, social alienation, attentional hyposensitivity, externalizing deviancy, and otherdirected aggression found in secondary psychopathic samples, whereas
the unstable BPD types would be more likely to show the affective
instability, irritability, anxiety, interpersonal hostility, attentional hypersensitivity, and both other- as well as self-directed aggression
(Blonigen et al., 2005; Cale & Lilienfeld, 2002; Claes, Vertommen,
Smits, & Bijttebier, 2009; Gratz, Dixon-Gordon, Breetz, & Tull, 2013;
Krause-Utz et al., 2012; Paris, 1997; Paris, Chenard-Poirier, & Biskin,
2013; Sadeh, Javdani, Finy, & Verona, 2011; Schug, Raine, & Wilcox,
2007; Verona & Vitale, 2006; Verona et al., 2012; Von CeumernLindenstjerna et al., 2010; Wynn, Hiseth, & Pettersen, 2012).
5.3. Serotonergic mechanisms in primary versus secondary psychopathy
A rst remarkable and informative characteristic of the serotonergic
system is that a relatively small number of serotonin synthesizing neurons originating in dorsal raphe nuclei innervate nearly the entire
neuroaxis, attesting for a holistically general role of serotonin throughout the brain. Thus, although serotonin has a host of specialized functions through a variety of receptors in different brain structures, the
adaptational signicance and the essential role that these processes
serve in mental health, adaptation, and coping behaviors can only be
fully understood within the holistic role that serotonin subserves in
neurophysiology.
Since serotonin synthesis is strongly dependent on the presence of
oxygen and during the earliest geological times the Earth's atmosphere
had little oxygen, serotonin sprang rst into being in unicellular systems
capable of photosynthesis and the cellular production of oxygen
(Azmitia, 2007, 2010). Azmitia (2010) summarizes that the indole
ring of tryptophan was the rst and principal means of converting sunlight into biological energy. In these simplest cells, in the presence of
sunlight, serotonin and related tryptophan derivatives function as a
powerful antioxidant and serve to help organisms to maintain homeostasis, regulate differentiation, and promote cell division (pp. 17). It

has been recently conrmed that vitamin D, which is closely linked to

sun exposure, also activates serotonin synthesis in humans by increasing tryptophan hydroxylase activity in the brain (Patrick & Ames,
2014). While serotonin may interact with sunlight to facilitate internal
homeostasis in more primitive life forms such as plants, in humans it
may have additionally evolved to interact with attention, care, and security to facilitate mental and physical health (Dankoski, Agster, Fox, Moy,
& Wightman, 2014). Interestingly, recent research has demonstrated
that the hormone oxytocin, which is released in response to loving
human interaction, touch, and trust, has the ability to improve serotonin
functionality at its core, which in turn facilitates mental equilibrium and
decreases stress and fear (Mottolese, Redout, Costes, Le Bars, & Sirigu,
2014). People with a lower inherent serotonin functionality may thus
need more of these regulatory inputs (sunlight and loving attention)
and a more secure environment or a greater sense of perceived control
in order to maintain psychological and physiological homeostasis. Thus,
although subsequent evolving biological systems such as humans show
increasing complexity and serotonin became involved in increasingly
complex physiological and behavioral functions, its holistic function in
maintaining health is remarkably consistent throughout evolution.
The core proposition stated here is that the primary role of serotonin
in the brain and central nervous system (CNS) is the active and dynamic
adjustment of neurophysiological equilibria in order to maintain physiological processes within a homeostatic range that is necessary for optimal growth, development, and well-being of psychological, emotional,
cardiac, metabolic, and endocrinological processes (Azmitia, 1999,
2007; Carnevali et al., 2012; Carver, Johnson, & Joormann, 2008; Hariri
& Holmes, 2006; Holmes, 2008; Lambe, Fillman, Webster, & Shannon
Weickert, 2011; Petty, Davis, Kabel, & Kramer, 1996; Pissios &
Maratos-Flier, 2007). Although most of us prefer the feeling of comfort
and tranquility that accompanies this homeostatic state, without transient disruptions to this internal balance in response to salient events,
physiological processes would become disconnected from external
events.
In response to a systematic review and structural analysis of the literature, we have recently argued that synergistic or additive genetic
contributions that facilitate the regulatory functionality of serotonin
by stabilizing its continuous turnover, output, synaptic receptivity,
and neuronal regulation, would effectively stabilize homeostatic
autoregulations and dampen internal uctuations to salient events
(Yildirim & Derksen, 2013). Such a neurophysiological prole would
promote a strong psychophysiological equilibrium that is resistant to
acute stressors (fearless) and prevent allostatic overload or morphological alterations of the system to prolonged stressors (emotionally resilient). In extreme cases, multiple serotonin regulating genotypes,
especially when coupled to additional risk factors such as high testosterone or strong GABAergic functioning in limbic structures, could substantially dampen homeostatic disruptions/allostatic regulations below
the threshold needed to respond adequately to aversive
(socio)emotional events such as threat, punishment, and the suffering
of others, thus provoking a certain emotional insouciance and contributing to the etiology of primary psychopathic phenotypes (see Yildirim
and Derksen (2013)).
Furthermore, serotonergic hyperstability naturally attenuates the
need for, and dependence on social attachments to regulate internal
states (Homberg & Lesch, 2011; Yildirim & Derksen, 2013). Human social attachments can be dened as mutual regulatory bonds that serve
to co-create positive emotions and co-regulate negative emotions, predominantly through right-hemisphere intuitive processes (Schulkin,
2011; Shore, 2001a). As discussed, loving human interaction can increase serotonin functioning through oxytocinergic mechanisms thereby improving mental and emotional health (Mottolese et al., 2014). We
thus develop strong social attachments and maintain close proximity
to these attachments in order to co-create positive emotional states
(sharing, in-group forming, affect synchrony) and benet from mutual
regulation during times of stress or threat (helping, soothing, team-

