Psychopaty Hare

Psychopathy
Oxford Handbooks Online

Psychopathy
Robert D. Hare, Craig S. Neumann, and Thomas A. Widiger
The Oxford Handbook of Personality Disorders
Edited by Thomas A. Widiger
Print Publication Date: Sep 2012 Subject: Psychology, Clinical Psychology

Online Publication Date: Nov 2012 DOI: 10.1093/oxfordhb/9780199735013.013.0022
Abstract and Keywords
Psychopathy refers to the personality disposition to charm, manipulate, and ruthlessly

exploit other persons. Psychopathic persons are lacking in conscience and feeling for
others; they selfishly take what they want and do as they please without the slightest
sense of guilt or regret. Psychopathy is among the oldest and arguably the most heavily
researched, well-validated, and well-established personality disorder. Yet it has only
indirect, informal entry in the DSMs. This chapter discusses traditional alternative
conceptualizations of psychopathy, emphasizing in particular the influential and heavily
researched Psychopathy Checklist-Revised. Discussed as well is the existing research
concerning the epidemiology, etiology, course, treatment, and biological aspects of
psychopathy, as well as its implications for DSM-5.
Keywords: psychopathy, PCL-R, DSM, antisocial personality disorder
Psychopaths have been described as “social predators who charm, manipulate, and
ruthlessly plow their way through life.…Completely lacking in conscience and feeling for
others, they selfishly take what they want and do as they please, violating social norms
and expectations without the slightest sense of guilt or regret” (Hare, 1999, p. xi). The
diagnosis of psychopathic personality disorder has a rich historical tradition. Psychopathy
is perhaps even the prototypic personality disorder. The term “psychopath” at one time
referred more generally to all personality disorders (i.e., pathologies of the psyche) in
Schneider’s (1923) influential nomenclature of 10 distinct “psychopathic” personalities.
Only Schneider’s affectionless psychopathic was aligned with the current concept of
psychopathy: “Affectionless psychopathic persons are personalities who are lacking or
almost lacking in compassion, shame, honor, remorse, and conscience” (Schneider, 1950,
p. 25). It was subsequent to the work of Schneider that the term “psychopath” became
confined to the particular personality disorder, albeit with aliases that are misaligned
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Psychopathy
with, or do not capture, the traditional construct (e.g., sociopath, antisocial personality
disorder).
Description and Diagnosis
The Cleckley Psychopath
There has long been an interest and effort in providing an adequate description of the
personality structure of psychopathy. The most influential clinical work was clearly
provided by Hervey Cleckley (1941, 1976) in his seminal text, The Mask of Sanity
(Cleckley also coauthored the text, The Three Faces of Eve with Corbett H. Thigpen;
Thigpen & Cleckley, 1954). In the original version of his text, Cleckley (1941) identified
21 characteristics of psychopathy: (1) usually very attractive person superficially, more
clever than average, superior general objective intelligence; (2) free from demonstrable
symptoms of psychosis, free from any marked nervousness of other symptoms of a
psychoneurosis; (3) no sense (p. 479) of responsibility, not concerned about irresponsible
behavior; (4) total disregard for the truth; (5) does not accept blame for actions; (6) no
sense of shame; (7) undependable, cheats and lies without compunction, commits
antisocial acts without adequate motivation; (8) execrable judgment; (9) inability to learn
or profit from experience; (10) egocentricity, incapacity for object-love; (11) general
poverty of affect, readiness of expression rather than depth of feeling; (12) lacks insight,
cannot see self as others see him; (13) no appreciation for kindness or consideration
shown by others; (14) alcoholic indulgences; (15) when drinking, readily places self in
disgraceful or ignominious position, bizarre behavior when drinking, seeking a state of
stupefaction; (16) does not choose to attain permanent unconsciousness by taking own
life; (17) sex life shows peculiarities, casual sex; (18) no evidence of adverse heredity,
familial inferiority; (19) often no evidence of early maladjustment; (20) inability to follow
any life plan consistently; and (21) goes out of way to make a failure of life.
Some of these features are a bit curious (e.g., no evidence of adverse heredity, familial
inferiority, often no evidence of early maladjustment, and goes out of way to make a
failure of life). This was perhaps a reflection of the lack of information in the 1930s about
behavioral genetics and developmental psychopathology, a psychodynamic orientation to
understanding abnormal behavior, and an emphasis on case studies rather than on
empirical investigation (Hare & Neumann, 2006, 2008). In any event, these more esoteric
