Advanced PCL-R Training

Anna C. Salter
 Anna C. Salter
acsalter@tds.net

R. D. Hare
rhare@interchange.ubc.ca
 New web site for victims
www. aftermath-surviving-
psychopathy.org

Society for the Scientific Study of Psychopathy

SSSP
www.psychopathysociety.org
 “Subtypes” of Psychopathy?

 PCL-R scores of 27 or higher

Threeclear clusters or “subtypes” with high PCL-R

scores

Classic or prototypical: high on all 4 facets

 Neumann, Hare, & Newman, 2007; NA Samples
(male, female offenders, male forensic psychiatric :
N =glib/6929 lack remorse
superficial or guilt
.73 .80
grandiose .73 .65 shallow
self-worth affect
.70
pathological .71 Interpersonal Affective .82 callous
lying lack empathy

conning .66 .59 fail to accept

manipulative .42 .55 responsibility

.50 .51

stimulation poor behavior

seeking .65 controls
.73

impulsivity .71 .70 early behavior

problems
.60 .67
Lifestyle Antisocial
irresponsible juvenile
.73 delinquency
.58 .54

parasitic revocation of
orientation cond. release
.60 .64
lack of criminal
realistic goals versatility

Model fit: x2(91)= 3842, TLI= .93, RMSEA= .07, SRMR= .05
 Prototypical (32%)

0
Facet 1 Facet 2 Facet 3 Facet 4
Macho: low on Interpersonal, high on
others
 Prototypical (32%) Macho (27%)

8
7
6
5
4
3
2
1
0
Facet 1 Facet 2 Facet 3 Facet 4
Manipulative: high on Interpersonal and
Affective, lower on others
 Prototypical (32%) Macho (27%)
Manipulative (25%)

8
7
6
5
4
3
2
1
0
Facet 1 Facet 2 Facet 3 Facet 4
 Variations
Prototypical (32%) Macho (27%)
Manipulative (25%)

8
7
6
5
4
3
2
1
0
Facet 1 Facet 2 Facet 3 Facet 4
 Variations
Prototypical (32%) Macho (27%)
Manipulative (25%) Pseudo (16%)

8
7
6
5
4
3
2
1
0
Facet 1 Facet 2 Facet 3 Facet 4
 Asperger’s Syndrome

 Murphy, 2007
 13 Asperger’s patients at Broadmoor
 PCL-R scores
 Mean = 15; varied from 11-22
 Variations
Prototypical Macho
Manipulative Pseudo
Asperger's

8
7
6
5
4
3
2
1
0
Facet 1 Facet 2 Facet 3 Facet 4
 Bjørkly, 2009
Table 2
Possible differences between characteristics of violence in Asperger’s
syndrome and psychopathy.
Asperger’s
Characteristic Psychopathy
Syndrome
Sensory reactivity Hypo Hyper
Interpersonal
Manipulative Naïve
communication
Typical violence Proactive Reactive

Reinforcement contingency Positive Negative

Relating to violence Denial Confession

“Findings from these comparisons indicated that there may be substantial
differences between the two diagnostic disorders regarding these five
criteria.”
Reasons for Cross-Cultural
Differences in Psychopathy
Rates?
Wernke & Huss, 2008
 Wernke & Huss, 2008
 Note international differences in
 Crime rates

 Incarceration rates

 Similar crime rates in NA, UK, and Europe

 But much higher incarceration rates in NA
 Argue that psychopaths commit crimes that lead to:
 Incarcerationin NA
 Probation, psychiatric facility, etc. in UK & Europe
 Psychopaths over-represented in NA, under-represented in UK
& Europe prisons
 Incarceration Rates (% of
Convicted Offenders)
USA UK
 Murderers 96 94
 Rapists 82 95
 Robbery 79 67
 Assault 62 27
 Burglars 60 38
 Motor vehicle 55 30
Schizophrenia, Psychopathy, Substance
Use, & Crime
 Schizophrenia, Psychopathy, Substance
Use, & Crime

 Tengström, Hodgins,Grann, Långström, & Kullgren

(2004)
 Criminal history of patients with various
combinations of schizophrenia, substance use, and
psychopathy
 Swedish male patients who received pretrial
assessments between 1988 and 1993, and were
found guilty of violent offences
 202 schizophrenics, & 78 offenders who met PCL-
R criteria for psychopathy
 Lifetime convictions since age 15, per year at risk
(free)
 Number of Convictions Per Year at Risk

