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3 Psychopathy
STEVEN M. GILLESPIE AND IAN J. MITCHELL
CHAPTER OUTLINE
3.1 INTRODUCTION
3.2 ASSESSMENT OF PSYCHOPATHY 3.2.1 Dissociating Psychopathy from Antisocial Personality Disorder
3.2.2 Psychopathic Subtypes
3.3 PSYCHOPATHY AND AGGRESSION
3.4 CORRELATES OF PSYCHOPATHY IN ADOLESCENTS AND CHILDREN
3.5 GENETIC BASIS OF PSYCHOPATHY
3.6 FAMILY FACTORS ASSOCIATED WITH THE DEVELOPMENT OF PSYCHOPATHY
3.7 ATTACHMENT, PSYCHOPATHY AND OFFENDING
3.8 FACIAL EXPRESSION RECOGNITION 3.8.1 A Neurobiological Model of Fearful Face Recognition Deficits in Psychopathy
3.8.2 Eye Scan Paths, Fearful Face Recognition and Psychopathy
3.9 PSYCHOPATHY AND AVERSIVE CONDITIONING
3.10 NEUROCHEMISTRY OF PSYCHOPATHY
3.11 CONCLUSIONS
3.12 SUMMARY
LEARNING OUTCOMES
BY THE END OF THIS CHAPTER, YOU SHOULD BE ABLE TO:
Understand why a psychological analysis of psychopathy is important in understanding the relation between personality traits and serious offending
Appreciate the principal research methods used to explore psychopathy
Understand the implications of existing findings for psychopathy.
AN EXAMPLE OF A PSYCHOPATH: THEODORE ROBERT BUNDY
Although Ted Bundy was not formally diagnosed using the Psychopathy Checklist – Revised, many of the core characteristics of psychopathy may be evident in his character and through the nature of his crimes. Ted Bundy was an American serial killer. He kidnapped, raped and killed his victims. Bundy was overtly normal, free from insanity or delusion, and his crimes were instrumental, organised and calculating. He typically approached his unsuspecting female victims in public places and used his charm and cunning to gain their trust before assaulting them. Following trial in 1979 Bundy was found guilty of two murders and sentenced to the death penalty. Bundy maintained his innocence until shortly before his death in 1989, following over a decade of denials.
3.1 INTRODUCTION
The term psychopathy refers to an individual suffering from a severe disorder of personality that is strongly linked with antisocial behaviour. The key clinical characteristics of the condition are a callous disregard for others and a lack of behavioural controls. The weighted prevalence (see Textbox 3.1) of psychopathy is estimated at 0.6% in 638 individuals, aged 16–74 years, in households in England, Wales and Scotland (Coid, Yang, Ullrich, Roberts, & Hare, 2009). However, the figure is thought to be much higher at around 7–8% in the UK prison population (Coid, Yang, Ullrich, Roberts, Moran et al., 2009). The condition is associated with high levels of crime and psychopaths are thought to account for a disproportionate amount of crime compared with non-psychopathic individuals.
TEXTBOX 3.1
Prevalence refers to the percentage of a population that is affected with a particular condition or disease at a given time.
The modern concept of psychopathy has evolved from the work of Hervey Cleckley (1941). In his influential book, The Mask of Sanity, he described a group of psychiatric patients who appeared outwardly normal, but were nonetheless extremely callous and unable to express remorse or guilt, to the point where they seemed to be devoid of human emotion. The patients were typically of above average intelligence and seemingly charming, though lacked the capacity for love. Their social behaviour was distinctly antisocial. The original patient group also showed a notable lack of anxiety or neuroses although the relationship of these traits to the condition is now hotly debated (see Section 3.2.2 on psychopathic subtypes).
As well as research with clinical and forensic samples, research examining the cognitive, affective and functional correlates of psychopathic traits in the general population has received growing attention. For example, research with non-clinical adult samples has revealed expected correlations of self-reported psychopathic traits with both empathy and morality (Seara-Cardoso, Neumann, Roiser, McCrory, & Viding, 2012). These findings are consistent with results showing that psychopathic traits can be observed in the general population (Hare & Neumann, 2008), and that psychopathy is better understood as a dimensional construct rather than as a taxonomy (Edens, Marcus, Lilienfeld, & Poythress, 2006; Guay, Ruscio, Knight, & Hare, 2007). Furthermore, functional neuroscience findings from the general population appear to closely mirror those from clinical samples, supporting the conclusion that individual differences in self-reported psychopathic traits relate to individual differences in brain function (Seara-Cardoso & Viding, 2014). Thus, although clinically elevated levels of psychopathic personality may be rare in the general population, continuities in the mechanisms underlying psychopathic personality nonetheless exist.