B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

work). In this manner, our social attachments serve to regulate our selfesteem and emotional health and keep us balanced amidst changing
and stressful environments. Strengthening serotonergic homeostasis effectively dampens internal disruptions to salient events and reduces the
need for social attachment to regulate internal states, ultimately engendering socio-emotional insouciance (Yildirim & Derksen, 2013). Just like
homeothermic organisms (i.e., warm-blooded) differ from ectothermic
organisms (i.e., cold-blooded) in that they can dynamically regulate
body temperature in response to changing environments making
them rather independent from environmental sources of heat, individuals with stable serotonergic functioning differ from those with unstable serotonergic systems in that they have a more effective and
dynamic regulation of internal states in response to changing social environments, stressors, and salient events, making them less dependent
on social attachments for stress-regulation.
In line with these premises, the interpersonal/affective factor has
been associated with higher operating ranges of serotonergic functioning (i.e., fenuramine challenge) (Dolan & Anderson, 2003), and expectedly, long-term treatment with selective serotonin re-uptake inhibitors
(SSRIs) has been specically linked to an increase of these core traits
(i.e., 8 weeks of sertraline treatment) (Dunlop et al., 2011). Earlier research already pointed out that long-term SSRI treatment consistently
leads to emotional blunting in reaction to adversity and indifference to
the feelings of others (just not caring) (McCabe, Mishor, Cowen, &
Harmer, 2010; Opbroek et al., 2002; Price, Cole, & Goodwin, 2009;
Price & Goodwin, 2009; Stahl, 2008). In other words, primary psychopathy may be characterized by a highly stable serotonergic system which
strengthens emotional resiliency and attenuates social reward dependence and, therefore, contributes to the etiology of an emotionally decient and socially detached phenotype.
On the contrary, destabilized serotonergic functioning mimicked by
acute increases and drops of serotonin activity (e.g., acute SSRI administration/tryptophan depletion) led to respectively greater fear/empathy/
moral conduct and greater aggression/impulsivity (Bigos et al., 2008;
Bjork, Dougherty, Moeller, & Swann, 2000; Browning, Reid, Cowen,
Goodwin, & Harmer, 2007; Burghardt, Bush, McEwen, & LeDoux,
2007; Burghardt, Sullivan, McEwen, Gorman, & Ledoux, 2004; Crean,
Richards, & de Wit, 2002; Crockett, Clark, Hauser, & Robbins, 2010;
Fikke, Melinder, & Landr, 2013; Harmer et al., 2003). These ndings indicate that individuals with higher serotonergic plasticity may be
predisposed towards both prosocial and antisocial behaviors, potentially dependent on social experiences throughout life.
Therefore, plasticity genotypes that decrease stability/increase
exibility of synaptic serotonin levels and postsynaptic serotonin receptor sites could particularly predispose towards decient serotonergic
regulation of physiology and increase the risk for secondary psychopathic/reactive aggressive phenotypes when additionally exposed to
stressful life-events and adverse social experiences (Caspi, Hariri,
Holmes, Uher, & Moftt, 2010; Davidson et al., 2000; Hariri & Holmes,
2006; Holmes, 2008; Homberg & Lesch, 2011; Whitaker-Azmitia,
2001, 2010). For example, stressful or traumatic life-events boost serotonergic neurotransmission and thus require the serotonergic system to
adapt by dynamically modulating synthesis, transport, degradation, and
receptivity so that a healthy baseline functioning can be maintained.
This balancing mechanism likely provides stability and continuity of
goal-directed behavior, emotional balance, and cognitive functioning.
In individuals with less efcient allelic congurations of various serotonin regulating genotypes (e.g., usually associated with lower expression), adaptations to prolonged neurotransmission may be less
efcient and contribute to psychopathology when external demands ultimately exceed serotonergic coping capacity (see Yildirim and Derksen
(2013)). If this homeostatic disruption is prolonged (i.e., lacking the opportunity for stress-recovery) and occurs in the developing brain, it can
have life-long desensitizing effects on the central serotonergic response
and contribute to disturbed brain development, especially vmPFC
maturation, and lead to trait-like emotional disturbances thereby

27

predisposing towards life-course persistent anxiety, depression, impulsivity, and aggression (i.e., neuroticism) (Ansorge, Morelli, & Gingrich,
2008; Caspi et al., 2010; Dolan & Anderson, 2003; Seo, Patrick, &
Kennealy, 2008; Whitaker-Azmitia, 2001, 2010; Yildirim & Derksen,
2013).
However, rather than reecting a proper impairment in brain
functioning, heightened neuroticism and aggression due to serotonin
deciency could actually reect evolutionary adaptations to a threatening and resource-scarce worldview. For example, Bilderbeck et al.
(2014) found that acute serotonin depletion led to more aggressive,
non-cooperative, and selsh strategies in a depletable resource sharing
experiment. In harsh, resource-scarce, and untrustworthy environments, long-term adaptiveness and homeostatic stability likely comes
by being opportunistic, competitive, and on-guard for potential threat
(threat and reward hypersensitivity), and by ercely protecting acquired resources and one's social reputation (reactive aggression).
One might say that the brain freezes into a trait-like ght-or-ight
modus operandi. Evolution may thus have endowed higher order social
animals, such as primates and humans, with the ability to adapt to the
social environments they are born into through increased plasticity of
serotonergic pathways during the rst years of life. In evolutionary
terms, secondary psychopaths may be well-adjusted but to a profoundly sick childhood environment.
As a side note and in order to prevent terminological confusion, we had
termed primary psychopathy simply as psychopathy and secondary
psychopathy as sociopathy in our review paper on serotonin
(i.e., Yildirim & Derksen, 2013). Although we had our reasons to do so,
primary and secondary psychopathy are established terms and thus
we have later decided to switch back to this terminology so that continuity with the existing literature may be preserved.
5.4. Neuroendocrinological interactions in primary versus secondary
psychopathy
5.4.1. The hypothalamic pituitary gonadal-axis (HPG-axis) and psychopathy
The prevalence and severity of psychopathic traits is higher in men
compared to women (Verona & Vitale, 2006). In addition, life-course persistent antisocial behavior is 10 to 14 times more likely to develop in
males than females (Eme, 2009; Moft, 2003, 2006; Moft, Caspi,
Rutter, & Silva, 2001). In response to these observations, the male gonadal
hormone, testosterone (abbreviated as T), has been repeatedly suggested
to play a role in the etiology of primary psychopathy, secondary psychopathy, and aggressive/antisocial behavior more generally (Archer, 1991,
2006; Book, Starzyk, & Quinsey, 2001; Carr, McCormick, & Hariri, 2011;
Montoya, Terburg, Bos, & van Honk, 2012; Terburg, Morgan, & Van
Honk, 2009; Van Honk & Schutter, 2006; Welker, Lozoya, Campbell,
Neumann, & Carr, 2014; Yildirim & Derksen, 2012a,b, 2013).
Indeed, high fetal T has been found to impact on the maturation and
reactivity of right-hemisphere regulatory modules (OFC) which could
signicantly increase the risk for social insensitivity, dominance, and
antisocial behavior more generally (Lombardo et al., 2012; Raine,
Yang, Narr, & Toga, 2012; Yildirim & Derksen, 2012a,b). Similarly, high
circulating T is reported to boost dopamine-mediated reward sensitivity
as well as amygdala-driven threat reactivity while concomitantly reducing the ability to cognitively appraise or regulate these subcortical processes because of a decoupling in fronto-limbic information ow
(Derntl et al., 2009; Hermans, Ramsey, & Van Honk, 2008; Hermans
et al., 2010; Mehta & Beer, 2009; Schutter & Van Honk, 2004; Van
Honk, Peper, & Schutter, 2005; Van Honk & Schutter, 2006; Van Honk
et al., 2001, 2004; Van Wingen, Mattern, Verkes, Buitelaar, &
Fernndez, 2010; Van Wingen et al., 2009).
These different neurobiological consequences are especially pronounced when high T individuals are additionally exposed to a negative
environment and may partly mediate the relationship between being
male and being antisocial or psychopathic (Raine et al., 2012; Yildirim
& Derksen, 2012b). Maldevelopment of the vmPFC and reduced

