Download antisocial personality disorder and psychopathy in adults

ANTISOCIAL PERSONALITY DISORDER AND
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: [email protected]
Abstract
Antisocial Personality Disorder (ASPD) and psychopathy are of interest to researchers, forensic psychologists, and public policy makers due to the high cost these
disorders exact on society and its citizenry. This article reviews historical conceptions of psychopathy and ASPD, as well as empirical findings that have led to new
developments in clinical conceptualizations. Commonly used methods of assessment, 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.
Science in the Courtroom, Copyright 2015 by the National Courts and Science
Institute, Inc. under the rules and provisions of Creative Commons Copyright.
Introduction
Individuals diagnosed with psychopathy
and antisocial personality disorder (ASPD) particularly 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 interpersonal and affective symptoms, including superficial
charm, grandiosity, deceitfulness, and emotional
insensitivity. In contrast, ASPD is characterized by
persistent antisocial and impulsive behavior with
limited reference to interpersonal-affective symptoms (DSM 5; American Psychiatric Association
[APA], 2013). It is the purpose of this article to
review historical background on ASPD and psychopathy, describe modern conceptions of these
disorders and common methods of assessment,
and discuss perspectives on treatment.
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 disorder, including indicators of psychological stability
(social poise and persuasiveness, lack of anxiety,
absence of thought disturbance or hallucinations/
delusions), shallow affect and superficial relationships with others, and impulsive behavioral deviance. Others concerned with psychopathy in adjudicated offenders (e.g., McCord & McCord, 1964)
placed greater emphasis on a callous-predatory
interpersonal style, absence of remorse (“guiltlessness”), and inability to form genuine attachments
(“lovelessness”). These conflicting perspectives
are seen in the alternative conceptions of psychopathy that exist in the literature today.
Historical Conceptions: Psychopathy
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 adjustment, including addictive, sexually deviant,
and antisocial patterns. The second edition of the
DSM (1968) contained the category Personality
Disorders and Other Non-Psychotic Mental Disorders, which included an “antisocial personality”
type similarly defined to Cleckley’s conception of
psychopathy.
The third edition of the DSM (1980) prominently shifted toward diagnoses based on specific
behaviorally oriented criteria, rather than the narrative 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 aggressive-antisocial tendencies, and omitted features pertaining to superficial charm, grandiosity,
shallow affectivity, and callousness. In an attempt
Early conceptions of psychopathy focused
on salient impulsive-aggressive behavior in individuals who did not appear to have any other mental
disorder. Phillipe Pinel (1801) used the term manie
sans delire (“insanity without delirium”) to describe 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. Subsequently, 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 personalities.
A key development came with the publication of Hervey Cleckley’s seminal text “The
Mask of Sanity” (1941), which further refined the
diagnosis of psychopathic personality. Based on
Antisocial Personality Disorder
Science in the Courtroom, Copyright 2015 by the National Courts and Science
Institute, Inc. under the rules and provisions of Creative Commons Copyright.
to capture the diagnostic construct of psychopathy, 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 currently 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 Diagnostic 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 covariation among a number of indicators, of the adult
symptoms of ASPD: a disinhibition factor (reflecting 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 composition of the sample, revealed two genetic factors 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 separable aggressive and non-aggressive (‘rule-breaking’) symptom subsets with differing etiologies
(Burt, 2009; Tackett, Krueger, Iacono, & McGue,
2005).
In addition to preserving DSM-IV definitions of ASPD and other personality disorders in
Section II, the manual for DSM-5 contains a new
dimensional trait system for characterizing conditions of these types in Section III, entitled Emerging Measures and Models. This system characterizes ASPD in terms of seven distinct traits from
two dispositional domains: antagonism and disinhibition. 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-aggressive and impulsive-antisocial tendencies—reflecting historic conceptions of criminal psychopathy (cf. Patrick, Fowles, & Krueger, 2009), and
acknowledging above-noted work demonstrating
distinct etiologies for aggressive as compared to
non-aggressive symptoms. This balanced approach represents a shift from the DSM-IV criterion-based diagnosis carried over to Section II,
which places greater emphasis on impulsive-disinhibitory 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 occurrence higher for men (3%) than women (1%;
APA, 2000). Alternative hypotheses have been
advanced to account for this gender difference,
Science in the Courtroom, Copyright 2015 by the National Courts and Science
Institute, Inc. under the rules and provisions of Creative Commons Copyright.
including socialization pressures associated with
sex role stereotypes and biologically-based dispositional 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 correctional institutions or forensic units of inpatient
psychiatric hosptials, the prevalence of ASPD is
generally much higher, with rates as high as 5080% 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 interpersonal-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 & Benning, 2006), but has proven important clinically.
