Psychopathy and Antisocial Personality Disorder

• Author: William Komer, Hy Bloom, and Lisa Ramshaw
• Pages: 407-445

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CHAPTER 21

Psychopathy and Antisocial

Personality Disorder

William Komer, Hy Bloom, and Lisa Ramshaw

I. INTRODUCTION

No text about psychiatry and the law would be complete without a discussion of psychopathy and anti-

social personality disorder (ASPD). ese are particularly relevant given their signicant association

with risk of violence and other criminal behaviour, and the implications they have for risk management.

Individuals with this level of personality pathology oen nd themselves in trouble with the law, and

they are invariably a challenge to the criminal justice system and to health care providers.

Assessing for the presence of psychopathy is a fundamental component of all forensic evaluations

where propensity for criminality and da ngerousness are the foreground issues. Hemphill and Hart (2003)

consequently contend that the assessment of psychopathy is a core skill for clinical-forensic psychologists,

and they caution that any forensic psychiatrist may be called upon to address these issues. Assessment

of psychopathy is relevant in assessing an accused’s criminal responsibility, in pre-sentence assessments,

in evaluations with respect to the rights and liberty of Review Board accused, and is fundamental to

Dangerous Oender and Long-Term Oender assessments (Criminal Code, 19 85).

Psychopathy is a personality construct characterized by three key symptom groupings: an arrogant,

interpersonally exploitative, and deceitful interpersonal style of relating; a shallow and decient way of

experiencing and expressing aect; and an impulsive, irresponsible, and antisocial behavioural lifestyle

(Cleckley, 1941; Hare, 1991, 2003; Millon, 1981; Cooke et al., 2004; Visser et al., 2012).

ere has, however, been considerable confusion by both the public and even mental health profes-

sionals about what “psychopath” denotes, and its signicance. For the public, “psychopath” has meant

anything from serial k iller, psychotic person, con artist, to corporate schemer and defrauder of the

vulnerable. Even professionals make the mistake of seeing psychopathy as synonymous with criminal

behaviour. Not all psychopaths are criminals (Slater & Pozzato, 2012), and contrary to further public

misconception, there is nothing about their appearance that makes them identiable. True to one of their

skills, they a re gied at blending into the landscape, for the express purpose of preying on others to meet

their own needs (Babiak et al., 2012). Yet other misconceptions and myths include that all psychopaths

are violent and that psychopathy is untreatable. As regards the former myth, Lilienfeld and Arkowitz

(2008) note that while psychopathy is a proven risk factor for future physical and sexual violence, “most

psychopaths a re not violent, and most v iolent people are not psychopaths” (p. 81).

ese authors point out how regrettable it is that DSM -I V-TR (APA, 2000) has drawn psychopathy

into the diagnostic criteria for ASPD, treated them as synonymous, and falsely given the impression

that longstanding criminality and violence in ASPD’s criteria are core to psychopathy. Lilienfeld and

Arkowitz (2008) further say, with respect to the incorrect idea that psychopathy is untreatable, that while

it is true that the nuclear personality cannot likely be changed, a number of criminal behaviours may, in

fact, be amenable to treatment.

ASPD is a DSM-I V-TR (APA, 2000) diagnosis characterized by a history of chronic antisocial, crim-

inal, and sometimes violent behaviour, the origins of which condition date back to childhood or early

William Komer, Hy Bloom, and Lisa Ramshaw

adolescence. Although the DSM-III (APA, 1980) and DSM -I V-TR (APA, 2000) suggest that psychopathy

can be equated with ASPD, most well-validated ratings of psychopathy (Hare, 1983, 2003) correlate to

a lesser degree of ASPD (Skeem et al., 2011). e dierence, Skeem et al. (2011) write, “arises largely be-

cause measures of psychopathy include personality traits inferable from behaviour, whereas measures of

ASPD more exclusively emphasize antisocial, criminal, and (to a lesser extent) violent behaviour” (p. 98).

is chapter is intended to serve as an introduction principally to psychopathy and less so to ASPD,

as dened by the American Psychiatric Association (APA) in DSM -I V-TR (APA, 2000). Our emphasis

here is on the practical — trying to help forensic, and perhaps general, psychiatrists as they attempt to

render assistance to courts, tribunals, review boards, and the like. In order to keep the chapter within

manageable bounds, we have centred on but one meaning of psychopathy — the Hare Psychopathy

Checklist-Revised (PCL-R) and its related schemes (1980, 1985, 1991, 2003). ere are several reasons for

this. First, the PCL-R and its derivatives are the most widely known and most oen-used measures of the

construct. Secondly, the Hare PCL-R and its derivatives have been subjected to “many reviews, discus-

sions, and meta-analyses, as well as unusually intensive scrutiny, both theoretical and empirical” (Hare

& Neumann, 2008). Finally, the PCL-R and its oshoot tools have not just stood the test of time, but have

demonstrated their validity, reliability, and generalizability through extensive research and accompany-

ing literature (Cooke et al., 2005; Bolt et al., 2007).

is chapter will also delineate the overlap and dierences between psychopathy and ASPD. A failure

to appreciate key distinctions between the two clinical entities and use of the terms in some circles as

synonymous has resulted in some confusion, which we hope to clarify.

