Law and Human Behavior

Forensic Mental Health Professionals’ Perceptions of

Psychopathy: A Prototypicality Analysis of the
Comprehensive Assessment of Psychopathic Personality
in Sweden
Karolina Sörman, John F. Edens, Shannon Toney Smith, Olof Svensson, Katarina Howner,
Marianne Kristiansson, and Håkan Fischer
Online First Publication, April 7, 2014. http://dx.doi.org/10.1037/lhb0000072

CITATION
Sörman, K., Edens, J. F., Smith, S. T., Svensson, O., Howner, K., Kristiansson, M., & Fischer,
H. (2014, April 7). Forensic Mental Health Professionals’ Perceptions of Psychopathy: A
Prototypicality Analysis of the Comprehensive Assessment of Psychopathic Personality in
Sweden. Law and Human Behavior. Advance online publication.
http://dx.doi.org/10.1037/lhb0000072
 Law and Human Behavior © 2014 American Psychological Association
2014, Vol. 38, No. 1, 000 0147-7307/14/$12.00 DOI: 10.1037/lhb0000072

Forensic Mental Health Professionals’ Perceptions of Psychopathy:

A Prototypicality Analysis of the Comprehensive Assessment
of Psychopathic Personality in Sweden

Karolina Sörman John F. Edens and Shannon Toney Smith

Karolinska Institutet, National Board of Forensic Medicine, and Texas A&M University
Texas A&M University

Olof Svensson Katarina Howner

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

National Board of Forensic Medicine Karolinska Institutet

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Marianne Kristiansson Håkan Fischer

Karolinska Institutet and National Board of Forensic Medicine Stockholm University

Assessments of psychopathic traits are used on a routine basis in forensic evaluations across Westernized
countries. Despite this, consensus has not yet emerged concerning what exactly are the “core” features of this
construct. Moreover, relatively little is known about how practitioners in the field construe this disorder. This
study explored perceptions and attitudes regarding psychopathy among individuals working in the forensic
mental health system (N ⫽ 90) in Sweden. Participants provided prototype ratings of what they considered to
be core psychopathy features based on the Comprehensive Assessment of Psychopathic Personality (CAPP),
a model that increasingly is the focus of research in North America and Europe. The study protocol also
included questions regarding (a) global perceptions and attitudes about a number of aspects of the psychopathy
construct (e.g., personal experience, perceived prevalence), and (b) attitudinal scales that assessed perceived
correlates of psychopathic traits across a variety of domains (e.g., violence proneness, treatment amenability)
and moral judgments and attitudes concerning how psychopathic offenders should be treated within the legal
system. The majority of the 33 individual CAPP items and the six CAPP scales were rated as at least
moderately prototypical of psychopathy, with Dominance, Self, and Attachment domains obtaining the highest
mean ratings. Participants viewed psychopaths as more likely to commit crimes than the average criminal,
without being blatantly “evil” people. We believe our results help to advance our understanding of the
psychopathy construct by exploring forensic professionals’ perceptions of this disorder in general and in
relation to the CAPP model specifically.

Keywords: psychopathy, forensic, practitioners, CAPP, attitudes, content validity