Adult criminal offenders diagnosed as psychopathic 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 DSM5, as noted above. In particular, research consistently demonstrates that children and adolescents
displaying callous-unemotional tendencies along
with impulsive conduct problems show a more severe trajectory in terms of persistence and severity
for aggressive-antisocial behavior (Frick & Marsee,
2006; Frick & White, 2008).
Contemporary approaches to the assessment of psychopathy include clinical rating scales
designed for use with adult offenders and delinquent youth that emphasize antisocial expressions
of core psychopathic tendencies, and self-report
inventories developed for broader use that focus more on dispositions and less on antisocial
acts. A three-component (Triarchic) model has
been advanced to clarify similarities and differences 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 psychopathy 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 interview and a review of institutional records.
The summation of item scores yields a total psychopathy 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 higher on classified as psychopathic, and those scoring 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 resemblance to Cleckley’s description of psychopathic
inpatients on a 7-point global rating scale. While
the items of the PCL-R provide effective coverage of the impulsive behavioral deviance and
affective-interpersonal dysfunction, the positive
adjustment features included among Cleckley’s
Science in the Courtroom, Copyright 2015 by the National Courts and Science
Institute, Inc. under the rules and provisions of Creative Commons Copyright.
criteria (e.g., social efficacy, absence of psychotic symptoms, low anxious/neuroticism) 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-aggressive conception advanced by criminality experts (e.g., McCord and McCord, 1964) more so
than the contrasting perspective of a feckless n’erdo-well conception put forth by Cleckley (1941).
Although developed to index psychopathy as a unitary diagnostic entity (syndrome),
the PCL-R contains subsets of items that define
correlated (~.50) but distinctive factors: an antisocial deviancy (AD) factor, encompassing restless, 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 tendencies including narcissism, low empathy, and use
of instrumental aggression (Hare, 2003). Additionally, 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, aggressiveness, early and recurring antisocial behavior, 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-Unemotional (CU) factor, reflecting emotional insensitivity
and an exploitative interpersonal style, and an
Impulsive/Conduct Problems (I/CP) factor, encompassing impulsive behavior, reckless acts, and an
inflated sense of self-importance. Children with
higher scores on the latter factor only tend to exhibit lower intellectual function, heightened negative 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 mainly 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
Science in the Courtroom, Copyright 2015 by the National Courts and Science
Institute, Inc. under the rules and provisions of Creative Commons Copyright.
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 significant tendency for African-American offenders to
score higher than European-American offenders
(Skeem, Edens, Camp, & Colwell, 2004). Additionally, 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 current revised version (PPI-R; Lilienfeld & Widows,
2005) consists of 154 items, organized into eight
subscales that index distinct dispositional tendencies relevant to psychopathy. Unlike the PCL-R,
the PPI-R provides direct coverage of more adaptive 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 Nonplanfulness 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 distinct thematic factors—Fearless Dominance (FD),
marked by the Social Potency, Stress Immunity,
and Fearlessness subscales; and Impulsive Antisociality (IA), marked by the Carefree Nonplanfulness, Rebellious Nonconformity, Blame Externalization, 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
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 alternative conceptions of psychopathy represented
in historic writings and contemporary assessment
instruments. The model proposes that psychopathy entails three distinct but intersecting symptomatic (phenotypic) facets: disinhibition, boldness,
and meanness. Disinhibition entails general proneness 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 model, alternative assessment inventories for psychopathy 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 model is also helpful for clarifying the correspondence
between APSD as defined in Section II of DSM-5
Science in the Courtroom, Copyright 2015 by the National Courts and Science
Institute, Inc. under the rules and provisions of Creative Commons Copyright.