3.2 ASSESSMENT OF PSYCHOPATHY
There are several tools available for assessing psychopathic traits in individuals. However, the most widely accepted instrument for determining whether or not a given individual can be diagnosed as a psychopath is the Psychopathy Checklist – Revised (PCL-R; Hare, 1991, 2003). The PCL-R is completed on the basis of semi-structured interviews and information held on file. There are 20 items, each of which is scored from 0 to 2 depending on the degree to which each is present in the person being assessed, with a maximum possible score of 40 (see Table 3.1 for the items). A diagnosis of psychopathy is made if the score is greater than 30 in North America (Hare, 1991, 2003), 26 in mainland Europe and 25 in the UK. The PCL-R items are grouped into two broad factors: Factor1 assesses the interpersonal/affective features of psychopathy, whereas Factor 2 measures the lifestyle/antisocial features of the disorder (See Table 3.1). Although the PCL-R was originally thought to be underpinned by two distinct factors, furth
er research suggests the presence of three (Cooke & Michie, 2001), or even four (Hare, 2003) distinct factors or facets (see Box 3.1).
Table 3.1 PCL-R items (Hare, 2003)
Factor 1 – interpersonal/affective features
Glibness/superficial charm (Interpersonal)
Grandiose sense of self-worth (Interpersonal)
Pathological lying (Interpersonal)
Conning/manipulative (Interpersonal)
Lack of remorse or guilt (Affective)
Shallow affect (Affective)
Callous/lack of empathy (Affective)
Failure to accept responsibility for own actions (Affective)
Factor 2 – lifestyle/antisocial features
Need for stimulation/proneness to boredom (Lifestyle)
Parasitic lifestyle (Lifestyle)
Poor behavioural controls (Antisocial)
Early behaviour problems (Antisocial)
Lack of realistic, long term goals (Lifestyle)
Impulsivity (Lifestyle)
Irresponsibility (Lifestyle)
Juvenile delinquency (Antisocial)
Revocation of conditional release (Antisocial)
Criminal versatility (Antisocial)
Additional items (not loading on Factors 1 or 2, sometimes referred to as orphan items)
Promiscuous sexual behaviour
Many short-term marital relationships
Variants of the PCL-R have also been developed. These include the PCL-Youth Version (PCL-YV; Forth, Kosson, & Hare, 2003) for the assessment of psychopathic traits in younger samples, and the PCL-Screening Version (PCL-SV; Hart, Cox, & Hare, 1995), a 12-item rating scale derived from the PCL-R. Self-report questionnaires have also been developed to measure psychopathic traits where the use of the PCL-R is either not appropriate, for example when assessing psychopathy among non-offenders, or where the PCL-R is deemed to be too time consuming or where clinicians and researchers have not received sufficient training to use the instrument. Two of the most commonly used of these are the Psychopathic Personality Inventory (Lilienfeld & Andrews, 1996), and the Levenson Self Report Psychopathy scales (Levenson, Kiehl, & Fitzpatrick, 1995).
BOX 3.1 THE THREE-FACTOR/FOUR-FACET MODEL OF THE PCL-R
The three-factor version identified by Cooke and Michie (2001), contains three correlated factors that tap interpersonal, affective, and behavioural/lifestyle features of the disorder. The model is made up of 13 items and excludes those items that reference antisociality, namely: poor behavioural controls; promiscuous sexual behaviour; early behavioural problems; many short-term marital relationships; juvenile delinquency; revocation of conditional release; and criminal versatility.
In contrast, Hare (2003) describes a best fitting two-factor/four-facet model. The model identified by Hare (2003) divides Factor 1 into interpersonal (four items) and affective (four items) features, and Factor 2 into behavioural/lifestyle (five items) and antisocial (five items) features and two items on leading on these four facets. Such multi-faceted models allow for greater interpretability and provide a more nuanced understanding of those traits that characterise a particular individual. These models also allow for a more refined understanding of the ways in which psychopathic traits are related to cognitive, affective and functional correlates of psychopathy.
3.2.1 Dissociating Psychopathy from Antisocial Personality Disorder
The clinical condition of psychopathy bears a strong overlap with the construct of antisocial personality disorder (ASPD), though the two disorders are dissociable. ASPD is a diagnostic category of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013), which is based predominantly on the behavioural profile of an individual. This profile is characterised by a disregard for societal norms and rules that can take the form of a persistent pattern of antisocial behaviour, impulsivity and irresponsibility. ASPD is highly prevalent in offenders, with 60–70% of all male offenders receiving a diagnosis (Fazel & Danesh, 2002). However, unlike psychopaths, individuals with ASPD do not necessarily show callous and unemotional traits. Accordingly, although many offenders with a diagnosis of psychopathy would also be labelled as suffering from ASPD, only a third of those with a diagnosis of ASPD would meet the diagnostic criteria for psychopathy (Coid, 1998). The comorbid presence of psychopathy is thought to be related to higher rates of offending compared with those who have a diagnosis of ASPD in the absence of psychopathy (Kosson, Lorenz, & Newman, 2006). Offenders with a diagnosis of ASPD with and without psychopathy are also distinguishable in terms of brain structure, with psychopaths, but not those with ASPD in the absence of psychopathy, showing structural abnormalities in areas associated with empathy and morality (Gregory, Simmons, Kumari, Howard, Hodgins, & Blackwood, 2012).