Despite extensive research in the field, there is still a lack of
consensus among researchers and theorists regarding the core
features of psychopathy (Skeem, Polaschek, Patrick, & Lilienfeld,
Karolina Sörman, Department of Clinical Neuroscience, Division of Social
and Forensic Psychiatry, Karolinska Institutet, Stockholm, Sweden; National
Board of Forensic Medicine, Sweden, and Texas A&M University; John F.
Edens and Shannon Toney Smith, Department of Psychology, Texas A&M
University; Olof Svensson, National Board of Forensic Medicine, Sweden;
Katarina Howner, Karolinska Institutet; Marianne Kristiansson, Karolinska
Institutet and National Board of Forensic Medicine, Sweden and Håkan
Fischer, Department of Psychology, Stockholm University.
Correspondence concerning this article should be addressed to Karolina
Sörman, Department of Clinical Neuroscience, Division of Social-and
Forensic Psychiatry, Karolinska Institutet, Psykiatriforskning, Huddinge
sjukhusområde, M58 SE-141 86 Stockholm Sweden. E-mail: Karolina
.Sorman@ki.se
1
2011). In his seminal work, Cleckley (1941) considered affective
and interpersonal deficits such as lack of empathy and remorse as
central features of this disorder. Violent or predatory behavior was
considered a secondary consequence of the shallow emotional
nature of psychopathy rather than something innate to the person-
ality construct. In several prominent modern definitions of psy-
chopathy, however, greater emphasis has been placed on behav-
ioral aspects, such as impulsivity, irresponsibility, and antisocial
conduct. This view of psychopathy has been heavily influenced by
the single most used and extensively researched assessment instru-
ment in the field to date, the Psychopathy Checklist-Revised
(PCL-R; Hare, 1991, 2003), as well as by operationalizations of
“psychopathy” (i.e., Antisocial Personality Disorder [APD]) in all
editions of the American Psychiatric Association’s diagnostic and
statistical manuals since 1980.
It is worth highlighting that one can be labeled/classified as psy-
chopathic (i.e., PCL-R ⱖ 30) using these systems by having engaged
in a wide variety of criminal behavior and other antisocial acts while
 2 SÖRMAN ET AL.
also not demonstrating many of the personality features that seminal
theorists such as Cleckley argued were central to the disorder. For
example, using the widely researched 2-factor model of psychopathy
that parses most of the 20 items into “personality” (Factor 1) and
“social deviance” (Factor 2) subscales (Hare, 2003), a score of 30
hypothetically could be achieved by the presence of only three (of
eight) items on Factor 1 (i.e., a total score of six on this subscale). That
is, one can obtain a score as high as 24 based solely on the 12 items
not loading onto Factor 1, thus requiring only an additional six points
(of a possible 16) from the eight Factor 1 items to achieve a total score
of 30. Of note, more than two thirds of North American male offend-
ers score six or more on Factor 1 (Hare, 2003, p. 164, Table 9.1). If
one were to employ an even lower cut-score to define high scores,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
such as ⱖ25 (see Hare, 2003, p. 31, Table 2.1), which appears
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commonly in legal cases; DeMatteo et al., in press one conceivably
could be labeled as “highly psychopathic” based only on one “maybe”
(i.e., a score of one) on one of the eight Factor 1 items. In terms of
diagnoses of APD, the situation is even more extreme: one can meet
the diagnostic threshold essentially without any symptoms being
present that reflect what many seminal theorists consider to be core
features of psychopathic personality.
Despite the dominance of the PCL-R and APD construals of
antisocial and psychopathic traits in the field, in the last few years
alternative models of psychopathy have been investigated that
place relatively greater emphasis on various affective and inter-
personal features (e.g., Lilienfeld & Andrews, 1996; Lynam &
Widiger, 2007; Patrick, Fowles, & Krueger, 2009; see also Kos-
son, Steuerwald, Forth, & Kirkhart, 1997) than does either the
PCL-R or the Diagnostic and Statistical Manual of Mental Disor-
ders (DSM). One such model is the Comprehensive Assessment of
Psychopathic Personality (CAPP; Cooke, Hart, Logan, & Michie,
2004), which was developed to (a) incorporate a broader array of
personality traits, with less focus on antisocial and criminal be-
havior and (b) focus on more dynamic features of the disorder,
which could demonstrate potential change over time (e.g., result-
ing from treatment). The CAPP model conceptualizes psychopathy
over six specific domains (Attachment, Behavioral, Cognitive,
Dominance, Emotional, and Self), encompassing 33 items. Initial
validation results concerning the CAPP model have been promis-
ing thus far, with research suggesting that it correlates relatively
highly with PCL measures and predicts other theoretically relevant
criterion measures (Clercx, 2013; Pedersen, Kunz, Rasmussen, &
Elsass, 2010; Stoll, Heinzen, Köhler, & Huchzermeier, 2011).
With any new model, one particular aspect of validity that is
critical to establish is content validity. In relation to the CAPP,
content validity was addressed initially by conducting a compre-
hensive literature review as well as interviews with clinicians
regarding perceived features of the disorder (Cooke, Michie, Hart,
& Clark, 2004). More recently, a few studies have specifically
investigated the content validity of the CAPP model by conducting
prototypicality analyses of the 33 items (e.g., Hoff, Rypdal,
Mykletun, & Cooke, 2012; Kreis, Cooke, Michie, Hoff, & Logan,
2012; Smith, Edens, Clark, & Rulseh, 2013). Prototypicality anal-
yses allow for further exploration of a measure’s content validity
by determining the extent to which the item content purportedly
taps the construct of interest (Kreis et al., 2012). The rationale
assumes that the more one resembles the target descriptors, the
closer one approximates the construct, although other more distally
associated features may be tapped as well.
Practitioners’ Perceptions About Psychopathy
Relatively few studies have examined how psychopathy is per-
ceived by practitioners and experts within the correctional and
forensic mental health fields (Rogers, Duncan, Lynett, & Sewell,
1994). In a study by Cruise, Colwell, Lyons, and Baker (2003),
perceptions of psychopathy in adolescents were examined among
juvenile detention and probation officers (N ⫽ 424). Factor anal-
yses revealed five basic dimensions that raters perceived to be
indicative of adolescent psychopathy: juvenile delinquency, seri-
ous/violent conduct problems, narcissistic/manipulation of others,
impulsivity/acting out, and family problems (see also Salekin,
Rogers, & Machin, 2001).
In a somewhat related line of research, Widiger and Lynam
(1998) proposed that psychopathy could be represented by general
personality traits and therefore be described by experts without the
constraint of specific conceptual boundaries. Miller, Lynam, Wi-
diger, and Leukenfeld (2001) subsequently surveyed experts who
rated a prototypical male or female psychopath using the Five-
Factor Model. The resemblance between this expert-generated
prototype and individual scores on the Revised NEO-Personality
Inventory (NEO-PI-R; Costa & McCrae, 1992) was investigated
among community members (N ⫽ 481). The results showed good
overlap between the expert-based prototype and the self-reported
NEO-PI-R profile.
More recently, a few studies have examined rater perceptions
about psychopathy in adults specifically using the CAPP model.
Kreis et al. (2012) investigated content validity of the model in its
original language by asking international mental health profession-
als (practitioners or researchers; N ⫽ 132) to evaluate how indic-
ative CAPP symptoms were to adult psychopathy. Most partici-
pants were psychologists (61.5%) or psychiatrists (26.9%),
working in hospitals (43.5%) or academia (31.3%). To investigate
both sensitivity and specificity, the symptoms were rated both in
relation to a specific psychopathic client with whom the partici-
pants had worked, but also a specific nonpsychopathic client. The
results showed that most CAPP symptoms were both sensitive to
and also highly specific to participants’ construals of psychopathy.
The large majority of symptoms were rated as highly representa-
tive, with 10 symptoms (i.e., Lacks remorse, Unempathic, Self-
centered, Manipulative, Lacks emotional depth, Deceitful, Insin-
cere, Self-aggrandizing, Sense of entitlement, and Self-justifying)
rated as very high (i.e., M ⱖ 6, on a scale from 1 to 7). Regarding
symptom specificity, there were significant differences in the
ratings for the psychopathic and nonpsychopathic client for all but
three of the CAPP symptoms (i.e., Unstable self-concept, Lacks
concentration, and Lacks pleasure). At the scale level, the Attach-
ment, Dominance, and Self domains received the highest ratings. A
confirmatory factor analysis (CFA) showed that two CAPP do-
mains (i.e., Attachment and Behavioral) achieved good fit but that
the remaining domains received good fit only following some
modifications.
In a related study, Hoff et al. (2012) collected CAPP prototypi-
cality ratings from 796 Norwegian participants, including commu-
nity residents, forensic mental health professionals, and correc-
tions professionals. Overall, the results supported the content
validity of the CAPP model. It is interesting to note that there was
for the most part substantial overlap between layperson ratings and
mental health professionals. The majority of the individual CAPP
 PSYCHOPATHY PROTOTYPE
symptoms were evaluated as prototypical of psychopathy, and all
CAPP domains were rated as at least moderately typical across all
three samples. Consistent with the study by Kreis et al. (2012), the
Self, Dominance, and Attachment received the highest ratings (i.e.,
they were seen as more prototypical of psychopathy, compared
with the Behavioral and Cognitive domains). Furthermore, a CFA
indicated that two domains (Attachment and Behavioral) were
underpinned by unidimensional constructs. The remaining do-
mains, however, achieved good fit only after removal of a few
problematic symptoms. We should note, however, that the rele-
vance of CFA results to prototype ratings seems somewhat ques-
tionable, given that the intent is not to identify an underlying
dimension within a sample that has varying levels of the trait.
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Rather, the goal is to identify highly prototypical items that for the
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most part will have skewed levels of endorsement, which can be
problematic in relation to statistical analyses intended to examine
the internal structure of a scale.
In addition to the prototypicality of specific symptoms and person-
ality traits as indicators of psychopathy, some recent research has
begun to investigate attitudes concerning psychopathy more broadly.
For example, Furnham, Daoud, and Swami (2009) surveyed commu-
nity members in Great Britain regarding their understanding of psy-
chopathic traits and their attitudes regarding psychopaths. They asked
participants to rate a list of descriptive phrases related to multiple
topics, including behavioral, etiological, and treatment-relevant is-
sues. They identified three basic dimensions underpinning these rat-
ings, which they labeled intelligence and social skills, demographics
(e.g., male), and criminality and aggression. Participants tended to
view psychopathic individuals as intelligent and socially adept, gen-
erally viewed psychopathy as a disorder stemming primarily from
environmental stressors, and perceived that psychopathic symptoms
would be amenable to various types of treatment.
More recently, Smith et al. (2013) surveyed over 400 individuals
attending jury duty in the United States regarding various perceptions,
attitudes, and beliefs they had concerning psychopaths. The protocol
included questions concerning knowledge and beliefs about psychop-
athy (e.g., prevalence in society) and attitudinal scales concerning
potential associated features (e.g., criminality, rehabilitation poten-
tial), etiological underpinnings, moral judgments and legal sanctions.
Jury panel members viewed psychopaths as relatively violence-prone
but did not strongly endorse the position that psychopathy can be
equated with being “evil” (cf. Edens, Clark, Smith, Cox, & Kelley,
2013). Similar to the results of Furnham et al. (2009), participants
tended to view psychopaths as somewhat more intelligent than the
average criminal and difficult to identify in society. They were some-
what prone to endorse punitive sanctions, such as that psychopathic
criminal should be treated more harshly in criminal justice settings
and that psychopaths should be incarcerated to protect society. In
contrast to the Furnham et al. study, jurors were more neutral about
the potential for psychopaths to change or be cured through treatment.
It is interesting to note that jurors tended to confuse psychopathic
traits with symptoms of psychosis, rating characteristics such as
delusional beliefs as relatively prototypical of psychopathy.
The Present Study
Given the preceding literature review, the present study sought
to expand on extant validation research on the CAPP by (a)
examining prototypicality ratings of a Swedish translation of the
3
standard CAPP prototype form among individuals working in the
forensic mental health system in Sweden, and (b) investigating
these individuals’ global perceptions and attitudes about a number
of aspects of the psychopathy construct, including perceived prev-
alence of psychopathy, perceived correlates of psychopathic traits
across a variety of domains (e.g., violence propensity, perceived
etiology, treatment amenability), as well as moral judgments and
attitudes concerning how psychopathic offenders should be treated
within the legal system. Similar to the results of Kreis et al. (2012)
and Hoff et al. (2012), we expected that individuals working in
forensic mental health settings would identify the majority of
CAPP items as prototypical of what they considered to be a
psychopath. In regards to global attitudes concerning psychopathy,
our results are somewhat more exploratory. We did expect, how-
ever, that individuals who work with forensic clients on a routine
basis would rate psychopaths as relatively prone to violence and
difficult to treat. We also expected participants to be relatively less
likely to endorse symptoms of psychosis as being prototypical of
psychopathy compared with community members.
Method
Participants and Setting
Participants were recruited from two different settings within
the Swedish forensic psychiatric system: forensic assessment units
in Stockholm and Gothenburg that are operated by the National
Board of Forensic Medicine, as well as forensic psychiatric treat-
ment wards operated by the Stockholm County Council. In total,
144 individuals were invited to participate in the study. The overall
response rate was 62.5%. The specific response rates were 61.4%
and 80.4% at the assessment units (Stockholm and Gothenburg,
respectively) and 48% at the treatment wards. The final sample
consisted of 90 forensic practitioners between 20 and 73 years of
age (M ⫽ 43 years, SD ⫽ 12.06). The sample was relatively evenly
split between women (52.2%) and men (47.8%).
In Sweden, the court may request a presentence forensic psy-
chiatric evaluation to inquire whether a crime has been committed
under the influence of a severe mental disorder (SMD), which is
a medico-legal concept reflecting a particular legal status that is
not linked to a specific psychiatric condition. An individual clas-
sified as SMD may suffer from a number of different diagnoses.
According to the National Board of Forensic Medicine, which
tracks all evaluations, psychotic disorders including schizophrenia
make up one third of the diagnoses. Other diagnoses may include
severe depression with suicidal intent, neuropsychological disabil-
ities with severe compulsive behavior, and in some instances
profound cases of personality disorder, dementia, mental retarda-
tion, or brain damage. Forensic psychiatric evaluations are con-
ducted at any of the three assessment units in Sweden (Stockholm,
Gothenburg, and Umeå) under the authority of the National Board
of Forensic Medicine, which is a governmental agency within the
Ministry of Justice. The Stockholm and Gothenburg departments,
from which our participants were recruited, perform more than
90% of these evaluations in Sweden.
SMD evaluations are performed by a team consisting of a senior
consultant forensic psychiatrist in charge of the evaluation, a
psychologist, a forensic social investigator and a member of the
ward staff. The majority of examinees is on remand and is there-
 4 SÖRMAN ET AL.