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 disinhibition 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), Anxiousness (low), and Withdrawal (low). This specifier 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 maintenance of therapeutic effects (Patrick, Drislane,
& Strickland, 2012). However, findings from
well-controlled studies conducted over the past
2-3 decades have revealed evidence of systematic change on the part of antisocial individuals to
interventions of certain types (Skeem et al., 2011).
In particular, treatments focusing on cognitive-behavioral modification of maladaptive thoughts and
beliefs, and practical skills training have demonstrated greater effectiveness than traditional insight-oriented psychotherapy approaches (Patrick
& Nelson, 2013).
Additionally, there has been a trend in
newer treatment programs for antisocial individuals 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 nuanced approaches to treatment, targeting specific
deficits or deviations. For example, brain biofeedback protocols, in which individuals learn to control 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 compelling example of how theoretical conceptions of
psychopathy can be used to inform applied practice. 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.
Science in the Courtroom, Copyright 2015 by the National Courts and Science
Institute, Inc. under the rules and provisions of Creative Commons Copyright.
References
American Psychiatric Association. (1952). Diagnostic and statistical manual of mental disorders, 1st ed. Washington, DC: Author.
American Psychiatric Association. (1968). Diagnostic and statistical manual of mental disorders, 2nd ed. Washington, DC: Author.
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders, 3rd ed. Washington, DC: Author.
American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders, 3rd ed., text revision. Washington, DC: Author.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, 4th ed., text revision. Washington, DC: Author.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: Author.
Benning, S. D., Patrick, C. J., Hicks, B. M., Blonigen, D. M., & Krueger, R. F. (2003). Factor structure of the Psychopathic Personality Inventory: Validity and implications for clinical assessment. Psychological Assessment, 15, 340-350.
Blair, R.J. (2006). Subcortical brain systems in psychopathy: The amygdala. In C. J. Patrick (Ed.), Hand
book of psychopathy (pp. 296-312). New York: Guilford Press.
Burt, S.A. (2009). Are there meaningful etiological differences within antisocial
behavior? Results of a meta-analysis. Clinical Psychology Rev, 29(2), 163-178.
Cleckley, H. (1941). The mask of sanity. St. Louis, Mo.: Mosby. (5th edition
published 1976).
Douglas, K. S., Vincent, G. M., & Edens, J. E. (2006). Risk for criminal recidivism: The role of
psychopathy. In C. J. Patrick (Ed.), Handbook of psychopathy (pp. 533-554). New York: Guilford Press.
Drislane, L. E., Patrick, C. J., & Arsal, G. (in press). Clarifying the content coverage of differing
psychopathy inventories through reference to the Triarchic Psychopathy Measure. Psychological Assessment.
Forth, A. E., Kosson, D. S., & Hare, R. D. (2003). The Psychopathy Checklist: Youth Version manual. Toronto, ON: Multi-Health Systems.
Frick, P. J. (2001). Effective interventions for children and adolescents with conduct disorder. Canadian Journal of Psychiatry, 46, 597-608.
Frick, P. J., & Marsee, M. A. (2006). Psychopathy and developmental pathways to antisocial behavior in youth. In C. J. Patrick (Ed.), Handbook of psychopathy (pp. 353-374). New York: Guilford Press.
Frick, P. J., O’Brien, B. S., Wooten, J. M., & McBurnett, K. (1994). Psychopathy and conduct problems in children. Journal of Abnormal Psychology, 103, 700-707.
Frick, P. J., & White, S. F. (2008). The importance of callous-unemotional traits for developmental models of aggressive and antisocial behavior. Journal of Child Psychology and Psychiatry, 49, 359-375.
Hare, R. D. (2003). The Hare Psychopathy Checklist – Revised, 2nd ed. Toronto, Ontario: Multi-Health Systems.
Science in the Courtroom, Copyright 2015 by the National Courts and Science
Institute, Inc. under the rules and provisions of Creative Commons Copyright.
Hall, J. R., & Benning, S. D. (2006). The “successful” psychopath. In C. J. Patrick (Ed.), Handbook of psychopathy (pp. 459-475). New York: Guilford Press.
Harris, G. T., & Rice, M. E. (2006). Treatment of psychopathy: A review of empirical findings. In C. J.