features were short lived. Cleckley revised and expanded his work with each edition
published over the course of his life. By the time of the most frequently cited fifth edition
(1976), one feature from 1941 (free from demonstrable symptoms of psychosis or marked
nervousness) had been split into two characteristics, several (e.g., execrable judgment
and inability to learn or profit from experience) had been pooled into single items, and
the three just noted (i.e., features 18, 19, and 21) had been deleted. Cleckley (1976) listed
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16 features in this edition of his text: (1) superficial charm and good “intelligence”; (2)
absence of delusions and other signs of irrational thinking; (3) absence of “nervousness”
or psychoneurotic manifestations; (4) unreliability; (5) untruthfulness and insincerity; (6)
lack of remorse or shame; (7) inadequately motivated antisocial behavior; (8) poor
judgment and failure to learn by experience; (9) pathologic egocentricity and incapacity
for love; (10) general poverty in major affective reactions; (11) specific loss of insight;
(12) unresponsiveness in general interpersonal relations; (13) fantastic behavior with
drink and sometimes without; (14) suicide rarely carried out; (15) sex life impersonal,
trivial, and poorly integrated; and (16) failure to follow any life plan.
Psychopathy Checklist-Revised
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Psychopathy
While Cleckley’s clinical writings influenced the way in which early researchers viewed
psychopathy, they did not lend themselves readily to empirical measurement (Hare, 1968,
1986). The Psychopathy Checklist-Revised (PCL-R) and its predecessor, the PCL (Hare,
1980), arose because of the concern in the 1970s about the lack of a reliable, valid, and
generally accepted tool for the assessment of psychopathy. The PCL-R is a clinical
construct rating scale that uses a semi-structured interview, case history information, and
specific scoring criteria to rate each of 20 items on a 3-point scale (i.e., 0, 1, and 2). The
20 features are as follows: glibness/superficial charm; grandiose sense of self-worth; need
for stimulation/proneness to boredom; pathological lying; conning/manipulative; lack of
remorse or guilt; shallow affect; callous/lack of empathy; parasitic lifestyle; poor
behavioral controls; promiscuous sexual behavior; early behavior problems; lack of
realistic, long-term goals; impulsivity; irresponsibility; failure to accept responsibility for
own actions; many short-term marital relationships; juvenile delinquency; revocation of
conditional release; and criminal versatility (Hare, 2003).
Based on analyses of very large samples of offenders, the evidence supports a model in
which 18 of the 20 items form four factors or dimensions (Hare, 2003; Neumann, 2007;
Neumann, Hare, & Newman, 2007). These are as follows: Interpersonal (glibness
superficial charm, grandiose sense of self-worth, pathological deception, conning
manipulative); Affective (lack of remorse or guilt, shallow affect, callous lack of empathy,
failure to accept responsibility for actions); Lifestyle (need for stimulation, proneness to
boredom, parasitic lifestyle, lack of realistic long-term goals, impulsivity, irresponsibility);
and Antisocial (poor behavioral controls, early behavior problems, juvenile delinquency,
revocation of conditional release, criminal versatility). Two other items (promiscuous
sexual behavior, many short-term relationships) do not load on any factor but do
contribute to the total PCL-R score. The Interpersonal Affective dimensions and the
Lifestyle Antisocial dimensions comprise, respectively, the original PCL-R Factors 1 and 2
(see Table 22.1) described by Hare (2003; also see Hare & Neumann, 2008). Total PCL-R
(p. 480) scores can vary from 0 to 40 and reflect the degree to which the individual
matches the prototypical psychopath. This is in line with recent evidence that, at the
measurement level, the structure of psychopathy is dimensional, whether assessed by the
PCL-R (Edens, Marcus, Lilienfeld, & Poythress, 2006; Guay, Ruscio, Knight, & Hare, 2007;
Walters, Duncan, & Mitchell-Perez, 2007), the Psychopathy Checklist: Screening Version
(PCL: SV; Hart, Cox, & Hare, 1995; Walters, Gray, et al., 2007), the Psychopathy
Checklist: Youth Version (PCL: YV; Forth, Kosson, & Hare, 2003; Murrie et al., 2007), the
Antisocial Process Screening Device (APSD; Frick & Hare, 2001; Murrie et al., 2007), or
by self-report (Marcus, Lilienfeld, Edens, & Poythress, 2006).
Table 22.1 Items and Factors in the Hare PCL Scales
PCL-R PCL: YV PCL: SV
F1 P1
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Interpersonal Interpersonal Interpersonal
1. Glibness/superficial 1. Impression management 1. Superficial

charm
2. Grandiose sense of self- 2. Grandiose sense of self- 2. Grandiose

worth worth
4. Pathological lying 4. Pathological lying 3. Deceitful
5. Conning/manipulative 5. Manipulation for