fore detained at the ward during the course of the evaluation. An Table 1
evaluation is generally completed within 4 weeks. Offenders who Participant Characteristics
are found to have committed the criminal act under the influence
of an SMD may be sentenced to forensic psychiatric care (in lieu Forensic Forensic Clinical
evaluators ward staff ward staff
of prison), with or without court restrictions. According to the
Swedish legislation, psychopathy in isolation does not constitute Total 34 30 24
an SMD. Therefore, offenders who exhibit pronounced psycho- Women 22 (64.7) 11 (36.7) 12 (50.0)
Age
pathic traits in the absence of other mental disorders generally
25 or below 0 (0) 1 (3.3) 2 (8.3)
would not be referred for an SMD evaluation. In rare instances 26–35 7 (21.2) 6 (20.0) 11 (45.8)
where psychopathic individuals do undergo SMD evaluations, they 36–50 14 (42.4) 13 (43.3) 6 (25.0)
typically are sentenced to prison and not to forensic psychiatric Above 50 12 (36.4) 10 (33.3) 5 (20.8)
care. Individuals who are detained within the forensic psychiatric Highest level of education
High school, at least 2 years 0 (0) 2 (6.7) 5 (20.8)
system may present with varying degrees of psychopathic traits, Post high school education, not
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however. college 0 (0) 15 (50.0) 10 (41.7)

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College, max 2 years 0 (0) 2 (6.7) 2 (8.3)

Occupational Subgroups College, more than 2 years 34 (100) 11 (36.7) 7 (29.2)
Profession
Participants were divided into three subgroups: (1) forensic Senior consultant forensic
evaluators at the National Board of Forensic Medicine, (2) forensic psychiatrist 10 (29.4) 0 (0) 0 (0)
Psychologist 12 (35.3) 0 (0) 0 (0)
ward staff at the National Board of Forensic Medicine, and (3) Forensic social investigator 12 (35.3) 0 (0) 0 (0)
clinical ward staff from the treatment units operated by the Stock- Ward staff 0 (0) 21 (70.0) 18 (75.0)
holm County Council. The subgroups differed with respect to Nurse 0 (0) 8 (26.7) 6 (25.0)
several occupational and educational differences: level of aca- Occupational therapist 0 (0) 1 (3.3) 0 (0)
demic education, occupational experience with structured assess- Work experiencea
⬍1 years 4 (11.8) 4 (13.3) 4 (16.7)
ments of personality, performance of forensic evaluations for the 1–5 years 10 (29.4) 7 (23.3) 6 (25.0)
courts, and degree and extent of interaction with clients. 5–15 years 14 (41.2) 8 (26.7) 7 (29.2)
Forensic evaluators. Forensic evaluators are senior consul- ⬎15 years 6 (17.6) 11 (36.7) 7 (29.2)
tant forensic psychiatrists, psychologists, and forensic social in- Victim historyb 6 (18.8) 7 (23.3) 4 (17.4)
vestigators at the National Board of Forensic Medicine who per- a
Number of years the participant has worked as an independent forensic
form SMD evaluations for the court. In addition, some of these evaluator/ward staff/treatment staff. b “Have you ever been victim of a
evaluators receive specialized risk assessment training. The ma- harmful act or acts by someone you consider a psychopath?”
jority of the forensic evaluators have undergone formal PCL-R
training, and some have received CAPP training, though the CAPP
Demographic information. Participants were asked basic de-
is not currently used as part of forensic assessments.
mographic questions (e.g., age, gender, level of education, occu-
Forensic ward staff. Forensic ward staff includes frontline
pation, and number of years of work experience). Because of
staff, nurses, and occupational therapists working at the wards at
concerns about maintaining anonymity, certain occupational and
the National Board of Forensic Medicine, where the detainees
training details were not requested (e.g., participation in previous
reside during the 4-week SMD evaluation. The majority of the
CAPP training) that might cause a participants’ identity to be
forensic ward staff have received PCL-R training.
discerned.
Clinical ward staff. The clinical ward staff subgroup is com-
Psychopathic traits. Participant conceptualizations of psy-
prised of frontline staff and nurses working at the forensic treat-
chopathic traits were assessed via a total of 77 items endorsed on
ment units, where offenders who have been charged with serious
a 7-point Likert rating scale. These ratings were divided into two
crimes are detained five years on average. At the forensic treat-
main sections.
ment units, ward staff very rarely undergo any PCL-R training, and
Universal protocol for conducting prototypicality studies
they do not conduct any psychological assessments for the courts.
with the comprehensive assessment of psychopathic
In the occupational subgroup analyses, two participants (one
personality. In the first section, we asked participants to rate
psychologist and one forensic social investigator) from the
how typical they thought the traits were of a male client who they
treatment units were excluded as they do not meet the definition
considered a prototypical psychopath. The Likert scale was an-
of forensic evaluators and therefore did not fit into any of the
chored at 1 (low prototypicality) to 7 (high prototypicality). The
three categories. For detailed descriptions on participant char-
first section reproduced the items from the Universal Protocol for
acteristics, see Table 1.
Conducting Prototypicality Studies with the Comprehensive As-
sessment of Psychopathic Personality (Kreis, 2008) in its entirety.
Measures
This protocol consists of 42 items, each with three supplemental
Participants completed a modified Swedish translation of a adjectival descriptors to aid interpretation of the item content (e.g.,
survey form regarding psychopathy that has been used in a previ- Unreliable: undependable, untrustworthy, irresponsible). In addi-
ous study of U.S. community members attending jury duty; Smith tion to the psychopathy-items, nine “foil” or control items are
et al. (2013). The survey included the standard CAPP prototype embedded in the protocol that tap features that are unrelated (e.g.,
rating protocol (Kreis, 2008) and several other measures described Strange, Perfectionistic) or diametrically opposed (e.g., Self-
below. conscious, Shy, Conscientious, Cautious, Dependent) to psychop-
 PSYCHOPATHY PROTOTYPE
athy. Following these 42 standard items, we supplemented the
standard CAPP protocol by adding three items to assess psychotic
symptoms (i.e., Peculiar behavior, Delusional beliefs, and Dis-
turbed thinking). Participants also completed some additional
items as part of the protocol that are not the focus of the present
research. The items regarding psychotic symptoms were originally
included in the Smith et al. (2013) protocol to investigate whether
U.S. jurors tend to conflate psychopathy with psychotic symptoms.
The CAPP model was developed by using a lexical approach;
that is, personality traits are described using natural language
indicators that ostensibly should be easily translated across cul-
tures and languages. To date, the CAPP has been translated into 16
different languages. Our translation of the CAPP prototype proto-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
col was reviewed by several bilingual individuals, fluent in English
This document is copyrighted by the American Psychological Association or one of its allied publishers.
and Swedish, some with previous experience with the psychopathy
construct and some with only layperson knowledge of this disor-
der.
Knowledge, attitudes, and beliefs about psychopathy.
Following completion of the CAPP protocol, participants re-
sponded to questions concerning whether they had ever been a
victim of a harmful act or acts by someone they consider a
psychopath and to questions regarding perceptions about preva-
lence of psychopaths (a) in the community and (b) at the assess-
ment/treatment units.
In the next section of the protocol, participants responded to a
series of 28 attitudinal statements about psychopathy that covered
a range of topics, including perceived association with crime and
violence propensity, moral judgments and legal perspectives, eti-
ology, immutability/rehabilitation potential, as well as quasi-
adaptive features that might be associated with psychopathy (e.g.,
intelligence). The content of these items was generated by Smith et
al. (2013) based on prior surveys (e.g., Furnham et al., 2009;
Helfgott, 1997) addressing perceived correlates of psychopathy. A
few minor alterations were made to the content of two items to
make them applicable to Swedish mental health professionals: (a)
the item “Psychopaths who commit crimes should be declared
insane and hospitalized” was reworded to “Psychopaths who com-
mit crimes should be classified as SMD and be sentenced to
forensic psychiatric care” and (b) for the item “Being a psycho-
path can be helpful or advantageous in some jobs (such as stock
broker, attorney, politician), “attorney” was replaced by “high-
level manager.”
The statements were rated on a one to 7-point scale (1 ⫽
Strongly Agree, 7 ⫽ Strongly Disagree). Similar to Smith et al.
(2013), to reduce the total number of analyses, the items were
grouped conceptually into broad domains and factor analyzed
(principal components analyses with varimax rotation; see Table 3
for factor loadings). To simplify the interpretation of these items,
we subsequently reverse-scored them such that higher scores in
Table 3 reflect stronger endorsement of these statements. Based on
the results of the factor analyses, we created nine scales by
summing raw scores of items significantly loading on the factors
within each domain. Prior to creating these subscales, the few
items with negative factor loadings were reverse-scored so that
item content was endorsed in a similar direction. Further details
about the factor analytic findings are available from the second
author upon request.
5
Procedure
Preceding data collection, staff members at the different units
were informed about the study through written study information
and also orally at weekly staff meetings. Participation was volun-
tary and confidential, and no identifying information was attached
to the completed forms. The study was approved by the Regional
Ethics Committee. No remuneration was provided for participa-
tion.
Results
CAPP Prototype Ratings
Table 2 presents descriptive statistics for the CAPP domains and
individual items, along with the “foil” items and psychotic-
spectrum items embedded in the protocol. Following convention
(Hoff et al., 2012), domains/items rated between four and five are
considered “moderately” prototypical and those above five are
considered “highly” prototypical. Overall, there was variability in
prototypicality ratings across symptoms, though a large majority of
the 33 items (82%) were rated as moderately prototypical (M ⱖ 4),
and 10 items (30%) were rated as very high (M ⱖ 6). The five
highest rated items were Manipulative, Lacks remorse, Deceitful,
Self-centered, and Self-aggrandizing. In contrast, a few CAPP
items received mean ratings below four. The items Lacks pleasure,
Lacks concentration, and Unstable self-concept were rated as the
least prototypical of psychopathy. Moreover, Lacks planfulness,
Restless, and Antagonistic, also received mean ratings below four.
In contrast to the generally high ratings for the CAPP items, the
mean rating for the foil items was only 2.34. None of the foils was
rated as even moderately prototypical, with the highest rated item
(Perfectionistic) only reaching a mean score of 3.56. Consistent
with the low ratings for Strange, the three psychotic-spectrum
items received a mean rating of only 2.49. For a graphic illustra-
tion of the CAPP ratings, see Figure 1. Also included in this figure
for comparison purposes are ratings provided by Norwegian fo-
rensic psychiatric experts from the Hoff et al. (2012) study de-
scribed earlier. As can be seen, there was quite a degree of
convergence across the two samples, particularly in relation to
what were considered to be highly prototypical items. There was
some variability, however, with Cognitive items generally being
rated as less prototypical in our sample.
All CAPP domains in our sample were rated as moderately to
highly prototypical (Table 2). The Dominance, Self, and Attach-
ment domains were rated as the most prototypical, with mean
scores greater than 5. The Cognitive and Behavioral domains were
rated as the least prototypical, with mean scores below 5. The
Dominance and Self domains were ranked significantly higher than
the remaining domains (based on paired sample t tests, p ⱕ .001).
All CAPP domains were rated as significantly more prototypical
than a scale based on the aggregated foil items (all paired sample
t tests were 15.53 or above, p ⬍ .001). We also examined potential
gender differences in CAPP prototype ratings across the six scales.
None of the effects was statistically significant. The largest com-
parison produced a Cohen’s d-value of .40, 95% confidence inter-
val (CI) ⫽ ⫺.02 to .82 for the Attachment domain.
In subsequent analyses, we examined potential differences be-
tween the three occupational subgroups with a multivariate anal-
 6 SÖRMAN ET AL.

