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A N T I S O C I A L P E R S O N A L I T Y D I S O R D E R A N D

P S Y C H O P AT H Y I N A D U LT S

Sarah J. Brislin & Christopher J. Patrick Florida State University

Address Correspondence to:

Christopher J. Patrick, Department of Psychology, Florida State University, 1107 West Call Street, Tallahassee, FL 32306. Email: cpatrick@psy.fsu.ed

Abstract

Antisocial Personality Disorder (ASPD) and psychopathy are of interest to research-ers, forensic psychologists, and public policy makers due to the high cost these disorders exact on society and its citizenry. This article reviews historical concep-tions of psychopathy and ASPD, as well as empirical findings that have led to new developments in clinical conceptualizations. Commonly used methods of assess-ment, including both self-report and interview-based measures, and correlates are discussed. Lastly, current approaches to treatment are briefly outlined in relation to empirical findings.

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Introduction

Individuals diagnosed with psychopathy and antisocial personality disorder (ASPD) partic-ularly interest researchers and practitioners due to the harm they cause to individual citizens and society as a whole. These two diagnoses overlap in some aspects, but have critical differences. Psychopathy is marked by impulsive antisocial behavior in conjunction with distinct interperson-al and affective symptoms, including superficiinterperson-al charm, grandiosity, deceitfulness, and emotional insensitivity. In contrast, ASPD is characterized by persistent antisocial and impulsive behavior with limited reference to interpersonal-affective symp-toms (DSM 5; American Psychiatric Association [APA], 2013). It is the purpose of this article to review historical background on ASPD and psy-chopathy, describe modern conceptions of these disorders and common methods of assessment, and discuss perspectives on treatment.

Historical Conceptions: Psychopathy

Early conceptions of psychopathy focused on salient impulsive-aggressive behavior in individ-uals who did not appear to have any other mental disorder. Phillipe Pinel (1801) used the term manie sans delire (“insanity without delirium”) to de-scribe these individuals. German psychiatrist J.L. Koch was the first to use the term “psychopathic” (1891), in reference to psychological conditions presumed to have a biological basis. Subsequent-ly, Emil Kraepelin used the term “psychopathic personalities” (1915) to define a narrower range of conditions that more closely resemble current conceptions of ASPD and psychopathy. Variants of the disorder identified by Kraepelin included antisocial, quarrelsome, and degenerative person-alities.

A key development came with the pub-lication of Hervey Cleckley’s seminal text “The Mask of Sanity” (1941), which further refined the diagnosis of psychopathic personality. Based on

his observations of inpatients in a large psychiatric hospital, Cleckley conceptualized psychopathy as a severe form of emotional pathology concealed by a façade of good mental health. He proposed sixteen specific diagnostic criteria for the disor-der, including indicators of psychological stability (social poise and persuasiveness, lack of anxiety, absence of thought disturbance or hallucinations/ delusions), shallow affect and superficial relation-ships with others, and impulsive behavioral devi-ance. Others concerned with psychopathy in adju-dicated offenders (e.g., McCord & McCord, 1964) placed greater emphasis on a callous-predatory interpersonal style, absence of remorse (“guiltless-ness”), and inability to form genuine attachments (“lovelessness”). These conflicting perspectives are seen in the alternative conceptions of psy-chopathy that exist in the literature today. Antisocial Personality Disorder

ASPD appeared in the first edition of the DSM (1952) as one condition within the broader category of Sociopathic Personality Disturbance, encompassing differing patterns of deviant ad-justment, including addictive, sexually deviant, and antisocial patterns. The second edition of the DSM (1968) contained the category Personality Disorders and Other Non-Psychotic Mental Dis-orders, which included an “antisocial personality” type similarly defined to Cleckley’s conception of psychopathy.