6
5
4
3
2
1
0
S S + SUD S+P S + P + P + SUD P
SUD
S = schizophrenia SUD = substance use disorder
P = psychopathy
 Schizophrenia, Psychopathy, Substance
Use, & Crime
 Among patients with schizophrenia, correlation
between PCL-R and number of convictions per year
at risk:
 General = .62
 Violent = .38
 “High ratings of psychopathy are associated with
earlier ages of first conviction for a criminal offense
and more convictions among the men with
schizophrenia, just as among men with no mental
illness” (p. 385).
 “These findings suggest that among
offenders with psychopathic traits, the
traits, not substance abuse, are
associated with criminal offending” (p.
367).
 What About Comorbidty

 Patients with schizophrenia and many

psychopathic features are at high risk for
violence

 Tengström et al., 2000

 Thomson et al., 2008

 PCL-R as a Predictor of Violent
Recidivism in Schizophrenic Offenders

1
PCL-R 0-25
0.8

0.6
% Surviving

0.4

0.2

0
0 12 24 36 48 60 72

Months
Tengström et al., 2000
 PCL-R as a Predictor of Violent
Recidivism in Schizophrenic Offenders

1
PCL-R 0-25
0.8

0.6
% Surviving

0.4 PCL-R 26-40

0.2

0
0 12 24 36 48 60 72

Months
Tengström et al., 2000
 PCL-R as a Predictor of Violent
Recidivism in Schizophrenic Offenders

1
PCL-R 0-25
0.8

0.6
% Surviving

0.4

0.2 PCL-R 26-40

0
0 12 24 36 48 60 72

Months
Tengström et al., 2000
 Dolan & Fullam, in press
 24 male patients with schizophrenia (DSM-IV)
– Secure psychiatric facility in England

– All convicted for violent offences

• PCL: SV scores
– Mean = 12.9

– Median split: High, Low psychopathy

 fMRI while pictures viewed

– Neutral, anger, disgust, sad, fear

– Differences between neutral and emotional

–
 Dolan & Fullam, in press
 “Psychopathic traits in patients with schizophrenia
are associated with dysfunction in the prefrontal-
limbic circuitry over and above that normally
associated with schizophrenia alone.”
Psychopathic Aggression
Nature of Aggression/Violence

Primarily Reactive

• crime of passion
• extreme provocation
• self-defense
• response to threat
• often relatively uncontrolled
Nature of Aggression/Violence

Primarily instrumental

 cold-blooded
 premeditated
 settle a score
 goal-directed
 controlled
 predatory
 Psychopaths capable of both reactive and
instrumental aggression/violence

 But even the reactive aggression/violence is

more controlled than in others

 Woodworth & Porter, 2002; Porter et al., 2003)

 Primary Nature of Canadian Homicides
as a Function of PCL-R Scores
PRIMARILY
REACTIVE
100
PRIMARILY
90 INSTRUMENTAL

80
71.8
70

60

50

40
28.2
30

20

10

0
LOW PCL-R MEDIUM PCL-R HIGH PCL-R
 Primary Nature of Canadian Homicides
as a Function of PCL-R Scores
PRIMARILY
REACTIVE
100
PRIMARILY
90 INSTRUMENTAL

80
71.8
70 67.4

60

50

40
32.6
28.2
30

20

10

0
LOW PCL-R MEDIUM PCL-R HIGH PCL-R
 Primary Nature of Canadian Homicides
as a Function of PCL-R Scores
PRIMARILY
REACTIVE
100
93.3 PRIMARILY
90 INSTRUMENTAL

80
71.8
70 67.4

60

50

40
32.6
28.2
30

20

10 6.7

0
LOW PCL-R MEDIUM PCL-R HIGH PCL-R
Aging
Aging and Psychopaths
 Psychopathy and Age

14

12 N = 800+
Harpur & Hare
Mean Factor Score

10
1994
8

6
PCL-R
4
Factor 1
2 Factor 2
0
16- 21- 26- 31- 36- 41- 46- 51- 56-
20 25 30 35 40 45 50 55 70
Age Period
Reduction in Criminality with
Age
 1/2 Reduce Criminal Activity
About 35 to 40

 Non-Violent Offenses Only

(Hare, McPherson & Forth, 1988; Harris,

Rice & Cormier, 1991)
 Effect of Aging

Male Offenders & Forensic Psychiatric

Patients
File Info File Info
+ Interview Alone
Total Decrease .5 Decrease 4
Factor 1 Increase .5 Decrease .5
Factor 2 Decrease 1 Decrease 4
(Hare, 2003)
Reduction in Criminality with
Age
 1/2 Reduce Criminal Activity
About 35 to 40