Table 2
Descriptive Statistics for Swedish Forensic Mental Health Professionals’ Comprehensive
Assessment of Psychopathic Personality (CAPP) Domain and Item Prototypicality Ratings

M (SD)
Total sample Forensic evaluators Forensic ward staff Clinical ward staff
Domain/items (N ⫽ 90) (n ⫽ 34) (n ⫽ 30) (n ⫽ 24)

Attachment 5.32 (1.01) 5.74 (0.71) 5.04 (1.13) 5.02 (1.07)

Unempathic 6.08 (1.43) 6.29 (1.09) 6.00 (1.86) 5.88 (1.30)
Uncommitted 5.27 (1.40) 5.91 (0.79) 4.70 (1.64) 5.09 (1.47)
Detached 4.97 (1.65) 5.09 (1.36) 5.11 (1.77) 4.58 (1.89)
Uncaring 4.96 (1.56) 5.65 (0.92) 4.33 (1.81) 4.58 (1.53)
Behavioral 4.82 (0.90) 5.24 (0.70) 4.66 (1.03) 4.47 (0.77)
Unreliable 6.01 (1.34) 6.50 (0.62) 5.72 (1.75) 5.75 (1.29)
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Reckless 5.74 (1.39) 6.18 (0.90) 5.37 (1.73) 5.64 (1.40)

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Aggressive 5.23 (1.35) 5.35 (0.77) 5.33 (1.49) 4.87 (1.78)

Disruptive 4.23 (1.59) 4.56 (1.46) 4.10 (1.83) 3.96 (1.46)
Lacks perseverance 4.22 (1.55) 5.09 (1.06) 3.90 (1.67) 3.39 (1.47)
Restless 3.52 (1.80) 3.76 (1.72) 3.53 (1.81) 3.29 (1.94)
Cognitive 4.10 (0.93) 4.01 (0.76) 4.00 (0.99) 4.33 (1.08)
Intolerant 4.78 (1.47) 4.68 (1.41) 4.83 (1.39) 4.78 (1.73)
Inflexible 4.51 (1.61) 3.50 (1.67) 4.93 (1.29) 5.29 (1.12)
Suspicious 4.36 (1.61) 4.24 (1.42) 3.93 (1.80) 5.00 (1.50)
Lacks planfulness 3.48 (1.82) 4.30 (1.67) 3.23 (1.79) 2.75 (1.75)
Lacks concentration 3.29 (1.67) 3.35 (1.50) 2.96 (1.67) 3.74 (1.86)
Dominance 5.73 (0.64) 5.85 (0.49) 5.62 (0.82) 5.72 (0.61)
Manipulative 6.63 (0.71) 6.68 (0.54) 6.57 (0.97) 6.67 (0.57)
Deceitful 6.26 (0.88) 6.41 (0.70) 5.97 (1.13) 6.37 (0.71)
Insincere 6.07 (1.15) 6.38 (0.85) 5.73 (1.41) 6.08 (1.10)
Domineering 5.80 (0.94) 5.74 (0.99) 5.79 (0.73) 5.88 (1.12)
Garrulous 5.68 (1.36) 5.88 (0.98) 5.90 (1.37) 5.29 (1.65)
Antagonistic 3.92 (1.42) 4.00 (1.16) 3.66 (1.74) 4.04 (1.37)
Emotional 5.10 (0.65) 5.35 (0.56) 4.97 (0.74) 4.91 (0.59)
Lacks remorse 6.42 (0.94) 6.62 (0.55) 6.43 (0.86) 6.08 (1.35)
Lacks emotional depth 5.87 (1.44) 6.26 (1.08) 5.55 (1.80) 5.71 (1.30)
Lacks anxiety 5.53 (1.32) 5.88 (1.09) 5.37 (1.56) 5.29 (1.23)
Lacks emotional stability 5.19 (1.36) 5.44 (0.82) 5.23 (1.57) 4.88 (1.54)
Lacks pleasure 2.43 (1.59) 2.42 (1.46) 2.30 (1.69) 2.48 (1.59)
Self 5.67 (0.66) 5.71 (0.57) 5.68 (0.70) 5.56 (0.74)
Self-centered 6.17 (0.93) 6.21 (0.77) 6.27 (0.94) 5.92 (1.10)
Self-aggrandizing 6.14 (1.05) 6.21 (0.64) 6.20 (1.27) 5.96 (1.23)
Self-justifying 6.13 (1.23) 6.56 (1.11) 6.17 (1.02) 5.50 (1.45)
Sense of uniqueness 6.03 (1.12) 5.88 (1.18) 6.10 (1.13) 6.17 (1.09)
Sense of invulnerability 5.99 (0.99) 5.91 (0.79) 5.93 (1.17) 6.17 (1.05)
Sense of entitlement 5.83 (0.93) 5.82 (0.72) 5.77 (1.14) 5.86 (0.94)
Unstable self-concept 3.37 (1.66) 3.41 (1.50) 3.33 (1.71) 3.38 (1.93)
Foils 2.34 (0.98) 1.74 (0.52) 2.37 (0.83) 3.15 (1.05)
Perfectionistic 3.56 (1.81) 2.59 (1.26) 3.79 (1.88) 4.58 (1.67)
Strange 2.90 (1.73) 1.91 (0.88) 2.97 (1.50) 4.13 (1.99)
Dependent 2.55 (1.73) 2.35 (1.54) 2.71 (1.94) 2.71 (1.81)
Restrained 2.50 (1.60) 1.79 (0.95) 2.23 (1.38) 3.75 (1.75)
Conscientious 2.40 (1.57) 1.32 (0.54) 2.63 (1.73) 3.54 (1.44)
Considerate 2.04 (1.44) 1.50 (0.75) 2.00 (1.34) 2.88 (1.92)
Cautious 1.78 (1.20) 1.35 (0.69) 1.80 (0.96) 2.38 (1.74)
Self-conscious 1.70 (1.06) 1.47 (0.90) 1.69 (0.89) 2.09 (1.41)
Shy 1.64 (1.13) 1.35 (0.73) 1.50 (0.94) 2.21 (1.56)
Psychotic symptomsa 2.49 (1.36) 1.63 (0.73) 2.34 (1.13) 3.78 (1.29)
Peculiar behavior 3.03 (1.77) 2.00 (0.92) 2.93 (1.56) 4.61 (1.80)
Delusional beliefs 2.43 (1.60) 1.53 (0.90) 2.17 (1.37) 3.88 (1.62)
Disturbed thinking 1.96 (1.34) 1.35 (0.73) 1.76 (1.06) 2.96 (1.73)
Note. Items were rated on a scale from 1 (not typical) to 7 (very typical).
a
Psychotic symptom items are not included in the original CAPP prototypicality protocol but were added for this study.