The third edition of the DSM (1980) promi-nently shifted toward diagnoses based on specific behaviorally oriented criteria, rather than the nar-rative prototype approach in DSM-I and DSM-II. This change improved the reliability of diagnostic classifications for many disorders, including ASPD. The criteria for ASPD emphasized behavioral expressions of impulsive-irresponsible and ag-gressive-antisocial tendencies, and omitted fea-tures pertaining to superficial charm, grandiosity, shallow affectivity, and callousness. In an attempt

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to capture the diagnostic construct of psychop-athy, a criterion pertaining to lack of remorse was added in the revised third edition (DSM-III-R; 1987); however, the criteria for diagnosis were criticized as it failed to capture the interpersonal and affective features of psychopathy.. The criteria for ASPD changed little from DSM-III-R to DSM-IV (1994), with a proposal to increase coverage of interpersonal-affective features considered but not adopted. As such, researchers and clinicians cur-rently conceptualize ASPD as a related diagnosis, as opposed to indexing psychopathy directly. Current Conceptions and Assessment Methods: Antisocial Personality Disorder

The criteria for ASPD in the main Diag-nostic Criteria and Codes section of the recently released DSM-5 (Section II) are identical to those specified in DSM-IV—requiring the presence of 3 out of 7 designated symptoms after age 15, and evidence of conduct disorder (taken to mean either 2 or 3 of 15 designated symptoms) before age 15. The adult (after age 15) criteria for ASPD are: irritability/aggressiveness, deceitfulness, impulsivity, irresponsibility, failure to conform to norms for lawful behavior, reckless disregard for safety of self or others, and lack of remorse. A recent study of adult twins (Kendler, Aggen, & Patrick, 2012) reported that two distinct factors emerged from a phenotypic factor analysis, a statistical method used to understand covaria-tion among a number of indicators, of the adult symptoms of ASPD: a disinhibition factor (reflect-ing tendencies toward impulsivity, irresponsibility, and deceitfulness); and an aggressive-disregard factor (reflecting irritability/aggressiveness and lack of concern for safety of self/others). Analyses of causal influences contributing to these adult symptoms, made possible by the twin compo-sition of the sample, revealed two genetic fac-tors that closely resembled the disinhibition and aggressive-disregard phenotypic factors. These

findings indicate that ASPD reflects two distinct sources of genetic risk as opposed to a single, unitary risk factor. This parallels results from factor analytic studies of the child (i.e., conduct disorder) symptoms of ASPD, which have revealed sepa-rable aggressive and non-aggressive (‘rule-break-ing’) symptom subsets with differing etiologies (Burt, 2009; Tackett, Krueger, Iacono, & McGue, 2005).

In addition to preserving DSM-IV defini-tions of ASPD and other personality disorders in Section II, the manual for DSM-5 contains a new dimensional trait system for characterizing condi-tions of these types in Section III, entitled Emerg-ing Measures and Models. This system charac-terizes ASPD in terms of seven distinct traits from two dispositional domains: antagonism and disin-hibition. Elevations on 6 of the 7 designated traits are required for the trait-based diagnosis of ASPD. Since four of these traits are from the domain of antagonism, this ensures that individuals achieving the diagnosis will exhibit a balance of callous-ag-gressive and impulsive-antisocial tendencies—re-flecting historic conceptions of criminal psychop-athy (cf. Patrick, Fowles, & Krueger, 2009), and acknowledging above-noted work demonstrating distinct etiologies for aggressive as compared to non-aggressive symptoms. This balanced ap-proach represents a shift from the DSM-IV crite-rion-based diagnosis carried over to Section II, which places greater emphasis on impulsive-dis-inhibitory tendencies (Kendler et al., 2012). It also dovetails with revisions to the diagnosis of child conduct disorder in DSM-5, entailing specification of a distinct subtype marked by “limited pro-social emotions” (i.e., callous-aggressive or antagonistic tendencies).

ASPD as defined in DSM-IV and Section II of DSM-5 has an estimated prevalence of 2% in the general community, with the rate of oc-currence higher for men (3%) than women (1%; APA, 2000). Alternative hypotheses have been advanced to account for this gender difference,

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including socialization pressures associated with sex role stereotypes and biologically-based dis-positional differences between men and women (Verona & Vitale, 2006). Rates of ASPD do not appear to differ as a function of race or ethnicity (APA, 2000). In clinical settings such as correc-tional institutions or forensic units of inpatient psychiatric hosptials, the prevalence of ASPD is generally much higher, with rates as high as 50-80% reported in correctional and forensic settings (Hare, 2003).