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PFC-driven control of strong limbic drives and emotions may increase

the risk for impulsivity and reactive aggression, especially in the context
of an environmentally induced serotonergic deciency (secondary psychopathy), while attenuated limbic modulation of PFC mediated
decision-making processes may contribute to higher levels of utilitarianism and instrumental aggression, especially in the context of an
genetically determined serotonergic hyperstability (primary psychopathy) (Carney & Mason, 2010; Mehta & Beer, 2009; Montoya et al., 2012;
Terburg et al., 2009; Van Honk et al., 2005; Van Wingen et al., 2010;
Yildirim & Derksen, 2012a,b, 2013).
5.4.2. The hypothalamic pituitary adrenal-axis (HPA-axis) and psychopathy
A second endocrinological system that has received much attention as
a possible determinant in the etiology of psychopathy and interacts closely with the HPG-axis, is the HPA-axis. The HPA-axis is involved in a number of biological processes including digestion, energy storage/
consumption, and immune system, but is mainly studied in the context
of psychopathology as the human stress circuitry that controls our physiological and behavioral reaction to stressors. In discussing HPA-axis mediated endocrinological proles we will distinguish between the more
subtle but longer-term basal activity changes in response to salient contingencies or according diurnal patterns and the more intense but
short-term phasic responses to immediate reinforcements (see Fig. 4)
(Schulkin, 2003). Basal HPA-axis activity, measured through diurnal
levels of cortisol (abbreviated as C) activity, increases sensitivity to future
contingencies and sensitizes the appraisal of potential harm, danger, and
social punishment (i.e., predictive allostasis), whereas sudden HPA-axis
responses to unexpected and immediately salient stimuli, measured
through the rise in C levels to such events, serves to mount an ad-hoc mobilizing response to salient confrontations in the here-and-now
(e.g., reactive allostasis or ght/ight/freeze response) (Schulkin, 2003).
First, high BAS scores, impulsivity, aggression, and antisocial behaviors in both psychopathic and non-psychopathic samples have been
most consistently related to lower levels of basal HPA-axis activity, especially in adolescent males (Alink et al., 2008; Cima et al., 2008;
Feilhauer, Cima, Korebrits, & Nicolson, 2013; Haltigan, Roisman,

Susman, Barnett-Walker, & Monahan, 2011; Hawes, Brennan, &

Dadds, 2009; Kariyawasam, Zaw, & Handley, 2002; Kobak, Zajac, &
Levine, 2009; Locke, Davidson, Kalin, & Goldsmith, 2009; Loney, Butler,
Lima, Counts, & Eckel, 2006; McBurnett, Lahey, Rathouz, & Loeber, 2000;
Oosterlaan, Geurts, Knol, & Sergeant, 2005; Pajer, Gardner, Rubin, Perel,
& Neal, 2001; Platje et al., 2013; Poustka et al., 2010; Van Goozen et al.,
1998; Vanyukov et al., 1993; Windle, 1994), although some found
higher levels of basal activity in conduct disordered and psychopathic
adolescents (Van Bokhoven et al., 2005; Welker et al., 2014). Second, reactive aggression, conduct disorder, and antisocial behavior have been
related to increased laboratory induced phasic HPA-axis reactivity
(i.e., social stress task, social conict situation, frustration induction, administration of exogenous C), especially in females (Bhnke, Bertsch,
Kruk, Richter, & Naumann, 2010; Kobak et al., 2009; Lopez-Duran,
Olson, Hajal, Felt, & Vazquez, 2009; McBurnett et al., 2005; Susman
et al., 2010). However, different studies also found lower HPA-axis reactivity in antisocial and aggressive subjects (Buydens-Branchey &
Branchey, 2004; Fairchild et al., 2008; Snoek, Van Goozen, Matthys,
Buitelaar, & van Engeland, 2004). Indeed, a large meta-analytic study reported that externalizing behavior is primarily related to dysregulated
basal C levels and shows no consistent relationship to HPA-axis reactivity (Alink et al., 2008). Third, In contrast to antisocial, aggressive, and
impulsive behaviors convergent with factor 2 and secondary psychopathy more specically, primary psychopathy has been consistently related to attenuated phasic HPA-axis reactivity to experimentally induced
social stress (i.e., public speaking task) or physical stress
(i.e., cannulation), but shows no consistent associations with basal
levels (Cima et al., 2008; Dolan, Anderson, & Deakin, 2001; Feilhauer
et al., 2013; Glenn, 2011b; Glenn, Raine, Schug, Gao, & Granger, 2011;
Loney et al., 2006; O'Leary, Taylor, & Eckel, 2010; Poustka et al., 2010;
Stadler et al., 2011).
In summary, a reduced HPA-axis reactivity to immediate stressors
may particularly contribute to the etiology of primary psychopathy
with more disinhibited and criminal primary psychopaths also showing
a reduction of basal HPA-axis activity. Conversely, a dysregulated HPAaxis activity at baseline (either too low or too high) may specically

Fig. 4. The hypothalamuspituitaryadrenal axis (HPA-axis). Allostasis can be reactive or predictive in nature (Schulkin, 2003). Reactive allostasis refers to the potentiation of physiological
processes (e.g., phasic catecholamine/HPA-axis reactivity) in response to unexpected and immediately salient events such as the ght-or-ight response to imminent threat, arousal
response to unexpected rewards, and the mobilization of energy resources in response to immediate challenges, and serves to mount an ad-hoc mobilizing response to highly salient
events in the here-and-now (Schulkin, 2003). Conversely, predictive allostasis refers to the sensitization of the psychophysiological system (e.g., increase in tonic catecholamine/HPAaxis activity) by inhibiting the autoregulatory tone and sensitizing neural modules involved in attention and emotion in order to prepare the organism when salient events are predicted
(e.g., conditioned cues/contexts) or likely to be expected (e.g., unconditioned but salient contexts such as novelty). Therefore, reactive allostasis is mainly reected by acute increases of C
in response to immediate events, whereas predictive allostasis in mainly reect by the dynamic increases and decreases of basal levels of C.