ysis of variance (MANOVA) using Wilks’ criterion (␭). The .39. Specifically, differences in ratings were found for the CAPP
omnibus test was significant, indicating that the CAPP, foil, and Attachment, F(2, 85) ⫽ 5.46, p ⫽ .01, partial ␭2 ⫽ .11; Behav-
psychotic-spectrum prototypicality ratings significantly differed ioral, F(2, 85) ⫽ 6.77, p ⬍ .01, partial ␭2 ⫽ .14; and Emotional,
across rater subgroups, F(16, 156) ⫽ 6.22, p ⬍ .01, partial ␩2 ⫽ F(2, 85) ⫽ 4.23, p ⬍ .05, partial ␭2 ⫽ .09, domains, as well as for
 PSYCHOPATHY PROTOTYPE 7

Table 3
Participants’ Perspectives on Psychopathy

M(SD)
Total Forensic Forensic Clinical
Attitudinal items sample evaluators ward staff ward staff EFA loadings

Factor 1 Factor 2
Criminality and violence potential
Crime propensity
Psychopaths are more likely to be violent than the average
criminal is. 4.44 (1.72) 4.35 (1.61) 4.66 (1.97) 4.33 (1.66) .79
Psychopaths are more likely to commit crimes than the average
criminal is. 4.86 (1.66) 5.36 (1.41) 4.63 (1.87) 4.48 (1.68) .76
Violence propensity
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Psychopaths are violent predators who prey on other people. 3.14 (1.78) 3.12 (1.67) 2.87 (1.93) 3.58 (1.79) .82
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Most psychopaths are murderers. 2.17 (1.79) 1.74 (1.66) 2.43 (2.00) 2.57 (1.65) .80
Factor 1 Factor 2 Factor 3
Moral judgments and legal perspectives
Responsibility and punishment
Psychopaths who commit crimes should be classified as SMD
and be sentenced to forensic psychiatric care. 2.84 (2.30) 1.68 (1.25) 2.60 (2.31) 4.71 (2.29) .76
Psychopaths can understand the difference between right and
wrong. 5.08 (2.00) 5.85 (1.60) 5.73 (1.48) 3.08 (1.82) ⫺.72 ⫺.35
If someone is a psychopath, we should be able to lock him or
her up to protect society, even if he or she has not
committed a crime. 1.73 (1.44) 1.38 (1.10) 1.70 (1.56) 2.33 (1.61) .68
Some psychopaths can avoid getting into trouble with the
criminal justice system. 5.47 (1.84) 5.94 (1.61) 5.57 (1.87) 4.75 (1.94) ⫺.67 .43
Psychopaths are responsible for their actions. 5.56 (2.05) 5.79 (1.90) 6.10 (1.56) 4.50 (2.49) ⫺.57 ⫺.33
Moral judgments
Psychopathy is caused by lack of morals or values. 3.63 (2.00) 2.97 (1.90) 3.77 (2.16) 4.38 (1.74) .80
“Psychopath” is another word for describing a person who is
basically evil. 2.93 (1.86) 2.65 (1.61) 2.83 (1.84) 3.58 (2.15) .68
Psychopathic criminals should be treated more harshly by the
criminal justice system than criminals who are not
psychopaths. 2.58 (1.81) 2.00 (1.52) 2.41 (1.92) 3.75 (1.60) .57
Noncriminal
Most psychopaths are in jails or prisons. 3.11 (1.87) 3.15 (1.81) 3.00 (1.95) 3.29 (1.97) ⫺.83
There are many psychopaths who do not commit crimes. 5.38 (1.64) 5.29 (1.57) 5.30 (2.07) 5.62 (1.14) .82
Etiology Factor 1 Factor 2
Bad parenting
Psychopathy is caused by physical or mental abuse during
childhood or adolescence. 3.65 (1.78) 4.03 (1.47) 3.29 (2.21) 3.42 (1.59) .83
Psychopathy is caused by poor or inadequate parenting. 3.13 (1.84) 2.88 (1.51) 3.13 (2.13) 3.46 (1.91) .81
Biological etiology
Psychopathy is caused by genes or hereditary factors. 4.38 (1.49) 4.79 (1.19) 4.00 (1.88) 4.26 (1.25) .84
Psychopathy is caused by brain damage (head injuries, tumors,
etc.). 3.48 (1.82) 3.75 (1.92) 3.30 (1.92) 3.35 (1.58) .81
Factor 1
Immutability/rehabilitation potential
There is no treatment that can cure a psychopath. 5.16 (1.65) 4.70 (1.47) 5.73 (1.46) 5.17 (1.88) .82
Psychopaths can never change; they will always be psychopathic. 4.71 (1.68) 4.53 (1.54) 4.73 (1.89) 5.00 (1.59) .72
Criminal psychopaths can be rehabilitated. 3.57 (1.54) 3.94 (1.32) 3.27 (1.68) 3.37 (1.53) ⫺.73
Factor 1
Quasi-adaptive features
Psychopaths are more likely to be successful in life than the
average person is. 4.03 (1.86) 3.09 (1.78) 4.47 (1.78) 4.92 (1.53) .80
Psychopaths are more intelligent than the average criminal is. 4.06 (1.74) 3.50 (1.71) 3.97 (1.69) 5.00 (1.59) .76
Psychopaths have better social skills than the average person. 4.20 (1.76) 3.74 (1.58) 4.53 (1.66) 4.58 (2.00) .72
Psychopathic criminals are less likely to get caught than the
average criminal is. 3.88 (1.58) 3.47 (1.64) 4.23 (1.59) 3.96 (1.46) .72
Being a psychopath can be helpful or advantageous in some jobs
(such as high-level manager, stock broker, politician). 5.02(1.91) 4.76 (1.72) 5.41 (1.86) 4.96 (2.26) .59
It is easy to tell if someone is a psychopath.a 4.03 (1.69) 4.47 (1.56) 4.07 (1.72) 3.46 (1.74)
Psychopaths do not have stable, long-term relationshipsa 5.48 (1.44) 5.59 (1.26) 5.37 (1.61) 5.42 (1.56)
Note. Item ratings range from 1 (strongly disagree) to 7 (strongly agree). Boldface indicates mean rating significantly differs from the midpoint of the
scale at p ⬍ .01.
a
Item did not load onto a particular factor.
 8 SÖRMAN ET AL.
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Figure 1. Forensic practitioner participant ratings of psychopathic traits plotted in comparison to data reported
by Hoff et al. (2012) for Norwegian forensic practitioners. Participants in the Hoff et al. study did not rate the
psychotic symptom (P) items that were included in the present study.