personal gain
Affective Affective Affective
6. Lack of remorse or guilt 6. Lack of remorse 4. Lacks remorse
7. Shallow affect 7. Shallow affect 5. Lacks empathy
8. Callous/lack of empathy 8. Callous/lack of empathy 6. Doesn’t accept

responsibility
16. Failure to accept 16. Failure to accept

responsibility responsibility
F2 P2
Lifestyle Behavioral Lifestyle
3. Need for stimulation 3. Stimulation seeking 7. Impulsive
9. Parasitic lifestyle 9. Parasitic orientation 9. Lacks goals
13. Lack of realistic, long- 13. Lack of goals 10. Irresponsibility

term goals
14. Impulsivity 14. Impulsivity
15. Irresponsibility 15. Irresponsibility
Antisocial Antisocial Antisocial
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10. Poor behavioral controls 10. Poor anger control 8. Poor behavioral
controls
12. Early behavioral 12. Early behavior 11. Adolescent

problems problems antisocial behavior
18. Juvenile delinquency 18. Serious criminal 12. Adult antisocial

behavior behavior
19. Revocation of 19. Serious violations of

conditional release release
20. Criminal versatility 20. Criminal versatility
Note: The PCL-R, PCL: YV, and PCL: SV items are from Hare (1991, 2003), Forth,
Kosson, and Hare (2003), and Hart, Cox, and Hare (1995), respectively. Note that the
item titles cannot be scored without reference to the formal criteria contained in the
published manuals. PCL-R items 11, Promiscuous sexual behavior, and 17, Many short-
term marital relationships, contribute to the Total score but do not load on any factors.
PCL: YV items 11, Impersonal sexual behavior, and 17, Unstable interpersonal
relationships, contribute to the Total score but do not load on any factor. F1 and F2 are
the original PCL-R factors, but with the addition of item 20. P1 and P2 are Parts 1 and
2 described in the PCL: SV Manual.
This dimensionality may pose a problem for diagnosing or categorizing a person

(p. 481)
as a “psychopath,” a problem shared by other clinical disorders (e.g., antisocial