Patrick (Ed.), Handbook of psychopathy (pp. 555–572). New York: Guilford Press.
Hicks, B. M., & Patrick, C. J. (2006). Psychopathy and negative affectivity: Analyses of suppressor effects reveal distinct relations with trait anxiety, depression, fearfulness, and anger-hostility. Journal of Abnormal Psychology, 115, 276-287.
Kendler, K. S., Aggen, S. H., & Patrick, C. J. (2012). A multivariate twin study of the DSM-IV criteria for antisocial personality disorder. Biological Psychiatry, 71, 247-253.
Koch, J. L. (1891). Die psychopathischen Minderwertigkeiten. Ravensburg, Germany: Maier.
Kraepelin, E. (1915). Psychiatrie: Ein lehrbuch (8th ed.). Leipzig: Barth.
Lilienfeld, S. O., & Widows, M.R. (2005). Psychopathic Personality Inventory—Revised (PPI-R)
professional manual. Odessa, FL: Psychological Assessment Resources.
McCord, W., & McCord, J. (1964). The psychopath: An essay on the criminal mind. Princeton: Van
Nostrand.
Patrick, C. J., Hicks, B. M., Krueger, R. F., & Lang, A. R. (2005). Relations between psychopathy facets and externalizing in a criminal offender sample. Journal of Personality Disorders, 19, 339-356.
Patrick, C. J., Fowles, D. C., & Krueger, R. F. (2009). Triarchic conceptualization of psychopathy:
Developmental origins of disinhibition, boldness, and meanness. Development and
Psychopathology, 21, 913-938.
Patrick, C., Drislane, L. E., & Strickland, C. (2012). Conceptualizing psychopathy in
Triarchic terms: Implications for treatment. International Journal of Forensic Mental Health, 11, 253-266.
Patrick, C. J., & Nelson, L D. (2013). Antisocial personality disorder. In: J. Smits (Ed.), Cognitive
behavioral therapy: A complete reference guide, vol 2: CBT for specific disorders (pp. 1263-
1298). New York: Wiley-Blackwell.
Pinel, P. (1962). A treatise on insanity (D. Davis, translator). New York: Hafner. (Original edition published in 1801)
Skeem, J. L., Edens, J. F., Camp, J., & Colwell, L. H. (2004). Are there racial differences in levels of
psychopathy? A meta-analysis. Law and Human Behavior, 28, 505-527.
Skeem, J. L., Manchak, S., & Peterson, J. K. (2011). Correctional policy for offenders
with mental illness: Creating a new paradigm for recidivism reduction. Law and Human Behavior, 35, 110-126.
Strickland, C. M., Drislane, L. E., Lucy, M. D., Krueger, R. F., & Patrick, C. J. (2013). Characterizing
psychopathy using DSM-5 personality traits. Assessment, 20, 327-338.
Sullivan, E. A., & Kosson, D. S. (2006). Ethnic and cultural variations in psychopathy. In C. J. Patrick (Ed.), Handbook of psychopathy (pp. 437-458). New York: Guilford Press.
Tackett, J. L., Krueger, R. F., Iacono, W. G., & McGue, M. (2005). Symptom-based
subfactors of DSM-defined conduct disorder: evidence for etiologic distinctions. Journal of
Abnormal Psychology, 114, 483.
Venables, N. C., & Patrick, C. J. (2012). Validity of the Externalizing Spectrum
Inventory in a criminal offender sample: Relations with disinhibitory psychopathology, personality, and psychopathic features. Psychological Assessment, 24, 88-100.
Science in the Courtroom, Copyright 2015 by the National Courts and Science
Institute, Inc. under the rules and provisions of Creative Commons Copyright.
Venables, N. C., Hall, J. R., & Patrick, C. J. (in press). Differentiating psychopathy from antisocial
personality disorder: A Triarchic model perspective. Psychological Medicine.
Verona, E., & Vitale, J. (2006). Psychopathy in women: Assessment, manifestations, and etiology. In C. J. Patrick (Ed.), Handbook of psychopathy (pp. 415-436). New York: Guilford Press.
Science in the Courtroom, Copyright 2015 by the National Courts and Science
Institute, Inc. under the rules and provisions of Creative Commons Copyright.