the scales consisting of the aggregated CAPP foil, F(2, 85) ⫽
22.17, p ⬍ .01, partial ␭2 ⫽ .34, and psychotic-spectrum items,
F(2, 85) ⫽ 30.18, p ⬍ .01, partial ␭2 ⫽ .42.
Post hoc tests with Bonferroni corrections showed that the mean
scores (Table 2) for the Attachment domain significantly differed
(p ⬍ .05) between the forensic evaluators and both groups of ward
staff, with the forensic evaluators giving higher mean ratings to
items on this CAPP domain (Cohen’s d ⫽ .74, 95% CI ⫽ .22 to
1.26 and .79, 95% CI ⫽ .23 to 1.35). Similar results were obtained
for CAPP Behavioral domain ratings, with the forensic evaluators
endorsing significantly higher mean ratings for these items than
either the forensic (p ⬍ .05, Cohen’s d ⫽ .66, 95% CI ⫽ .14 to
1.18) or clinical ward staff (p ⬍ .01, Cohen’s d ⫽ 1.05, 95% CI ⫽
.47 to 1.63). The forensic evaluators also gave significantly higher
mean CAPP Emotional domain ratings than did the clinical ward
staff (p ⬍ .05, Cohen’s d ⫽ .76, 95% CI ⫽ .20 to 1.32).
Ratings for the aggregate CAPP foil items significantly differed
between all three subgroups, with the forensic evaluators endors-
ing lower mean ratings for these items than either the forensic (p ⫽
.01, Cohen’s d ⫽ .91, 95% CI ⫽ .37 to 1.45) or clinical ward staff
(p ⬍ .01, Cohen’s d ⫽ 1.70, 95% CI ⫽ 1.06 to 2.34). The clinical
ward staff mean ratings were also significantly greater than those
ascribed by the forensic ward staff (p ⬍ .01, Cohen’s d ⫽ .82, 95%
CI ⫽ .24 to 1.4), indicating that the clinical ward staff perceive
these foil characteristics as somewhat more prototypical of psy-
chopathy than the other rater subgroups. A similar pattern emerged
for the psychotic-spectrum aggregate items, with the forensic
evaluators’ mean ratings being significantly lower than the foren-
sic (p ⫽ .02, Cohen’s d ⫽ .75, 95% CI ⫽ .23 to 1.27) or clinical
ward staff (p ⬍ .01, Cohen’s d ⫽ 2.05, 95% CI ⫽ 1.39 to 2.71) and
the clinical ward staff rating these items significantly higher than
the forensic ward staff (p ⬍ .01, Cohen’s d ⫽ 1.19, 95% CI ⫽ .59
to 1.79).
To examine whether gender, years of experience, or the inter-
action of rater gender and profession subgroup impacted the rat-
ings, we then entered these variables into the model as predictors.
Results reflected no main effect of gender or years of experience,
nor were there any interactive effects on prototypicality ratings
across gender and profession subgroups.
Knowledge, Attitudes, and Experiences Concerning
Psychopaths
Regarding victimization experiences, approximately 20% of the
participants reported that they believed they had been the victim of
a harmful act by someone they consider a psychopath. These rates
did not appreciably differ across the three subgroups (Table 1).
Also, those who reported such victimization did not significantly
differ from those who did not in their prototype ratings on any of
the CAPP domains.
Participants were also asked about perceived prevalence rates of
psychopathy (in the community as well as at the assessment/
treatment units). Only a small number of participants reported
believing that psychopaths were as common as 1 out of 5 or 1 out
of 10 individuals in the community (1.1% and 4.5%, respectively).
The majority of participants (45.5%) reported believing that 1 out
of 100 individuals in the community is a psychopath, with 48.9%
of participants reported that psychopaths are even less common (1
out of 1,000 or 1 out 10,000 individuals). Regarding prevalence on
the unit, only a small number of participants (4.6%) reported that
 PSYCHOPATHY PROTOTYPE
1 out of 5 detainees is a psychopath. In contrast, 23% reported that
1 out of 10 is a psychopath, 26.4% reported that 1 out of 20 is a
psychopath, 27.6% reported that 1 out of 50 is a psychopath and
18.4% reported that 1 out of 100 at the unit is a psychopath.
Next, we examined potential differences between subgroups
regarding perceived prevalence of psychopathy. Because of small
cell sizes for these analyses, the response options were dichoto-
mized. For prevalence in the community, we collapsed the re-
sponse options into 1 out of 100 or more versus 1 out of 1000 or
less. For prevalence at the unit, we collapsed the response options
into 1 out of 20 or more versus 1 out of 50 or less. With regards
to perceived prevalence in the community, there was a trend of
significant differences between the subgroups. This was driven by
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a significant difference between clinical ward staff and forensic
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evaluators; 66.7% of ward staff reported that 1 out of 100 (or
more) individuals is a psychopath, whereas only 35.3% of the
forensic evaluators thought that psychopathy was that common in
the community, ␹2(1, n ⫽ 58) ⫽ 5.55, p ⬍ .05. Regarding
prevalence at the units, there was a significant difference between
the two groups of ward staff; 75% of the clinical ward staff
reported that 1 out of 20 or more individuals at the unit is a
psychopath, whereas only 39.3% of the forensic ward staff be-
lieved that psychopaths were that common on the ward, ␹2(1, n ⫽
52) ⫽ 6.68, p ⫽ .01.
Regarding responses to the 28 attitudinal items (see Table 3 for
descriptive statistics), our participants viewed psychopaths as more
crime-prone than the average criminal and they also tended to see
psychopaths as more likely to be violent than the average criminal.
They quite strongly disagreed however with the statement that
most psychopaths are murderers per se and that psychopathy can
be equated with “evil.” They relatively strongly endorsed the
position that psychopaths are responsible for their own actions, are
capable of avoiding contact with the criminal justice system, and
can differentiate between right and wrong. Regarding punitive
actions, participants disagreed with the position that psychopathic
criminals should be treated more harshly by the criminal justice
system than other criminals. They also disagreed quite strongly
with the item stating that psychopaths should be locked up in order
to protect society, regardless of whether they had committed a
crime.
Participants were rather neutral in terms of attributing either
abusive backgrounds or biological/hereditary factors as potential
causes of psychopathy. Regarding immutability/rehabilitation po-
tential, participants were neutral about whether criminal psycho-
paths can be rehabilitated, however they quite strongly endorsed
the position that psychopaths cannot change (i.e., will remain
psychopathic) and that there is no treatment that can cure a
psychopath.
Considering potentially quasi-adaptive features associated with
psychopathy, participants had on average relatively neutral views
concerning items stating that psychopaths are more intelligent than
the average criminal and that criminal psychopaths are less likely
to get caught than the average criminal. It is interesting that
participants were neutral about the statement that psychopaths are
more likely to be successful in life than the average person is,
however they endorsed the position that psychopathic traits might
be particularly advantageous in certain occupations (e.g., high-
level manager).
9
In subsequent analyses, we examined potential differences be-
tween the three occupational subgroups on the factors by conduct-
ing a MANOVA using Wilks’ criterion (␭). The omnibus test was
significant, indicating that the level of endorsement for the attitu-
dinal scale items significantly differed across rater subgroups,
F(18, 150) ⫽ 1.85, p ⫽ .03, partial ␩2 ⫽ .18. Significant differ-
ences in ratings across subgroups were only obtained for the
quasi-adaptive features, F(2, 83) ⫽ 5.02, p ⫽ .01, partial ␩2 ⫽ .11;
moral judgments, F(2, 83) ⫽ 7.88, p ⬍ .01, partial ␩2 ⫽ .16; and
responsibility and punishment, F(2, 83) ⫽ 5.44, p ⫽ .01, partial
␩2 ⫽ .12, scales. Post hoc tests with Bonferroni corrections
showed that the mean scores (Table 3) for the quasi-adaptive
features scale significantly differed between the forensic evalua-
tors and the clinical ward staff (p ⬍ .05, Cohen’s d ⫽ .73, 95%
CI ⫽ .15 to 1.31), with the forensic evaluators providing lower
mean ratings on this scale. An inspection of results obtained for the
moral judgment scale reflected that the clinical ward staff endorsed
these items significantly more so than either the forensic evalua-
tors (p ⬍ .01, Cohen’s d ⫽ 1.04, 95% CI ⫽ .46 to 1.62) or forensic
ward staff (p ⫽ .03, Cohen’s d ⫽ .71, 95% CI ⫽ .13 to 1.29).
Finally, significant differences on the responsibility and punish-
ment scale were found between the clinical ward staff and both the
forensic evaluators (p ⫽ .02, Cohen’s d ⫽ .72, 95% CI ⫽ .14 to
1.3) and forensic ward staff (p ⫽ .01, Cohen’s d ⫽ .81, 95% CI ⫽
.23 to 1.39), with the clinical ward staff providing lower ratings on
these items than either of the other subgroups.
To examine whether gender, years of experience, or the inter-
action of rater gender and profession subgroup impacted the atti-
tudinal scale ratings, we then entered these variables into the
model as predictors. Results reflected no main effect for gender or
years of experience nor were there any interactive effects on
attitudinal item ratings across rater gender and profession sub-
group.
Finally, we examined whether these EFA-defined attitudinal
scales were significantly related to prototype ratings on the six
CAPP domains (Table 4). In the total sample, there was only one
significant (negative) relationship between the Behavioral domain
and the quasi-adaptive attitudinal scale. These results need to be