Space here precludes detailed examination of a great variety of related topics such as the nature and

prevalence of psychopathy in the ordinary public (see Babiak & Hare, 2007), gender dierences, and

theories of causation, including heritability, the possible biological basis of psychopathy and the way

our understanding of the condition is rapidly becoming informed by advances in neurosciences and

neuroimaging. ese subjects will, however, be touched on briey. Fortunately, there are several excel-

lent edited texts on all of these topics, (see, for example, Patrick, 2006). Toward the end of the chapter

we do venture into the historically controversial issue of the extent to which individuals designated to

be psychopathic are or are not treatable. We included the treatability issue because it is so frequently of

interest to judges and members of decision-making tribunals. A forensic psychiatrist can expect to be

questioned on t he topic.

II. PSYCHOPATHY

A. A Brief History of Psychopathy

e concept of psychopathy has a longer and richer history than most other personality disorders

(Hare & Neumann, 2008), although its history is equally replete with diverse and occasionally confused

interpretations of the nature of the condition and the meaning of the term. Millon, Simonson, and Birket

Smith (1998) make the point that psychopathy was the rst personality disorder to be recognized in

psychiatry. Its portrayal to the world at large in the media has engendered much fascination, but equally,

considerable misconception. As Skeem et al. (2011) write, “[f]or the public at large, psychopathy remains

a poorly understood concept reecting some combination of our childhood fears of the bogeyman, our

adult fascination with human evil, and perhaps even our envy of people who appear to go through life

unencumbered by feelings of guilt, anguish, and insecurity” (p. 96).

Pinel (1801) is generally acknowledged as the rst clinician to recognize psychopathy as a discrete

condition in which the patient, although extremely intermittently violent, has no underlying psychosis

Psychopathy and Antisocial Personality Disorder 

(manie sans délire). However, it was Pinel’s student Esquirol (1838) who designated psychopathy as

“monomania” — a solitary pathological preoccupation in an otherwise sound mind.

A number of historical writers described the condition principally as a personality style and way of

relating, and de-emphasized the behavioural component, as set out in Table 21.1 below.

Table . The Evolution of the Concept of Psychopathy

Yea r Writer Description of Condition

,  Phillipe Pinel “La folie raisonnante”

Although not psychotic and in control of their faculties, patients are

impulsive and destructive.

“Manie sans delire”

Patients are aware of their violent, impulsive, and irrational behaviour.

 Benjamin Rush Have sound understanding of things, but deranged in other ways: victims of

their passions, “cannot speak the truth upon any subject…” (p. ).

 Carl Otto “The mental character will have an inclination to use hypocrisy and sly

charades as the best means for obtaining a goal or conducting a plan.” (as

quoted by Millon et al., , p. )

 J.C. Pritchard “Moral insanity”

Psychopathy is in the personality disorder realm.

 Isaac Ray “Moral mania”

A poorly understood condition of “freaks of conduct and whimsical notions”

without the “slightest aberration of reason.”

 C. Lambroso The criminal (l’uomo delinquente) has distinct clinical features consistent

with predatory animals: taller, a smaller skull with distinguishable landmarks,

acute eyesight, and insensitivity to pain.

 E. Bleuler Identif‌ied moral def‌icits, excessive drive, and lack of inhibition as features

setting the criminal apart, and presciently described emotional def‌icits,

more so than f‌lawed reasoning, as the basis for which born criminals choose

not to abide by laws.

 Emil Kraepelin “Psychopathic personality” is a lifelong trait. Four subtypes are

• “morbid liars and swindlers”

• “criminals by impulse”

• “professional criminals”

• “morbid vagabonds”

 K. Birnbaum Conceived of psychopathy as a social disorder. Coined the term “sociopath.”

 Hervey Cleckley “The Mask of Sanity”

Classic core conception of the psychopath as a guiltless, superf‌icially

charming, emotionally shallow, and impulsive person who is incapable of

prof‌iting from experience.

,  B. Karpman Two types of psychopaths:

) Primar y: True callous and antisocial characters with innate def‌icits and

af‌fective regulation

) Secondary: Due to neuroticism, emotional reactivity, and mediated by

environmental factors