Not for Violent Crime

(Hare, McPherson & Forth, 1988; Harris,

Rice & Cormier, 1991)
 Effect of Aging

Ages 46 - 50

% %
Convicted Violent
 Psychopaths 42.9% 30%

 Nonpsychopaths 40.4% 8.8%

(Hare et. Al, 1992)
 Psychopathy & Aging

Almost ½ of psychopaths convicted of

crimes after 40

Percentage of violent crimes increased

(Hare et al., 1992)

“It appears that the psychopath’s propensity
for violence and aggression may be
relatively persistent across much of the life
span.” (Hare, 1992, p.295)
Performance on Conditional Release as a
Function of PCL-R and Age at Release

 Porter et al., 2001

 PCL-R 30+ N = 93

 PCL-R <30 N = 224

 Days Free on Conditional Release
as a Function of PCL-R & Age
3000
Mean # Successful Days

Non-psychopaths
2500 Psychopaths

2000 N = 224
1500

1000

500 N = 93
0
18-24 25-29 30-34 35-39 40-44 45-49
Age
Porter et al., 2001
 Older Psychopaths & Time in
Community
Age < 30 >30

40 – 44 1000 days 200 days

45 – 49 2500 days 100 days

(Porter et al., 2001)
“We found no evidence that older offenders
scoring high on the PCL-R were more
successful than their younger
counterparts.” (Porter et al., 2001)
“Clearly, older psychopaths had far less
opportunity to offender . . . This suggests
that the age-related decline in criminal
charges and convictions for psychopaths
was, in part, an artifact, and that the
criminal (and violent) propensities of the
aging psychopaths may have been greatly
underestimated.”
(Hare, 2003, p. 62)
Performance of Sex Offenders
Following Release

Porter, Ten Brinke, & Wilson, in

press
 Porter et al., in press
 310 Male offenders: PCL-R
 non-sexual

 sexual: child molesters, rapists, mixed

 PCL-R predicted nonviolent and violent

offenses, but not sexual offenses
 Porter et al., in press
 But among child molesters, high PCL-R scores
predictive of sex offenses

 Overall, psychopaths (PCL-R of 30 or more) 2 ½

times more likely to receive parole than other
offenders

 They also manage to remain out of prison following

release for about half as long as other offenders
 Adjusting Violence Risk
Assessments for Age or Passage of
Time
Harris & Rice, 2007
 Harris & Rice

 3 studies to determine if age at release is

a factor in risk for violence

 Over 1300 violent offenders

 VRAG, PCL-R, RRASOR, Static 99

 Age at release: 10% over 50, 3% over 60

 Harris & Rice
 “Without doubt, age at release and the amount
an offender has aged must be better indexes of
the dynamic effects of aging than age at index
offense.”

 But not so.

 Age at 1st offence consistently better predictor
of violence than age at release
 Harris & Rice

 We suggest that these results imply the

dynamic effects of aging are quite small (and
perhaps negligible) in comparison to the static
effects of enduring antisocial proclivity
 Harris & Rice

 This proclivity is well-measured by the PCL-R

 PCL-R strongly correlated with age at 1st
offence

 PCL-R was as predictive of violence at age 50+

as at younger ages
 Behavioral Genetics
 Blonigen, Carlson, Krueger, & Patrick,
Personality and Individual Differences, 2003, 35-
179-197

 “Substantial evidence of genetic

contributions to variance in the
personality construct of psychopathy.”
 Blonigen, Hicks, Krueger, Patrick, & Iacono,
Psychological Medicine, 2005, 35, 1-12.
 “The interpersonal-affective (Fearless
Dominance) and antisocial (Impulsive
Antisociality) traits of psychopathy, …are
equally and substantially heritable with each
accounting for roughly half of the total
variance in both men and women.”
 Larrson, Andershed, & Lichstenstien, Journal
of Abnormal Psychology, 2006, 115, 221-230.

 “A genetic factor explains most of the

variation in the psychopathic personality”
 Behavioral Genetics

 Viding, Blair, Moffitt, & Plomin (2005).