considered, however, in the context of the generally skewed nature
of the CAPP prototype ratings, which appreciably restricts the
amount of variance that can be explained, particularly for the
highly prototypical Self and Dominance domains.
When comparing subgroups, a few more notable effects
emerged. Among the forensic evaluators, there was a significant
negative association between the Emotional domain and the quasi-
adaptive attitudinal scale (r ⫽ ⫺.34, p ⬍ .05, 95% CI
[⫺.61, ⫺.002 ]), as well as a significant positive association
between the Self domain and the noncriminal scale (r ⫽ .47, p ⫽
.005, 95% CI [.16, .70]). Among the forensic ward staff, there were
significant negative relationships between the Behavioral domain
and the quasi-adaptive attitudinal scale (r ⫽ ⫺.42, p ⬍ .05, 95%
CI [⫺.68, ⫺.07]) as well as between the Self domain and the
responsibility and punishment scale (r ⫽ ⫺.40, p ⬍ .05, 95% CI
[⫺.67, ⫺.05]). There was also a positive correlation between the
Attachment domain and the immutability/rehabilitation potential
scale (r ⫽ .40, p ⬍ .05, 95% CI [.05, .67]). Among the clinical
ward staff there were significant positive correlations between the
Emotional domain and the crime propensity scale (r ⫽ .49, p ⬍
.05, 95% CI [.11, .75]), the Behavioral domain and the bad
 10 SÖRMAN ET AL.
Table 4
Correlations Between Comprehensive Assessment of Psychopathic Personality (CAPP) Prototype Ratings and Attitudinal Scales [95%
Confidence Interval]
Attitudinal scales Attachment Behavioral
Crime propensity .01 [⫺.20, .22] .13 [⫺.08, .33]
Violence propensity ⫺.007 [⫺.21, .20] ⫺.06 [⫺.26, .15]
Responsibility and punishment ⫺.03 [⫺.24, .18] ⫺.07 [⫺.27, .14]
Moral judgments ⫺.05 [⫺.25, .16] ⫺.16 [⫺.36, .05]
Noncriminal .17 [⫺.04, .36] ⫺.08 [⫺.28, .13]
Bad parenting .03 [⫺.18, .24] .10 [⫺.11, .30]
Biological etiology .07 [⫺.14, .28] .06 [⫺.15, .27]
Immutability/rehabilitation
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potential .04 [⫺.17, .25] ⫺.18 [⫺.37, .03] ⫺.001 [⫺.21, .21]
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Quasi-adaptive features ⫺.16 [⫺.36, .05] ⫺.28ⴱⴱ [⫺.46, ⫺.08] .02 [⫺.19, .23]
ⴱⴱ
p ⱕ .01.
parenting scale (r ⫽ .42, p ⬍ .05, 95% CI [.02, .70]), and between
the Self domain and the biological etiology scale (r ⫽ .46, p ⬍ .05,
95% CI [.07, .73]). There was also a negative correlation between
the Emotional domain and the responsibility and punishment scale
(r ⫽ ⫺.44, p ⬍ .05, 95% CI [⫺.72, ⫺.05]). Though the magnitude
of some of these differences is relatively large, given the total
number of comparisons and the relatively small size of the three
subgroups, they should be interpreted with considerable caution.
Discussion
To date, only a few studies have explored perceptions and
attitudes about psychopathy among individuals who work in the
mental health field. Our study contributes new results to this
understudied area by exploring perceptions and attitudes about
psychopathy in general, as well as CAPP prototypicality ratings in
particular, among individuals working in the forensic mental
health system in Sweden. These results are informative regarding
ongoing debates about conceptualizations of psychopathy gener-
ally as well as regarding the content validity of the CAPP model
specifically.
In regards to the CAPP model, perceptions’ of psychopathy in
our sample were highly overlapping with that of international
mental health experts and researchers (Kreis et al., 2012), as well
as forensic practitioners from Norway (Hoff et al., 2012). At the
item level, our participants viewed the prototypical psychopath as
highly dominant (Manipulative, Deceitful, Insincere), self-
absorbed (Self-centered, Self-aggrandizing, Self-justifying), and
also someone who is Unreliable, Unempathic, and Lacks remorse.
This view resonates with early conceptualizations of psychopathy
that focus heavily on affective and interpersonal aspects rather
than criminalistic and overtly antisocial features (e.g., Cleckley,
1941). A few CAPP items (Lacks pleasure, Lacks concentration,
and Unstable self-concept) were not seen as particularly indicative
of psychopathy by our participants. These same items also re-
ceived the lowest ratings in both previous expert rater studies
(Hoff et al., 2012; Kreis et al., 2012). The scale based on the
aggregated foil items was rated even lower by our participants than
forensic raters in the recent Norwegian study (Cohen’s d ⫽ 1.31,
95% CI ⫽ 1.03 to 1.59, based on raw data provided in Table 2 by
Hoff et al., 2012), which suggests good discrimination with traits
CAPP domains
Cognitive Dominance Emotional Self
⫺.02 [⫺.23, .19] .05 [⫺.16, .25] .11 [⫺.10, .31] .008 [⫺.20, .22]
.02 [⫺.19, .23] .13 [⫺.08, .33] ⫺.09 [⫺.29, .12] .01 [⫺.20, .22]
⫺.20 [⫺.39, .007] ⫺.15 [⫺.35, .06] ⫺.12 [⫺.32, .09] ⫺.11 [⫺.31, .10]
.09 [⫺.12, .29] .07 [⫺.14, .27] ⫺.09 [⫺.29, .12] .08 [⫺.13, .28]
.06 [⫺.15, .26] .02 [⫺.19, .23] ⫺.03 [⫺.24, .18] .09 [⫺.12, .29]
.10 [⫺.11, .30] ⫺.03 [⫺.24, .18] .09 [⫺.12, .29] ⫺.05 [⫺.25, .16]
⫺.07 [⫺.28, .14] ⫺.09 [⫺.29, .12] .08 [⫺.13, .29] ⫺.03 [⫺.24, .18]
.15 [⫺.06, .35] .13 [⫺.08, .33] .10 [⫺.11, .30]
.09 [⫺.12, .29] ⫺.18 [⫺.37, .03] ⫺.02 [⫺.23, .19]
not typically associated with this disorder among Swedish profes-
sionals.
At the domain level, all CAPP domains were rated as moder-
ately to highly prototypical of psychopathy in our sample. The
Dominance, Self, and Attachment domains were rated as the most
prototypical, with mean scores greater than 5. This is identical to
the findings in both previous studies of mental health experts and
researchers (Hoff et al., 2012; Kreis et al., 2012). The Behavioral
and Cognitive domains were considered least prototypical of psy-
chopathy, with mean scores somewhat below 5. These domains
also received the lowest rankings by the Norwegian forensic staff
(Hoff et al., 2012). The Cognitive domain received even lower
ratings by our participants, compared with the Norwegian forensic
staff (Hoff et al., 2012, p. 418, Table 2), as well as the mental
health experts and researchers (Kreis et al., 2012, p. 408), with
Cohen’s d ⫽ 0.97, 95% CI ⫽ .71 to 1.23, and 0.84, 95% CI ⫽ .56
to 1.12, respectively. The Behavioral domain was also rated ap-
preciably lower by our participants, compared to the international
mental health experts (Cohen’s d ⫽ 0.97, 95% CI ⫽ .69 to 1.25;
Kreis et al., 2012, p. 407).
To our knowledge, this is the first study to explore broader
perceptions and attitudes about the psychopathy construct among
forensic practitioners. Overall, our participants viewed psycho-
paths as more crime-prone than the average criminal, although
they disagreed that most psychopaths are murderers or blatantly
“evil” people. They quite strongly endorsed the position that
psychopaths can understand the difference between right and
wrong and that they are responsible for their own actions—senti-
ments consistent with how most legal systems (including Sweden)
view psychopathic traits in relation to criminal responsibility (De-
Matteo & Edens, 2006). Respondents did not endorse items sug-
gesting punitive actions specifically directed against psychopaths
(e.g., that they should be locked up to protect society; that they
should be treated more harshly by the criminal justice system).
Regarding immutability/rehabilitation potential, participants en-
dorsed the position that psychopaths cannot change (i.e., will
remain psychopathic) and that there is no treatment that can cure
a psychopath. Although it is a popular conception that psychopaths
are untreatable, recent research evidence suggests that psycho-
pathic traits, especially in youth, are at least somewhat responsive
 PSYCHOPATHY PROTOTYPE
to intervention, although so far there is no specific treatment that
has received extensive empirical support (Caldwell, Skeem, Sale-
kin, & Van Rybroek, 2006; Salekin, Worley, & Grimes, 2010).
It is interesting that our participants did not strongly endorse
various quasi-adaptive features (e.g., avoiding arrest, being more
intelligent) as related to being psychopathic. They did, however,
quite strongly endorse the position that there are many psycho-
paths who do not commit crimes, that some psychopaths can avoid
getting into trouble with the criminal justice system, and that
psychopathic traits can be advantageous in some high profile jobs
(e.g., high-level managers, politicians). This is generally consistent
with conceptualizations of ‘successful psychopaths’ and the idea
that some individuals with a high degree of psychopathic traits can
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live relatively crime free in the community— or at least avoid
This document is copyrighted by the American Psychological Association or one of its allied publishers.
arrest for any criminal behavior in which they engage (Hall &
Benning, 2006).
The embedded “foil items” in the CAPP protocol were rated
significantly higher by both groups of ward staff compared to the
evaluators. This is most probably because of differences in training
as well as evaluators’ clearer conceptualization of what types of
features are not representative of psychopathy. Similarly, there
was a marked difference between the groups with regards to the
ratings on the psychotic-spectrum items. Forensic evaluators rated
these items very low, indicating that they see psychopathy and
psychosis as clearly distinct concepts. Both groups of ward staff
rated these items higher, however, with the clinical ward staff
rating the items markedly higher than both other groups. The