B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

predispose towards reactive aggression, impulsivity, and secondary

psychopathic development (see also Yildirim and Derksen (2013) for
extended discussion).
5.4.3. The testosterone-to-cortisol ratio in primary versus secondary
psychopathy
However, the HPG- and HPA-axis, which respectively regulate T and
C secretion, contribute interactively to the interindividual variation in
social, emotional, and motivational behavior. For example, a larger variance of dominant, aggressive, antisocial, or psychopathic behavior is
explained when considering interactive rather than main effects (see
Dabbs, Jurkovic, and Frady (1991); Glenn et al. (2011); Mehta and
Josephs (2010); Terburg et al. (2009); Van Honk and Schutter
(2006)). Therefore, studying interactions and interdependent equilibria,
rather than alterations in either system exclusively, will bring forth a
more complete and coherent view of the neuroendocrinological proles
underpinning associated clinical conditions.
The HPG- and HPA-axis have mutually regulatory effects on each
other such that dynamic uctuations in one system directly inuence
the activity of the other (e.g., Bedgood, Boggiano, & Turan, 2014; Viau,
2002). One demonstration of this interdependency is that men with
higher HPA-axis activity show a lower T responsivity to social threat,
whereas those with lower HPA-axis activity show a stronger T
responsivity, which have been associated respectively with social avoidance versus confrontation (Bedgood et al., 2014). Therefore it has been
asserted that the HPA- and HPA-axis directly modulate each other's output in a mutually inhibitory manner (see Van Honk and Schutter
(2006); Viau (2002)). However, when articially hypogonadal males
(i.e., due to Leuprolide administration) were subsequently administered
T compared to placebo, they showed a signicantly dampened C secretion but paradoxically also an increased CRH-stimulated ACTH secretion, indicating that the effect of T on the HPA-axis is likely to be
exerted peripherally instead of centrally (Rubinow et al., 2005). In
fact, since peripherally stimulated C secretion is known to provide feedback autoregulation on HPA-axis activity, this nding may actually suggest that T dampens HPA-axis feedback inhibition and thus prolongs its
activation (e.g., Sharma, Aoun, Wigham, Weist, & Veldhuis, 2014). Accordingly, a number of studies have reported tight coupling between
the HPA- and HPG-axis (e.g., Dismukes, Johnson, Vitacco, Iturri, &
Shirtcliff, in press; Johnson et al., 2014; Welker et al., 2014), such that
C and T levels rose and fell together throughout the day (Johnson
et al., 2014). Thus, in addition to a mutually inhibitory effect, there are
likely also some mutually excitatory effects (see also Sharma et al.
(2014)).
One possibility is that an acute T surge boosts HPA-axis activity and
facilitates active coping, whereas trait-like increases in T that may arise
due to repeated successes, victories, and a higher self-condence, may
eventually dampen HPA-axis activity. Similarly, acute HPA-axis uctuations in response to immediate stressors may boost T levels and facilitate dominant and competitive responding but prolonged HPA-axis
activation, especially when due to inescapable social stressors and especially in males with a lower social status, may ultimately dampen T output and lead to withdrawal and depression.
T and C have differential effects within fronto-limbic regions (Wood,
1996), where they regulate motivational response proles to both
threat and reward (Hermans et al., 2010; Schulkin, 2003; Van Honk
et al., 2004). For example, while T reduces fronto-limbic coupling and
may therefore lead to disinhibited behavior as discussed above, C administration increases fronto-limbic coupling which is related to behavioral inhibition (Van Peer, Roelofs, & Spinhoven, 2008). Accordingly, in a
large study of male US military veterans, behavioral inhibition was positively associated with C, whereas behavioral activation was positively
associated with T (Windle, 1994). In response to these ndings, it
was initially argued that high ratios of T to C levels (TNNNC) might
lead to a fearless, detached, and dominant pursuit of rewards thereby
representing the predatory style of psychopathy.

29

However, since these initial arguments, a number of contrasting

results have been reported that demand a more nuanced explanation.
Beginning with community and non-clinical samples, some studies report that T shows positive association with core psychopathic traits,
state dominance, and reactive aggression, but exclusively when basal
C activity is also increased (low basal T: basal C ratio) (Denson, Mehta,
& Ho Tan, 2013; Geniole, Carr, & McCormick, 2011; Welker et al.,
2014). In contrast, other studies in community samples report that T
is positively correlated to psychopathic traits, but only in the context
of low basal C levels or a reduced C reactivity to a social stressor (high
basal T: C ratio) (Glenn et al., 2011; Tackett, Herzhoff, Harden,
Page-Gould, & Josephs, 2014). It has also been reported in youngsters
that high T contributes to externalizing behavior in the context of low
basal C activity, but only in youth with high levels of disagreeableness
and emotional instability, suggesting that personality variables may
also crucially modulate the relationship between the T:C ratio and behavior (Tackett et al., 2014). Still, in other samples with subjects of similar demographics as community samples, such as army veterans, high T
levels were related to deviant behaviors but these associations were not
modulated by C (Mazur & Booth, 2014).
Similarly, in incarcerated and clinical samples, some studies report
that high T is related to the interpersonal domain of psychopathy and is
characteristic of incarcerated youth but only when basal C activity is additionally increased (Dismukes et al., in press; Johnson et al., 2014), whereas
others report that T is more strongly related to severe conduct disorder,
externalizing behavior, and callousness when C levels are low (Popma
et al., 2007), or when T and C are uncoupled (Johnson et al., 2014).
These recent ndings suggest that antisocial deviancy and a variety
of psychopathic traits are sometimes related to low T:C ratios and
other times to high T:C ratios (both in the context of high T levels). It
might be hypothesized that these divergent ndings relate to the
various emotional pathologies that may contribute to psychopathic behavior. Emotionally disturbed individuals may be characterized by a
high T activity in the context of a more trait-like HPA-axis deregulation
(either too low or too high activation patterns) which may particularly
contribute to callous hostility, impulsivity, reactive forms of aggression,
and secondary forms of psychopathy, whereas emotionally decient individuals may be characterized by high T activity in the context of a
HPA-axis hyporesponsivity to acute stressors, which may particularly
contribute to callous insouciance, risk-taking, instrumental aggression,
and primary psychopathic traits.
In accordance, several studies have reported that a high coupling of
basal T and C activity is related to stressful life events such as childhood
abuse and dangerous/potentially traumatic experiences (Bobadilla,
Asberg, Johnson, & Shirtcliff, in press; Dismukes et al., in press), suggesting
that this pathway may be more characteristic of secondary psychopathy.
In contrast, the intensity of HPA-axis reactivity to acute stressors is determined primarily by genetic factors and less by social experiences (Wst
et al., 2004), suggesting that a low HPA-axis responsivity coupled with
high T may particularly characterize those with a strong genetic foundation for antisocial behavior such as observed in primary psychopathy.
See Table 8 for an overview of the etiological, neural, serotonergic, and
hormonal differentiations between primary and secondary psychopathy.
6. Conclusions and typology; the primary and secondary
psychopathic continuum
6.1. The primary psychopathic continuum
Taken together, the etiology of primary psychopathic traits such as
fearlessness, callous insouciance, moral utilitarianism, and social potency, are strongly rooted in an emotionally decient temperament.
This emotional deciency is largely engendered by a constitutionally
dened hyporesponsivity of the right-hemisphere fronto-amygdalar
complex to socio-affective stimuli or peripheral cues. On the level of
neurophysiology, such a neural information processing prole has been