3.2.2 Psychopathic Subtypes
The original work of Cleckley (1941) led to the generation of a strong representation of the prototypical psychopath. However, it is widely recognised that individuals with high psychopathic traits, and even those with a formal diagnosis of psychopathy, can deviate markedly from this model. Karpman described variants of the condition that he termed primary and secondary (Karpman, 1941). The critical difference between these two conditions is that primary psychopaths, in keeping with the original formulation of the disorder, show a lack of nervousness and an inability to experience fear and anxiety. In contrast, secondary psychopaths appear neurotic and anxious. This work has led to some debate as to whether or not psychopathic subtypes with elevated levels of trait anxiety may exist (see Box 3.2).
BOX 3.2 CAN PSYCHOPATHS BE ANXIOUS?
Whether psychopaths can be anxious remains a source of contention. Cleckley’s (1941) original concept of psychopathy emphasised the unemotional nature of the sufferers and their apparent fearlessness. This appears to be in marked contrast to the contemporaneous work of Karpman (1941) that emphasised the anxious traits of some sufferers.
These conflicting stances can be potentially resolved in different ways:
Karpman is wrong and that psychopaths are never anxious
There are discrete subtypes of psychopath with separate fearless and anxious variants
Although fear and anxiety are very similar emotions they can nonetheless co-exist such that an individual can be both fearless and anxious.
The third proposition is supported by the fact that fear and anxiety, though superficially similar, are largely dissociable emotions, as illustrated in Table 3.2.
Table 3.2 Differentiating the emotions of anxiety and fear
Anxiety Fear
Long acting Expressed in response to current dangers
Directed against the potential occurrence of diffuse future threats. Threat is specific and definable
Slow onset Quick onset
Long duration Brief duration
Not associated with particular facial expressions Accompanied by arousal, distinctive facial emotional expressions and fear related behaviours
Associated with hypervigilance and hyperarousal Results in the release of escape and avoidance behaviours
Extended amygdala and the bed nucleus of the striaterminalis critically involved Central amygdala nuclei involved
Reduced by both alcohol and benzodiazepines Strong effect of benzodiazepines but less so alcohol
Support for the distinction of primary and secondary psychopathy has come from psychophysiological studies. Lykken (1957) demonstrated that primary psychopaths made abnormal physiological responses in aversive conditioning paradigms. Thus, relative to secondary psychopaths and non-psychopathic controls, primary psychopaths showed weak electrodermal reactions in response to aversive stimuli and rapid extinction of the conditioned association. This result is in keeping with the conclusion that the hypoemotionality of psychopathy is limited to the primary variant. This view is supported by observations that primary psychopaths frequently appear fearless and may actively seek out fear-inducing challenges.
The possibility of subtypes is supported by evidence
that the original configuration of the PCL-R as a model consisting of two factors could be better represented by three- or four-facet models (Neumann, Vitacco, Hare, & Wupperman, 2005; Cooke & Michie, 2001; Cooke, Michie, & Hart, 2006; Cooke, Michie, Hart, & Clark, 2004; Skeem & Cooke, 2010). One of the still-to-be-resolved debates that has emerged from this approach is whether antisocial behaviour represents a core trait of psychopathic personality, or a behavioural consequence that is expressed as a product of having a specific collection of personality traits (Neumann et al., 2005; Cooke et al., 2004; Skeem & Cooke, 2010). As highlighted by Skeem, Johansson, Andershed, Kerr, and Louden (2007), the multifaceted nature of the PCL-R, along with variability in score configurations across the different facets, may support the existence of psychopathic variants.
One potential limitation of the PCL-R is that it generates a single psychopathy score and in doing so, fails to acknowledge the relative contribution of the Factor 1 and Factor 2 items. This accordingly rules out the possibility of identifying psychopathic subtypes. Furthermore, the PCL-R bears no direct reference to low anxious or fearless – an observation that has prompted some to question the extent to which these features represent defining aspects of the disorder. Although Neumann and colleagues provide evidence that lack of fear and anxiety are comprehensively accounted for by existing PCL-R items (Neumann, Johansson, & Hare, 2013), psychopathic variants that are characterised by heightened levels of trait anxiety have nonetheless been identified.
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