Psychopathy

While ASPD as defined in Section II of DSM-5 provides only limited coverage of the interpersonal and affective symptoms emphasized in historic accounts of psychopathy, a separate body of work exists on this condition as defined by antisocial deviance in conjunction with inter-personal-affective features. This conception of psychopathy as a distinct variant of ASPD does not readily accommodate cases of “successful psychopathy” (i.e., in which blithe indifference and callous-exploitative tendencies are expressed in non-criminal ways; Cleckley, 1976; Hall & Ben-ning, 2006), but has proven important clinically. Adult criminal offenders diagnosed as psycho-pathic are more prone to violence, more likely to re-offend after release, and more resistant to conventional treatments (Douglas et al., 2006; Hare, 2003). Extensive research also documents the importance of psychopathic traits in youth, resulting in the inclusion of the “limited pro-social emotions” specifier for conduct disorder in DSM-5, as noted above. In particular, research consis-tently demonstrates that children and adolescents displaying callous-unemotional tendencies along with impulsive conduct problems show a more se-vere trajectory in terms of persistence and severity for aggressive-antisocial behavior (Frick & Marsee, 2006; Frick & White, 2008).

Contemporary approaches to the assess-ment of psychopathy include clinical rating scales designed for use with adult offenders and delin-quent youth that emphasize antisocial expressions of core psychopathic tendencies, and self-report inventories developed for broader use that fo-cus more on dispositions and less on antisocial acts. A three-component (Triarchic) model has been advanced to clarify similarities and differ-ences among alternative psychopathy inventories in terms what they measure (Patrick, Fowles, & Krueger, 2009).

Psychopathy Checklist-Revised (PCL-R)

The measure of psychopathy that has been used most widely in research studies and clinical settings is the Psychopathy Checklist-Revised (PCL-R; Hare, 2003). Designed to index psychop-athy as described by Cleckley (i.e. well-concealed behavioral pathology) in incarcerated offender samples, the PCL-R includes 20 items rated on a 0-2 scale (absent, equivocal, or present) using information derived from both a face-to-face inter-view and a reinter-view of institutional records.

The summation of item scores yields a total psy-chopathy score. While many published studies have examined PCL-R defined psychopathy in terms of high versus low scoring groups (i.e., with participants assigned PCL-R scores of 30 or high-er on classified as psychopathic, and those scor-ing 20 or lower classified as non-psychopathic), the PCL-R is widely used as a continuous score measure as well (Hare, 2003; Skeem et al., 2011).

Items selected for inclusion in the PCL-R were based on their ability to differentiate between offenders characterized as high or low, in resem-blance to Cleckley’s description of psychopathic inpatients on a 7-point global rating scale. While the items of the PCL-R provide effective cov-erage of the impulsive behavioral deviance and affective-interpersonal dysfunction, the positive adjustment features included among Cleckley’s

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criteria (e.g., social efficacy, absence of psychot-ic symptoms, low anxious/neurotpsychot-icism) are not directly represented. Scores on the PCL-R as a whole show positive associations with measures of impulsivity, aggressiveness, sensation seeking, Machiavellianism, and persistence of offending, and negative relations with measures of empathy and affiliation (Hare, 2003; Skeem, Manchak, & Peterson, 2011). PCL-R total scores also correlate strongly with overall symptoms of DSM-defined ASPD (i.e., mean r across 10 offender studies = .67, according to Hare [2003]). This pattern of correlations indicates that psychopathy as defined by PCL-R total scores captures the predatory-ag-gressive conception advanced by criminality ex-perts (e.g., McCord and McCord, 1964) more so than the contrasting perspective of a feckless n’er-do-well conception put forth by Cleckley (1941).

Although developed to index psychop-athy as a unitary diagnostic entity (syndrome), the PCL-R contains subsets of items that define correlated (~.50) but distinctive factors: an anti-social deviancy (AD) factor, encompassing rest-less, impulsive, irresponsible, and law breaking features, and an affective-interpersonal (AI) factor, encompassing features of charm, grandiosity, lack of guilt or empathy, and shallow affect. Some work indicates that these two factors can be further separated into narrower facets (Hare, 2003). The AI factor is associated with maladaptive tenden-cies including narcissism, low empathy, and use of instrumental aggression (Hare, 2003). Addition-ally, when controlling for overlap with scores on the AD factor, the AI factor is also associated with adaptive tendencies of some types including low levels of fear, distress, and depression as well as social assertiveness (Hicks & Patrick, 2006). By contrast, the AD factor is mainly associated with maladaptive tendencies such as lack of affective and behavioral restraint, sensation seeking, ag-gressiveness, early and recurring antisocial behav-ior, and substance use problems.