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B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

Table 8
Overview of the etiological, neural, serotonergic, and hormonal differentiations between
primary and secondary psychopathic subtypes.
Primary psychopathy

Secondary psychopathy

Etiology
Core mechanism

Emotional deciency

Constitutional inuence
Environmental inuence

Strong
Moderate

Emotional dysregulation/
hypoappraisal
Moderate
Strong

Neural
Brain morphology
Amygdalar reactivity

Prefrontal functionality

Normative in controlled types Altered

Altered in disinhibited types
Dampened
Normative in detached
types
High in unstable types
Enhanced in controlled types Impaired
Impaired in disinhibited types

Hormonal
Testosterone
Basal HPA-axis activity

High
Normative in controlled types
Low in disinhibited types
Phasic HPA-axis reactivity Dampened

Neurophysiological
Serotonin

Serotonin hyperstability

High
Dysregulated (hypo- or
hyperactivity)
Dysregulated (hypo- or
hyperreactivity)

Serotonergic deciency

suggested to arise due to a higher testosterone activity/reactivity,

hyperstability of serotonergic functioning (i.e., little uctuations), and a
corresponding attenuation of HPA-axis reactivity to immediate stressors
(i.e., dampened reactive allostasis). Furthermore, this emotional deciency is stable throughout life and common to all primary psychopaths
regardless of adaptive or maladaptive life strategies. Whether adaptive
or maladaptive patterns arise is dependent on other biological, social,
and psychological factors that moderate and shape how this emotional
deciency is crystallized in behavior (controlled or disinhibited), cognition (aggressive/inexible or assertive/exible), and neurobiology
(healthy or disturbed maturation and functioning of the PFC and hippocampus). Therefore, different variants of primary psychopathy may be
crucially differentiated.
Contemporary literature differentiates between non-criminal,
successful, unsuccessful, and criminal subtypes of psychopathy.
However, these terms do not denote psychologically dened personality styles and have not been operationalized in a theoretically coherent
or empirically supported manner. For example, a popular distinction
often made is between successful and unsuccessful or criminal variants
of psychopathy, but the precise denition of successful is highly inconsistent. Some researchers use the term successful psychopathy to
refer to psychopathic personality styles who have successfully evaded
capture for committed crimes, regardless of severity (serial killers are
an extreme sample) (Gao & Raine, 2010; Ishikawa et al., 2001; Raine
et al., 2004; Widom, 1977; Yang et al., 2005). Others use this term for
psychopathic personalities who have achieved successes in legal professional pursuits (Benning, Patrick, Iacono, 2005; Mullins-Sweatt et al.,
2010; Smith & Lilienfeld, 2013; Yildirim & Derksen, 2013). Others still,
use the same term to refer to subclinical manifestations of psychopathy
as can be identied in the general population (Coid et al., 2012; Hall &
Benning, 2006; Sifferd & Hirstein, 2013). Apart from this inconsistency,
however, the terms criminal, non-criminal, successful, and unsuccessful
should not be used as adjectives to a psychiatric condition because they
do not represent psychological concepts, merely inform about specic
and changeable situational parameters (i.e., in prison or not, in a highranking job or not), but above all, are not reective of any particular
endophenotype, symptom, behavioral pattern, or stable personality trait.
We want to propose a new terminology that is dened through
psychological constructs and rmly rooted in empirical research. In response to the above review, we might differentiate between three
types of individuals with primary psychopathic features who reside on

a continuum that spans from controlled/well-adjusted to disinhibited/

maladjusted (see also Fig. 5);
(1) The rst and most well-adjusted group is characterized by the
same emotional deciencies as their pathological counterparts
but have nonetheless become properly socialized. These individuals can hardly be designated psychopaths but do display core
psychopathic features such as boldness (on the TriPM), fearless
dominance (on the PPI), and interpersonal features (on PCL instruments) (e.g., Babiak et al., 2010; Guelker, 2012; Lilienfeld
et al., 2012; Patrick et al., 2009; Smith et al., 2013). However,
due to various protective factors such as an authorative socialization, loving maternal engagement, rewarding social network,
and altruistic and prosocial role-models, they are not mean or
disinhibited (TriPM), not coldhearted or impulsively antisocial
(PPI), and do not display pathological levels of affective, lifestyle,
and antisocial features (PCL instruments). On the contrary,
despite their fearless, narcissistic, and socially insensitive nature,
socialized variants are adapted to society in a healthy and constructive manner (Dutton, 2012; Lilienfeld et al., 2012; Lykken,
1995; Smith et al., 2013). Therefore, we do not believe that this
group should be recognized as disordered, malevolent, or pathological, or even designated psychopathic, but rather praised as a
much needed force in contemporary society, especially in elds
where self-condence and the absence of fear are much needed
assets (e.g., entrepreneurs, military leaders, intelligence agents,
surgeons, lawyers, and even U.S. presidents) (see Dutton
(2012); Lilienfeld et al. (2012); Lykken (1995)). We have not included this group in Fig. 5 because this gure is intended to be a
schematization of exclusively pathological personalities.
(2) The second group is termed controlled primary psychopathy and
consists of individuals who show the same core characteristics
and emotional deciency as the rst group but who, due to less
favorable childhood experiences such as maternal neglect/disengagement and social rejection, have become disafliated from
their social surroundings. These primary psychopaths display
high scores on both the boldness and meanness domains
(TriPM), fearless dominance, Machiavellian egocentricity, and
coldheartedness facets (PPI), and signicant interpersonal and
affective features (PCL instruments). Thus, in addition to their
emotional deciency, this group is additionally characterized
by a malignant narcissistic personality prole as Kernberg described it (i.e., need for control/power, aggression, callousness,
and sometimes sadism) (Kernberg, 1992). Nonetheless, despite
their malignant narcissistic style, controlled primary variants
are not disinhibited (TriPM), impulsively antisocial (PPI), and
do not display high scores on the lifestyle and antisocial features
(PCL instruments).
Compared to their more disinhibited counterparts discussed
below, controlled psychopaths are characterized by a more healthy
maturation and functionality of brain regions involved in executive
functioning, attentional processing, and behavioral stability/exibility (most notably the hippocampus and PFC), enabling them
to pursue long-term goals, sensitively adjust behavioral strategies
in response to feedback, and successfully navigate society. To
achieve what they strive at, controlled psychopaths think and reect in a strategic, mathematical, and rational manner, are cunning
and manipulative, and even though they have strong internal
drives towards coveted rewards and may even have violent tendencies and fantasies, they are able to regulate their behavior
when necessary, construct and work towards long-term goals,
live convincing double-lives, and evade capture for their wrongdoings for prolonged periods (e.g., white collar criminals, frauds,
swindlers, sexual deviants, and even serial killers may belong to
this group) (Blackburn et al., 2008; Cleckley, 1941; Gao & Raine,
2010; Poythress & Hall, 2011).