 UK Twin study of 3687 7-year old twin pairs
 Rated by teachers and parents on items
similar to those on the APSD (Frick & Hare,
2001)
 Assessed heritability:
 of antisocial behaviors; callous-emotional
traits
 Concluded that genes account for 70% of
the individual differences in callous-
unemotional traits
 “The core symptoms of psychopathy are
strongly genetically determined”

 Genetic contribution was highest when

callous-unemotional traits were combined
with antisocial behaviors
 Origins

 Behavioral genetics
 Large-sample twin studies

 Evaluate heritability of traits that may be

precursors to adolescent and adult psychopathy

 Referred to as Callous-unemotional (CU) traits

 General Findings

 Consistent evidence of substantial heritability of

CU traits

 Common genetic factor may underlie CU traits

and antisocial behaviors
 The Lexical Decision Task

Williamson, Harpur, & Hare, 1991

• Words have both denotative (explicit, literal) and connotative

(implicit, implied) meanings

• The impact of the affective connotations of words can be

evaluated by recording:

−
Lexical decision times
−
Brain activity associated with the decisions
−
Event-related potentials (ERPs)
 The Lexical Decision Task

Neutral & emotional words, and pronounceable

nonwords, briefly presented in random order on a
computer screen. e.g.,

RAPE

EPRA

TREE

ETER

“Press button as quickly as possible if you saw a

word”
 Reaction Time and Word Type

msec
950
Nonpsychopaths Psychopaths
900

850

800

750

700
Neutral Positive Negative
Emotionality of Words
Williamson, Harpur, & Hare, 1991
 Matching Emotional Tone
 A man thrown overboard from a sinking ship

1. A man running from a monster

2. A man surfing on a large wave

3. A woman standing on a yacht

4. A boy carrying a lamp into his room

(Hare, Williamson, et al., 1988; Williamson et al., 1991)

 Matching Emotional Tone:
Nonpsychopaths

 A man thrown overboard from a sinking ship

 A man running from a monster

 Matching Emotional Tone:
Psychopaths
 A man thrown overboard from a sinking
ship

 A man surfing on a large wave

 Rating Metaphors
6 Point Rating Scale
-3 Very Negative
+3 Very Positive

“Man is a worm that lives on the corpse of the

earth”

“Love is an antidote for the world’s ills”

(Herve, Hayes, & Hare, in press)

 Attributing Emotions
Stories Design to Elicit Emotions

Happiness
Sadness
Embarrassment
Guilt

(Blair et al., 1995)

 Attributing Emotions
No Differences Between Psychopaths &
NonPsychopaths

Happiness
Sadness
Embarrassed
 Attributing Emotions
Differences in Psychopaths & Nonpsychopaths
Guilt Stories

Psychopaths
Little guilt to others

Indifference or positive emotions, especially intentional

harm

Happiness for intentional harm

 Response to Acts of Violence
Nonpsychopaths Felt

Anxiety

Guilt

Fear

(Walsh, 1999)
 Response to Acts of Violence
Psychopaths Felt

Excitement
Power
Satisfaction
Justification
Increased Self-Esteem

(Walsh, 1999)
 Institutional Violence
N = 728 Males

PCL-R Score No. with Infractions

>30 44%

<30 16%
(Hare et al., 2000)
 Institutional Violence

Mean PCL-R score:

• At least 1 infraction 19.2

• No infractions 14.6

• At least 1 violent infraction 21.0

• No violent infractions 13.6

(Hare et al., 2000)
Functional Differences
 Some illustrations of
applications of
cognitive/affective neuroscience
to the study of psychopathy
 Pinel, 2000

The major structures of the limbic system: amygdala, hippocampus,

cingulate cortex, fornix, septum, mammillary body
Pinel, 2000
 Brain Imaging in Psychopathy
SPECT
single photon emission computed tomography
(Intrator et al., 1997)

Substance abusers
Lexical decision task
Assessed with PCL-R
Neutral & emotional words
Regional cerebral blood flow (rCBF)
Mid-ventricular slice: 50 mm above OM line
Nonpsychopath Neutral
Words
Nonpsychopath Emotional
Words
Psychopath Neutral
Words
 Emotional
Psychopath Words

Note
 Intrator et al., 1997
• Psychopaths showed less anterior and more
posterior activation during processing of neutral and
emotional words

• Activation in psychopaths less widespread than in

others

• Suggests superficial, localized processing, and little

interaction among brain regions

• While processing emotional words psychopaths

showed increased activity in areas related to
linguistic processes
 Functional Magnetic Resonance Imaging
(fMRI)
• Blood Oxygen Level Dependent (BOLD) effect
(Forster et al. 1998)

• Measures changes in blood flow during cognitive,

emotional, behavioral tasks

• Research done at UBC

• Bruce Foster, Peter Liddle, Kent Kiehl, Andra
Smith, Kristin Laurens, Robert Hare
 fMRI Study of Emotional Words