Variants of the PCL-R have been

devel-oped for use with children and adolescents. An interview-based youth version exists for assessing psychopathy in older adolescents (Psychopathy Checklist: Youth Version [PCL:YV]; Forth, Kosson, & Hare, 2003), and alternative informant-rating versions are available for use with children and younger adolescents—the most widely used being the Antisocial Process Screening Device (APSD; Frick, O’Brien, Wooten, & McBurnett, 1994). The ASPD, designed for use with children aged 6-13, consists of 20 items rated by parents/guardians or teachers. Like the PCL-R, the items of the APSD also define two distinct factors; a Callous-Unemo-tional (CU) factor, reflecting emoCallous-Unemo-tional insensitivity and an exploitative interpersonal style, and an Impulsive/Conduct Problems (I/CP) factor, encom-passing impulsive behavior, reckless acts, and an inflated sense of self-importance. Children with higher scores on the latter factor only tend to ex-hibit lower intellectual function, heightened nega-tive emotional reactivity, and a propensity towards reactive aggression. In contrast, children who score high on both factors of the APSD show low levels of anxiety and negative emotional reactivity, and elevated levels of proactive as well as reactive aggression (Blair, 2006; Frick & White, 2008).

Since the PCL-R was developed based on data from offenders and has been used main-ly with male correctional and forensic samples, prevalence estimates are available mainly for samples of this type. Using a total-score criterion of 30 or higher, 15-25% of men in correctional and forensic settings achieve a PCL-R diagnosis of psychopathy (Hare, 2003). As noted earlier, ASPD has a prevalence rate of 50-80% in offender samples, resulting in an asymmetry between these two diagnoses—i.e., most offenders diagnosed as psychopathic using the PCL-R also meet criteria for ASPD, but most diagnosed with ASPD do not meet PCL-R criteria for psychopathy. Prevalence figures from studies of PCL-R psychopathy in female offenders have been more mixed, with some studies reporting rates comparable to those

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separate aspect of psychopathy, corresponding to callous-unemotionality or meanness (see next section below). Unlike the two broad factors of the PCL-R, which are moderately interrelated, the FD and IA factors of the PPI are largely uncorrelated (Benning et al., 2003).

The Triarchic Model of Psychopathy

The Triarchic model (Patrick, Fowles, & Krueger, 2009) was developed to reconcile alter-native conceptions of psychopathy represented in historic writings and contemporary assessment instruments. The model proposes that psychopa-thy entails three distinct but intersecting symptom-atic (phenotypic) facets: disinhibition, boldness, and meanness. Disinhibition entails general prone-ness to impulse control problems, associated with weak behavioral restraint and impaired regulation of urges and emotional reactions. Boldness entails high self-confidence and social efficacy, tolerance or even preference for unfamiliar or uncertain situations, and the capacity to remain calm and focused in threatening or otherwise challenging situations and recover quickly from stressors. Meanness entails lack of social connectedness, exploitativeness, empowerment through cruelty, destructive excitement seeking, and defiance of authority.

From the perspective of the Triarchic mod-el, alternative assessment inventories for psy-chopathy can be viewed as indexing the three phenotypic constructs of the Triarchic model to varying degrees. For example, the PCL-R and its youth-oriented variants (e.g., PCL:YV, APSD) index disinhibition and meanness to a strong degree and boldness to a lesser, indirect degree (Venables, Hall, & Patrick, in press), whereas the PPI/PPI-R indexes boldness strongly and directly while also providing appreciable coverage of disinhibition and meanness (Drislane et al., in press). The mod-el is also hmod-elpful for clarifying the correspondence between APSD as defined in Section II of DSM-5 for men and other studies reporting lower rates

(Verona & Vitale, 2006). Regarding the question of racial differences in PCL-R psychopathy, a recent meta-analysis reported a small but signifi-cant tendency for African-American offenders to score higher than European-American offenders (Skeem, Edens, Camp, & Colwell, 2004). Addition-ally, some cross-cultural evidence suggests that American prisoners score higher in general on the PCL-R than European prison samples (Sullivan & Kosson, 2006).