B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

31

Fig. 5. The different antisocial phenotypes schematized according two axes of emotional reactivity/neuroticism and self-control/cognitive functioning. The color gradient from green to
orange and nally red represents the degree of pathology and maladjustment (green = moderate, red = severe). In our view, but not yet empirically established, the entire grid is
continuous rather than categorical meaning that secondary psychopathy and disinhibited primary psychopathy, or that narcissistic personality and controlled primary psychopathy, reside
on a continuum that spans from low (primary psychopathy) to high emotionality (secondary psychopathy/narcissism), but that disinhibited and controlled primary psychopathy also
reside on a continuum that spans from impaired to intact self-control. (For interpretation of the references to color in this gure legend, the reader is referred to the web version of
this article.)

Furthermore, controlled psychopaths may have a particular

motivation towards control and power and may be disproportionately likely to develop sexual deviancies as a result (e.g., Blackburn
et al., 2008; Schimmenti, Passanisi, & Caretti, 2014). In its most
severe form, controlled psychopathy might even lead to more
predatory, brutal, and perverse acts of violence than seen in
disinhibited variants, with power-hungry pedophiles and serial
killers representing the more extreme manifestations of this subtype. Because controlled psychopaths are astute and have an aptitude for understanding the psychological processes of their
victims, potential witnesses, and professional observers (psychologist, parole boards), they are likely to be more efcient than their
disinhibited counterparts in using relational aggression, persuasion, charm, and manipulation to reach self-serving goals and get
out of trouble.
(3) The third and behaviorally most disturbed variant is termed
disinhibited primary psychopathy. Disinhibited primary psychopaths are characterized by high scores across all domains of psychopathy as dened by the TriPM, PPI, and the PCL instruments.
In addition to their malignant narcissistic personality, disinhibited
primary psychopaths are impulsively irresponsible, impetuously
risk-taking, persistently antisocial, and many are also overtly aggressive (Cleckley, 1941; Hare, 1993, 2003; McCord & McCord,
1964). Because strong emotional reactions can fuel aggressive,
violent, and impulsive crimes and since primary psychopaths
are characteristically unemotional, their criminality and shortsightedness may instead arise from cognitive and motivational
risk endophenotypes such as novelty/stimulation seeking,
reward hypersensitivity, impetuous risk-taking, decient executive functioning, dampened fear-conditioning, and an attentional hyposensitivity for errors, risks, and punishments (Buckholtz
et al., 2010; Gao & Raine, 2010; Gao et al., 2011; Hartzler &
Fromme, 2003; Ishikawa et al., 2001; Snowden & Gray;, 2010;
Swogger et al., 2010).

Disinhibited psychopaths display severe conduct problems in

their youth that continues into their adult age; show contentment with, or insouciance towards, life-situations that would
leave most people severely depressed or anxious; are able to
work but parasitically rely on friends, family, and social aid services for nancial support; make and change plans on a whim
without considering the consequences involved; lack long-term
goals or express highly unrealistic future ambitions; often take
impetuous risks and engage in criminality for the sake of shortlived sensation or reward; have no sense of duty or loyalty to
any sort of principle other than what suits them at the moment;
and some might occasionally engage in overt acts of (primarily
instrumental) aggression, threat, and intimidation. However,
the larger majority does not go on to commit severely violent
acts such as rape or murder, but instead wanders in the periphery of society living a meaningless, parasitic, antisocial, and
short-sighted lifestyle (Cleckley, 1941; Hare, 1993; Lykken,
1995).

In summary, boldness (TriPM), fearless dominance (PPI), and interpersonal features (PCL instruments) potentially represent the core domains on which primary psychopaths show homogeneity (e.g., Babiak
et al., 2010; Lilienfeld et al., 2012; Patrick et al., 2009). Conversely, the
heterogeneity observed in the primary psychopathic population is likely
to manifest on the other domains of these instruments. See Fig. 5 for a
schematization of the different primary psychopathic subtypes.
6.2. The secondary psychopathic continuum
In contrast, individuals who also score exceptionally high on all
psychopathy domains but who do not display the emotional deciency
that is so characteristic of primary psychopathy, may belong more specically to the secondary psychopathy group. Given the literature thus