Kiehl, Smith, Hare, Mendrek, Forster,

Brink, & Liddle, 2001
 fMRI Study of Emotional Words

Offenders brought from prison to university

Psychopaths and nonpsychopathic controls

Task
involved memory for neutral and emotional
words

Images show areas where differences occurred

Areas of Reduced Activation
 Areas of Increased Activation

Anterior superior temporal gyrus

 Müller et al., 2008

 Used structural MRI, event-related fMRI at same time

 Psychopaths showed:
 volume reductions in right superior temporal gyrus (STG)
 reduced event-related fMRI in STG

 Suggests disruption of frontotemporal integration in

high PCL-R
 Poor cognitive-emotion integration
 Connections
 Differences only in RH
 Consistent with role of RH in executive
function & impulse control, and in affective
processes

 “Taken together, our findings suggest that abnormal

‘connectivity’ in the amygdala–OFC limbic network
may contribute to the neurobiological mechanisms
underpinning the impulsive, antisocial behaviour and
emotional detachment associated with psychopathy.”
 Predicted by Kiehl, 2006; Kiehl et al., 2004
Newspaper Report, August 8, 2009
Neural Correlates of Moral Decision-
Making in Psychopathy

Glenn, Raine, & Schug, 2009

 Glenn et al., 2009
 Reduced functioning in medial prefrontal cortex,
posterior cingulate, and angular gyrus in individuals
high on the interpersonal factor of psychopathy may
indicate dysfunction of complex social processes
important for interpersonal interactions central to
behaving morally.

 These regions have been found to be involved in

self-referential thinking, emotional perspective taking,
recalling emotional experiences to guide behavior,
and integrating emotion into social cognition.
 Glenn et al., 2009
 Dysfunction in these regions suggests failure to
consider how one’s actions affect others, failure to
consider the emotional perspective of the harmed
other, or a failure to integrate emotion into
decision-making processes.
 Deeley et al., 2006
 fMRI to emotional faces
 No group differences to happy faces. “In
contrast, when processing fearful faces
compared with neutral faces, the control
group showed increased activation but the
psychopathy group decreased activation in
the fusiform gyrus.”
 Fusiform gyrus: an extrastriate visual cortical region
located in the inferior temporal lobe involved in
processing/identifying faces
Psychopathy and affective theory of
mind

Shamay-Tsoory, Harari, Aharon-Peretz,

& Levkovitz, in press
 Theory of Mind

 Psychopathy: impaired recognition of affective

state of others
 Theory of Mind
 Israeli criminals diagnosed with ASPD
 SRP-II scale

 ToM tasks : Inferences about others:

 Cognitive
 Affective

 Compared with:
 Noncriminal controls
 Various patient groups
 Theory of Mind
 Theory of Mind (ToM):
 The capacity to make inferences
regarding others’ mental states: their
knowledge, needs, intentions and beliefs

 Hypothesis:
 Psychopathy related to impairment only in
emotional aspects of ToM (affective ToM)
 associated with orbitofrontal (OFC)
dysfunction.
Structural Differences
 Psychopathy as a disorder of the moral
brain: Fronto-temporo-limbic grey matter
reductions demonstrated by voxel-based
morphometry

de Oliveira-Souza, Hare, Bramati, Garrido,

Ignácio, Tovar-Moll, & Moll, 2008
 Rio Structural Imaging Study

 Civil psychiatric patients in Rio de Janeiro

 No criminal records but high PCL: SV scores
 Control group

 Grey matter reductions in patients with high PCL: SV

scores
 Frontopolar cortex
 Orbitofrontal cortex
 Anterior temporal cortex
 Superior temporal sulcus region
 Insula
 Conclusions

 The pattern of grey matter reductions in

patients with high psychopathy scores
comprises a distributed fronto-temporal
network that plays a critical role in moral
sensibility and behavior
“Abnormal temporal and prefrontal cortical
gray matter thinning in
psychopaths”

Yang, Raine, Colletti, Toga, & Narr, 2009

 Cortical Thinning
 Participants “recruited from the community”
 27 psychopaths
 32 nonpsychopaths
 PCL-R; scores not provided for either group

 “Psychopaths showed significant cortical gray matter

thinning in the right frontal and temporal cortices”

 Thinning significantly correlated with Affective factor, but

not other PCL-R factors
 Cortical Thinning
 “Confirm(s) the contribution of structural
impairments in psychopathy, and further indicates
that localized cortical thinning, especially in the right
medial temporal cortex, and to a lesser degree, in the
right dorsolateral and ventromedial prefrontal cortices
may be linked to the emotional deficits in
psychopaths.”