magnitude of this difference is somewhat surprising, although
previous studies have demonstrated that psychopathy tends to be
conflated with psychosis among nonmental health professionals
(Edens, Desforges, Fernandez, & Palac, 2004; Helfgott, 1997;
Smith et al., 2013). Clinical ward staff may have rated these items
as higher because of an illusory correlation between these con-
structs based on their work setting. Their clients typically present
with multiple diagnoses, with psychotic disorders being very com-
mon in clients sentenced to forensic psychiatric care in Sweden.
Although there is no strong association between psychopathy (as
defined by the PCL-R) and severe mental disorder, their co-
occurrence specifically in forensic settings (see, e.g., Nolan, Vol-
avka, Mohr, & Czobor, 1999; Tengström, Hodgins, Grann, Lång-
ström, & Kullgren, 2004) may lead to a greater conflation of the
two among staff who may be relatively less familiar with the
research literature, diagnostic nomenclature, or both.
Overall, our results suggest that the CAPP model encapsulates
the perceptions of psychopathy that experts and practitioners in the
field have. Even though some of the model’s unique features (e.g.,
the Cognitive domain), as well as some individual items, were not
seen as strongly indicative of psychopathy, it is important not to
overstate the relevance of prototypicality studies when considering
the construct validity of the CAPP model. Studies such as ours are
informative regarding extant perceptions of psychopathic features
among mental health professionals, but they are not dispositive
descriptions of the core characteristics of the underlying syndrome.
Perhaps these lower-rated items are in fact highly salient to the
psychopathy construct but simply have not been historically
thought of as especially indicative of psychopathy by mental
health professionals. Perhaps certain traits are important concep-
tually yet less obvious to those working in the mental health field
relative to other more overt traits (e.g., Self-aggrandizing), which
11
are more clearly represented within traditional assessment meth-
ods. Interestingly, despite the heavy emphasis on behavioral as-
pects of psychopathy during the last few decades, our participants
did not rate the Behavioral domain as overwhelmingly indicative
of psychopathy. This could be a function of the items themselves
or perhaps represents less focus on overt manifestations of psy-
chopathic traits relative to other features.
Occupational status resulted in a few differences on attitudinal
ratings regarding psychopathy as well. The clinical ward staff did
not as highly endorse the position that psychopaths can understand
the difference between right and wrong and that they are respon-
sible for their own actions. This may again result from their
primary exposure to psychopathic traits occurring with patients
suffering from severe mental illness. Consistent with this, com-
pared with the participants from the assessment units at the Na-
tional Board of Forensic Medicine, the clinical ward staff more
strongly endorsed the position that psychopaths should be consid-
ered SMD and be sentenced to forensic psychiatric care. They also
somewhat more strongly endorsed moral judgments and punitive
actions (i.e., psychopaths are “evil” and should be treated more
harshly by the criminal justice system). This is consistent in the
sense that individuals sentenced to forensic psychiatric care with
court supervision in Sweden might actually be incarcerated for
longer periods compared to a determinate prison sentence. It is
interesting that the clinical ward staff more strongly endorsed the
quasi-adaptive features compared with the forensic evaluators,
perhaps due to their extended work experience with patients over
many years, where they (perhaps) see psychopathic traits on the
ward as being somewhat more beneficial (in a Machiavellian
sense, at least) than would forensic evaluators.
Noted earlier, the attitudinal questions administered in our study
were used in an earlier study of community members attending
jury duty in the United States; (Smith et al., 2013). Mean scores on
these 28 items across these two diverse data sets were generally
fairly comparable, though a few differences are worth noting. Jury
panel members viewed psychopaths as more violence-prone than
our participants. Even though the jury panel members did not
strongly endorse the position that most psychopaths are murderers
per se and that psychopathy can be equated with “evil,” their
ratings for these statements were substantially higher than those of
the forensic evaluators (i.e., more in line with the rating of the
clinical ward staff). This might be due to a tendency among
laypeople to associate typical examples of psychopaths with mass
murderers or infamous serial killers (Edens et al., 2013). More-
over, in line with the clinical ward staff, the jury panel members
more strongly endorsed punitive actions (i.e., psychopathic crim-
inals should be treated more harshly by the criminal justice system
and psychopaths should be locked up to protect society, regardless
of whether they have committed any crimes; Smith et al., 2013). In
contrast to our participants, the jury panel members were more
neutral about the potential for psychopaths to change or be “cured”
via treatment. Finally, in contrast to our participants, jury panel
members tended to view psychopaths as somewhat more intelli-
gent than the average criminal and difficult to identify in society;
they did not, however, strongly endorse the position that psycho-
pathic traits might be particularly advantageous in certain occupa-
tions (e.g., politician).
A few limitations of our research should be considered, which
hopefully will inform future research on the CAPP specifically and
 12 SÖRMAN ET AL.
perceptions of psychopathy among forensic professionals more
broadly. Our occupational subgroups in particular were small,
which means these analyses were somewhat underpowered statis-
tically and prevented us from conducting certain types of analyses
that might be informative (e.g., CFA or item response theory
analyses). As we noted in the introduction, however, prototypical-
ity data are quite different from data derived from samples that
exhibit varying degrees of a dimension or trait and the applicability
of many statistical approaches to highly skewed data seems some-
what questionable— even though Kreis et al. (2012) and Hoff et al.
(2012) did report that CAPP domains showed reasonable fit in
CFAs with certain modifications. Future studies should further
explore practitioners’ perceptions about psychopathy in larger
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
groups of participants, also recruited from correctional facilities
This document is copyrighted by the American Psychological Association or one of its allied publishers.
where staff interact with individuals with potentially higher de-
grees of psychopathic traits that are also not confounded with
major mental disorders. Of note, Hoff et al. (2012) reported that
their small correctional sample rated the Strange foil item in the
CAPP protocol appreciably lower compared to the forensic staff,
though they were not queried about psychotic-spectrum symptoms
specifically.
Furthermore, even though our translation of the CAPP items in-
volved several bilingual expert and layperson reviewers and the
lexical nature of the item development process was designed for easy
translation into new languages, our prototype measure was not based
on any established prior translation. The official Swedish translation
of the CAPP model is currently under development (M. Pauli, per-
sonal communication, April 12, 2013). Because our prototype results
largely overlapped with those of previous international studies (Hoff
et al., 2012; Kreis et al., 2012) with forensic researchers and practi-
tioners, however, it seems highly likely that our translation comports
well with the English and other translated versions of the CAPP. It is
conceivable, however, that relatively lower ratings for the Cognitive
domain items in our study may have resulted from translation issues.
Finally, as noted earlier, there are some intrinsic limitations to
prototypicality studies such as this, in that they assess perceptions of
the salience of symptoms to a disorder rather than the presence of
specific symptoms within a particular examinee or patient. Whether
these rater perceptions are in fact accurate characterizations of the
disorder of interest is unknown. Nevertheless, such studies can serve
as one important indicator of content validity, even though multiple
other types of research (e.g., multitrait multimethod matrix studies,
criterion-related validity studies) are necessary to examine the con-
struct validity of a new model of psychopathy.
In conclusion, we believe our results help to advance our un-
derstanding of the psychopathy construct by exploring how foren-
sic professionals in Sweden view this disorder in general and also
in relation to the CAPP model specifically, which is currently
being investigated in several countries. We agree with various
scholars (e.g., Poythress & Petrila, 2010; Skeem & Cooke, 2010)
who have argued that the field benefits both from rigorous debates
about the core features of this disorder and from various research
methodologies examining the validity of competing models and
instruments designed to operationalize it.
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Received May 27, 2013
Revision received October 1, 2013
Accepted October 3, 2013 䡲