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B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

far, secondary psychopathic traits such as emotional dysregulation/

hypoappraisal (i.e., emotional disturbance), callous hostility, and reactive aggression might be explained by the interaction between genetic
liabilities, hormonal imbalances, and social experiences that can interactively impair the maturation of affective regulatory and appraisal systems situated in the vmPFC. More specically, the emotional
disturbance that is associated with secondary psychopathy is likely to
result from dysfunctional top-down appraisal and regulation of emotions and control over behavioral urges rather than dampened
bottom-up emotional input as observed in primary psychopathy. On
the level of neurophysiology, secondary psychopathy is likely characterized by high levels of testosterone activity/reactivity, a decient serotonergic regulation of affective and motivational processes, and a
corresponding dysregulation of the HPA-axis (either over- or underactive; impaired predictive allostasis). Furthermore, these emotional disturbances can predispose towards a large range of both internalizing
and externalizing disorders, but could specically lead to secondary
psychopathy in the context of hostile attributional biases and social disafliation due to relational trauma's (abandonment) and/or severe
levels of abuse, neglect, and/or rejection.
Because of their hostile, aggressive, and impulsive nature, secondary
psychopaths particularly display high levels of meanness and disinhibition (TriPM), impulsive antisociality and coldheartedness (PPI), and affective, lifestyle, and antisocial features (PCL instruments). However,
since secondary psychopaths do not possess the fearlessness and social
potency that characterizes primary psychopathy more specically, their
scores on the boldness domain (TriPM), fearless dominance scale (PPI),
and the interpersonal facet (PCL instruments) are likely to be somewhat
lower compared to primary variants (e.g., Cox et al., 2013; Poythress,
Edens, et al., 2010).
In response to the above analysis we might hypothetically
differentiate between two secondary psychopathic subtypes who reside on a continuum that spans from normatively neurotic/affectively
stable to highly neurotic/affectively unstable (see Fig. 5 for
schematization);
(1) The rst group which is phenotypically most similar to primary
psychopathy is termed detached secondary psychopathy characterized by a peculiar dissociation of emotion and cognition (emotional hypoappraisal). An important point of divergence between
primary psychopathy and detached secondary psychopaths
regards their reaction to acute stressorsthat is, primary psychopaths show a properly dampened fear and insouciance towards
the outcomes of their actions afterwards, whereas detached
secondary psychopaths mainly display an inability to appraise
the potential consequences of their behavior beforehand but
usually react strongly to immediate threat and provocation and
may react with strong affect, such as frustration and anhedonia,
after discovering that they have made a bad decision. Furthermore, in spite of their impulsivity and aggression, this group is
not necessarily dysregulated in affect, anxious, or neurotic and
can be seen as a hybrid and severe expression of the ASPD and
NPD categories of the DSM (Kerig et al., 2012; Kernberg, 1998;
Orsillo et al., 2007; Porter, 1996; Poythress et al., 2006; Shore,
2001b).
(2) The second group is termed unstable secondary psychopathy
and includes individuals who are primarily dysregulated in affect
(emotional dysregulation) and, therefore, display high levels of
anxiety, dysphoria, hostility, and rage in addition to callousness,
impulsivity, and aggression. Unstable secondary psychopaths
are fearful of the outside world and discharge intrapsychic
conicts in an aggressive and externalizing manner. In other
words, these individuals are characterized by an underlying
character neurosis that mediates their acting-out and violent
behavior. This subtype can be seen as a hybrid and more severe expression of the BPD and ASPD categories of the DSM

(Blackburn et al., 2008; Davidson et al., 2000; Karpman, 1941;

Putnam & Silk, 2005; Scott et al., 2014; Shore, 2001b; Sprague
et al., 2012; Yildirim & Derksen, 2013).
7. Future directions
There are still a number of questions that need to be answered before we gain a more complete understanding of both primary and secondary psychopathy. We can divide these questions into three main
categories; (1) clarifying sources of homogeneity and heterogeneity between psychopathic subsamples, (2) identifying biological risk and protective factors, and (3) validating the relevance of primary and
secondary psychopathy across ethnicity, culture, and gender.
First, there is a need to dene the boundaries of the psychopathy
construct by clarifying which features and traits are integral to primary
and secondary psychopathy (i.e., emotional deciency vs. emotional
disturbance), which traits are more likely to emerge in individuals
with such a personality pattern (e.g., instrumental vs. reactive antagonism), and which traits show heterogeneity (e.g., self-control vs. affect
instability). Current debates focus mainly on whether adaptive features
such as low neuroticism belong in the operationalization of psychopathy (see Patrick (2006); Skeem et al. (2011)), whether psychopaths
are impulsive, hostile, and aggressive by denition (see Patrick
(2006); Poythress and Hall (2011)), and whether neurotic and fearful
individuals should be eligible for the diagnosis of psychopathy (Skeem
et al., 2011). Indeed, we have already provided answers to these questions in this review. That is, one way of reconciling inconsistent data
on the external correlates of psychopathy is to divide this heterogeneous group into more homogeneous clusters that show divergent etiological pathways and, therefore, also diverge regarding phenotypical
expressions. Within this framework it is understandable that if primary
and secondary psychopaths share the same diagnosis due to similar
PCL-R proles, that external correlates to neuroticism, hostility, and impulsivity would show inconsistency because these are precisely the constructs on which these groups have been found to diverge.
Another source of heated debate is whether antisociality, especially
behavior that is punishable by law (i.e., criminality), is central to primary psychopathy or consequential to core features such as fearlessness
(Hare & Neumann, 2010; Skeem & Cooke, 2010a,b). For example, using
structural equation modeling Cooke and Michie (2001) concluded that
antisocial behavior is best viewed as a likely consequence of psychopathy rather than part of the inherent personality structure. Indeed, as put
forward in this review, the PCL-R indexes a much more maladjusted and
criminal individual than was initially intended by Cleckley (see also
Skeem and Cooke (2010a,b)). Furthermore, since the dominant tool to
assess psychopathy, the PCL-R, includes both emotional detachment
and social deviance, it is expected that included individuals would indeed show criminal behaviors (i.e., tautological error). As proposed in
this review, we should begin focusing more on primary psychopaths
who show high factor 1, PPI-I, and boldness scores, but vary regarding
levels of social deviancy. In so doing we would be better able to index
the entire range of possible primary psychopathic phenotypes rather
than including only those who are persistently criminal or more generally disinhibited. Studies that compare primary psychopathic subgroups
regarding psychological constructs (e.g., disinhibition, executive functioning, impulsivity, risk-taking, conscientiousness) are highly needed.
Second, we need to know which biological mechanisms may account for the variability observed within the primary psychopathic
group more specically. It is particularly important to examine whether
the more adapted primary psychopaths show differences in neurobiology that protects them from developing antisocial and criminal behaviors (see Gao and Raine (2010) for suggestions). Although we have
discussed in detail the biological basis on which primary and secondary
psychopathy might diverge and have also asserted that there might be
important differences in PFC morphology and functionality between
controlled and disinhibited forms of primary psychopathy, there is an
urgency to uncover the monoaminergic mechanisms that might show