Psychopathic Personality Inventory

The Psychopathic Personality Inventory is a self-report measure of psychopathy developed for use with general community samples. The cur-rent revised version (PPI-R; Lilienfeld & Widows, 2005) consists of 154 items, organized into eight subscales that index distinct dispositional tenden-cies relevant to psychopathy. Unlike the PCL-R, the PPI-R provides direct coverage of more adap-tive features low anxiousness and fear (indexed by the Stress Immunity and Fearlessness subscales) and interpersonal efficacy/assertiveness (indexed by the Social Potency subscale). The PPI-R also includes coverage of impulsivity (Carefree Non-planfulness subscale), oppositionality (Rebellious Nonconformity), alienation (Blame Externalization), aggressiveness (Machiavellian Egocentricity), and a lack of empathic concern (Coldheartedness subscale).

Analyses of relations among the subscales of the original PPI yielded evidence of two dis-tinct thematic factors—Fearless Dominance (FD), marked by the Social Potency, Stress Immunity, and Fearlessness subscales; and Impulsive Anti-sociality (IA), marked by the Carefree Nonplanful-ness, Rebellious Nonconformity, Blame External-ization, and Machiavellian Egocentricity subscales (Benning et al., 2003). The eighth PPI subscale, Coldheartedness, does not load appreciably on either of these factors—and appears to index a

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and psychopathy: ASPD reflects disinhibition very strongly and meanness to a subsidiary degree, with limited representation of boldness (Venables et al., in press; Venables & Patrick, 2012). By contrast, meanness and boldness are emphasized prominently (albeit in differing proportions), along with disinhibitory tendencies, in most conceptions of psychopathy.

Innovative aspects of the new trait-based diagnosis of ASPD in Section III of DSM-5 can also be appreciated in relation to the Triarchic model. The inclusion of traits from the domains of both Antagonism and Disinhibition provides for balanced representation of meanness and disin-hibition in the trait-based diagnosis. In addition, the trait-based diagnosis includes a “psychopathic features” specifier, entailing extreme scores on additional traits of Attention Seeking (high), Anx-iousness (low), and Withdrawal (low). This spec-ifier provides for the designation of a classically low-anxious, socially efficacious (i.e., bold) variant of ASPD-consistent with Cleckley’s conception of psychopathy as a ‘masked’ form of pathology (Strickland, Drislane, Lucy, Krueger, & Patrick, 2013).

Perspectives on Treatment

A long-held belief among researchers and clinicians has been that psychopathy and ASPD are highly resistant to therapy, or perhaps even untreatable (Cleckley, 1941; Harris & Rice, 2006). Undoubtedly, these conditions present unique challenges for treatment given the obstacles that characteristics such as emotional insensitivity, deceitfulness, weak behavioral restraint, and interpersonal detachment pose to motivation for change, compliance with treatment, and main-tenance of therapeutic effects (Patrick, Drislane, & Strickland, 2012). However, findings from well-controlled studies conducted over the past 2-3 decades have revealed evidence of system-atic change on the part of antisocial individuals to

interventions of certain types (Skeem et al., 2011). In particular, treatments focusing on cognitive-be-havioral modification of maladaptive thoughts and beliefs, and practical skills training have demon-strated greater effectiveness than traditional in-sight-oriented psychotherapy approaches (Patrick & Nelson, 2013).

Additionally, there has been a trend in newer treatment programs for antisocial individ-uals to rely more on empirical findings as a basis for refining techniques of change and matching interventions to distinct needs of individuals (Frick, 2001; Skeem et al., 2011). Along this line, recent phenotypic and etiological research pointing to distinct processes underlying differing facets of psychopathy can serve as a basis for more nu-anced approaches to treatment, targeting specific deficits or deviations. For example, brain biofeed-back protocols, in which individuals learn to con-trol brain responses through real-time perceptual feedback, could provide a useful technique for training individuals high in meanness to increase their reactivity to affective-social cues (e.g., facial expressions of fear or sadness), or for training individuals high in disinhibition to enhance on-line recognition of behavioral errors (cf. Hall, Bernat, & Patrick, 2007). While work of this type remains at an early formative stage, it does provide a com-pelling example of how theoretical conceptions of psychopathy can be used to inform applied prac-tice. As innovative new treatments are devised that incorporate advances in understanding of processes underlying ASPD and psychopathy, the longstanding pessimism surrounding treatment of individuals with these conditions can be expected to give way to cautious optimism about prospects for reducing the costly toll they exact on society.

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