B.O. Yildirim, J.J.L. Derksen / Aggression and Violent Behavior 24 (2015) 941

heterogeneity in primary psychopathy more specically. This might

greatly facilitate the development of new pharmacological interventions aimed at reducing violence and antisocial behavior in primary psychopathy. As shortly introduced in Section 5.1, the dopamine circuitry in
primary psychopathy is a currently under-researched area but might be
good starting point. Dopamine and the genes that code for
dopaminergic components have been consistently related to constructs
that diverge in primary psychopaths such as self-control, error/
punishment learning, aggression, impulsivity, executive functionality,
and social cognition (e.g., Dalley & Roiser, 2012; Frank & Fossella,
2011; Heinz & Smolka, 2006; Langley, Heron, O'Donovan, Owen, &
Thapar, 2010; Pine, Shiner, Seymour, & Dolan, 2010; Rujescu, Giegling,
Gietl, Hartmann, & Mller, 2003; Skuse & Gallagher, 2011; Volavka,
Bilder, & Nolan, 2004; Wanat, Willuhn, Clark, & Phillips, 2009).
Antisocial traits in psychopathy are positively correlated with tonic dopamine activity (r 0.75), phasic mesolimbic dopamine reactivity to
cued or potential reward, and a range of dopaminergic risk genotypes
associated with criminality and aggression (Bjork et al., 2012;
Buckholtz et al., 2010; Soderstrom et al., 2001, 2003; Wu & Barnes,
2013). These results indicate that disinhibited primary psychopaths
may display higher levels of mesolimbic dopamine activity and reactivity and a greater number of risk alleles than more controlled variants.
Intriguingly, recent ndings have indeed indicated that the dopamine
regulating medication Clozapine substantially reduced impulsive violence, aggression, and anger in forensic psychiatric inpatients with
high levels of psychopathy (Brown et al., 2014). Moreover, monoamines, such as serotonin and dopamine, exert their effects in a mutually regulating and reciprocally interconnected manner (e.g., Boureau &
Dayan, 2011; Deakin, 2003; Seo et al., 2008; Soderstrom et al., 2001,
2003; Stahl, 2008; Tops, Russo, Boksem, & Tucker, 2009; Weitemier &
Murphy, 2009), indicating that studying interactions and interdependent equilibria, rather than alterations in singular monoaminergic
systems, will bring forth a more complete and coherent view of neurobiological proles that contribute to the heterogeneity in primary
psychopathy.
Third, contemporary explanations on the expression and etiology of
psychopathy are exclusively extrapolated from North American and
Western European males. It is, thus, unclear how these ndings would
generalize to other ethnicities or cultures (Sullivan & Kosson, 2006).
Hare (1991) acknowledges that differences likely exist in the way psychopathy manifests across ethnic and cultural groups and advises
against the use of the PCL-R in non-validated samples (e.g., in Asian,
South American, African countries). A rst and foremost step would
be validating the relevance of psychopathy instruments in those continents since the use of these instruments outside North America and
Europe is limited and, thus, research regarding specic manifestations
is currently very scarce. For example, one study found that Brazilian inmates showed much lower PCL-R scores than North American samples
and rather than the cutoff score of 30, the researchers reported that psychopathy could be reliably identied using a cutoff score of only 23
(Morana, Arboleda-Flrez, & Cmara, 2005).
Another point of importance is to clarify the reason behind the
higher prevalence of psychopathic traits in North American and
European offender samples compared to the rest of the world
(Sullivan & Kosson, 2006). For example, among 499 Inuit Eskimos,
only one was identied as exhibiting personality features coherent
with the Western construct of psychopathy, which is a prevalence of
about 0.2% (Murphy, 1976). Furthermore, the prevalence of antisocial
personality traits in different villages in Taiwan is around 0.3% (Hwu,
Yeh, & Chang, 1989). In contrast, a classication of psychopathy may
apply to about 0.61.2% of Western society (Coid, Yang, Ullrich,
Roberts, & Hare, 2009; Coid et al., 2012), indicating that the anonymity,
lack of social control, social inequality, emphasis on personal control,
competitive atmosphere, and hierarchical structure of increasingly individualized societies might more readily incite psychopathic development at lower levels of genetic risk or that psychopaths are more

33

likely to thrive in such a society (Lykken, 1995; Stout, 2006). Although

the scientic community has primarily emphasized biological and psychological processes as an explanation for psychopathy, it would be interesting to know how cultural norms and values inuence the
development of psychopathic traits in biologically at-risk individuals
(e.g., individualism vs. collectivism) (Stout, 2006). See Sullivan and
Kosson (2006), Skeem, Edens, et al. (2003), and Stout (2006) for
interesting reviews and discussions on the topic of psychopathy and
ethnicity/culture.
Similarly, most of the research on psychopathy has been conducted
in males and it is currently unclear whether these ndings can be generalized to women. Preliminary studies have already indicated that similar to males, primary and secondary psychopathy can also be identied
in females (Hicks, Vaidyanathan, & Patrick, 2010). Female secondary
psychopaths were also characterized by higher levels of negative emotionality and lower levels of behavioral constraint compared to the
primary psychopathic females. Contrastingly, primary psychopathic females showed few distinguishing personality features compared to controls (i.e., female prisoners low on psychopathy), but were prolic
criminals especially regarding nonviolent crimes, and exhibited relatively few mental health problems despite substantial exposure to traumatic events (abstract). Nonetheless, women are suggested to express
psychopathy differently (i.e., histrionic/borderline in women versus
narcissistic/antisocial in men) and psychopathic traits in women also
show a different pattern of external correlations compared to men
(Skeem et al., 2011; Sprague et al., 2012; Verona et al., 2012). For
example, in addition to externalizing dynamics and other-directed aggression, females with psychopathic traits show higher levels of internalizing psychopathology and inward-directed aggression (Blonigen
et al., 2005; Cale & Lilienfeld, 2002; Sadeh et al., 2011; Verona & Vitale,
2006; Verona et al., 2012; Wynn et al., 2012). More research is needed
to clarify if primary and secondary forms of psychopathy manifest
differently in females and whether the factor structure and external
correlations of psychopathy instruments differs across gender (Skeem
et al., 2011).

Contributors
Bari O. Yildirim collected, reviewed, and structurally analyzed the
data, and wrote the rst and revised version of this manuscript. He
constructed the theoretical models regarding sub-categorizations of
primary and secondary psychopathy, the potential fronto-limbic, serotonergic, and testosterone/HPA-axis alterations that may contribute to
these proles, and made the suggestions for improving differential diagnosis, resolving conceptual issues, and validating the psychopathy construct across gender, ethnicity, and culture. Jan J.L. Derksen actively
supported the writing process by carefully reviewing and commenting
on new developments.

Acknowledgments
No grant was received for this work and there are no third funding
parties. Since it is a comprehensive and long paper we would like to sincerely thank the reviewers who took their time to read and provide
commentary.

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