personality disorder [ASPD]; Marcus et al., 2006; Widiger & Mullins-Sweatt, 2005) that
are described and treated as categorical but in fact may be dimensional. But the
dimensionality of a personality disorder does not preclude the use of “diagnostic”
thresholds for making clinical decisions (Widiger & Mullins-Sweatt, 2005). With respect
to psychopathy, a PCL-R cut score of 30 has proven useful for “classifying” persons for
research and applied purposes as psychopathic, although some investigators and
commentators have used other cut scores for psychopathy (e.g., 25 in some European
studies).
Derivatives
A derivative of the PCL-R, the PCL: SV (Table 22.1) was constructed for use in
nonforensic contexts. It is used as a screen for psychopathy or as a stand-alone
instrument for assessing psychopathy in civil psychiatric and community populations (Guy
& Douglas, 2006; Hare, 2007). It is closely related to the PCL-R, both conceptually and
empirically (Cooke, Michie, Hart, & Hare, 1999; Guy & Douglas, 2006). The Psychopathy
Checklist: Youth Version (PCL: YV; Forth et al., 2003) is an age-appropriate, downward
extension of the PCL-R (see Table 22.1). Both the PCL: SV and the PCL: YV have much the
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same conceptual, psychometric, structural, and predictive properties as the PCL-R (e.g.,
Book, Clark, Forth, & Hare, 2006; Neumann, Kosson, Forth, & Hare, 2006; Vitacco,
Neumann, Caldwell, Leistico, & Van Rybroek, 2006; Vitacco, Neumann, & Jackson, 2005).
There is little doubt that the PCL-R and its derivatives have become the dominant
instruments for the assessment of psychopathy and that their use has resulted in the
accumulation of a large body of replicable findings, both basic and applied. Although
some might view such a situation as felicitous, others (e.g., Cooke & Michie, 2001) have
expressed concerns that the PCL-R has become the construct. The proceedings of the
first two meetings of the new Society for the Scientific Study of Psychopathy (SSSP) in
2005 and 2007 made it clear that although the PCL-R might be the dominant measure of
psychopathy, it has encouraged, not impeded, attempts by researchers to devise and
validate other measurement tools, a healthy development for the field. Indeed, efforts
over the past decade have expanded the assessment repertoire to include a variety of
behavioral rating scales, specialized self-report scales, and omnibus personality
inventories (e.g., Frick & Hare, 2001; Lilienfeld & Fowler, 2006; Livesley 2007; Lynam &
Gudonis, 2005; Lynam & Widiger, 2007; Paulus, Neumann, & Hare, in press; Williams,
Paulhus, & Hare, 2007). Many of these measures are conceptually related to the PCL-R;
others have their origins in empirical research on psychopathology and general
personality.
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FFM
For example, Widiger and Lynam (1998) translated the PCL-R description of psychopathy,
on an item-by-item basis, into the language of the Five-Factor Model (FFM) of general
personality structure. At the domain level, the FFM includes neuroticism, which assesses
emotional adjustment and stability; extraversion, which assesses an individual’s
proneness to positive emotions and sociability; openness to experience, which refers to an
individual’s interest in culture and to the preference for new activities and emotions;
agreeableness (versus antagonism), which is concerned with an individual’s interpersonal
relationships and strategies; and conscientiousness (versus undependability), which
relates to self-control, ability to plan, organization, and completion of behavioral tasks.
McCrae and Costa (2003) have further differentiated each of the five broad domains of
the FFM into six more specific facets. The facets of agreeableness versus antagonism
include trust versus mistrust, straightforwardness versus deception and manipulation,
altruism versus exploitation, compliance versus aggression, modesty versus arrogance,
and tender-mindedness versus callousness.
Miller, Lyman, Widiger, and Leukefeld (2001) surveyed 23 psychopathy researchers and
asked each to rate the prototypical, classic Cleckley psychopath on each of 30 bipolar
scales that corresponded to the 30 facets of the FFM. The psychopath was described as
being low in all facets of agreeableness (i.e., mistrustful, deceptive and manipulative,
exploitative, aggressive, arrogant, and callous), low on three facets of conscientiousness
(i.e., immoral and irresponsible, negligent, and reckless), low in the anxiousness,
vulnerability (i.e., fearlessness), and self-consciousness facet of neuroticism (i.e,. glib
charm), low in the warmth facet of extraversion (i.e., interpersonally cold), and high in
the neuroticism facet of impulsiveness, and the extraversion facets of assertiveness and
excitement-seeking, consistent largely with the PCL-R description of psychopathy
(p. 482) (Lynam & Widiger, 2007). As we show later, it also is possible to translate FFM
traits in terms of the PCL-based four-factor model of psychopathy.
Studies that conceptually relate their measures to the PCL-R benefit from the large body
of theory and research that resulted from widespread adoption of the PCL-R family of
instruments. Rather than being concerned about its popularity, clinicians might better
view the PCL-R as an “anchor for the burgeoning nomological network of
psychopathy” (Benning, Patrick, Salekin, & Leistico, 2005, p. 271). This network not only
includes diverse measurement tools but also input from behavioral genetics,
developmental psychopathology, personality theory, cognitive neuroscience, and
community studies.
The enormous increase in theory and research on psychopathy over the past two decades
owes much to the development and adoption of the PCL-R as a common metric for
assessing the construct (Hare & Neumann, 2006, 2008). Its impact has been felt by
researchers who conduct basic research on the etiology and nature of psychopathy (e.g.,
Blair, Mitchell, & Blair, 2005; Gao, Glenn, Schug, Yang, & Raine, 2009; Kiehl, 2006;
Newman, Curtin, Bertsch, & Baskin-Sommers, 2010; Patrick, 2006; Viding, Larsson, &
Jones, 2008), and by those more concerned with the implications of psychopathy for the
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mental health and criminal justice systems (e.g., Felthous & Saß, 2000; Gacono, 2000;
Hervé & Yuille, 2007). The Buros Mental Measurements Yearbooks described the PCL-R
as the standard tool for the assessment of psychopathy (Acheson, 2005; Fulero, 1995).
While the empirical support for this view is strong, some investigators believe that the
PCL-R has drifted from Cleckley’s clinical accounts, and that low anxiety and fearlessness
should be included in, and antisociality excluded from, the list of PCL-R items. Hare and
Neumann (2008, 2010a) have discussed these and related issues in detail elsewhere.
Here, we offer a few comments on the role of low anxiety, fearlessness, and antisociality
in the psychopathy construct.
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Low Anxiety
Some theorists have suggested that the PCL-R should have included low anxiety, in large
part because it was said to be included within Cleckley’s (1941, 1976) description of
psychopathy (Brinkley, Schmitt, & Newman, 2005; Lykken, 1995; Salekin, Rogers, &
Machin, 2001). Low anxiousness was reported in the Miller et al. (2001) FFM survey of
psychopathy researchers. However, Cleckley was rather unclear and inconsistent
concerning the presence of anxiety. In the first edition he devoted only half a sentence to
the topic, stating that the psychopath is “usually free from any marked nervousness or
other symptoms of psychoneurosis” (Cleckley 1941, p. 239). However, this statement
would apply to the average person, and not just the psychopathic. It suggests an absence
of problematic anxiety, rather than a problematically low level of anxiousness, which are
really very different in their implications for personality disorder. Coverage of
anxiousness in later editions increased to about half a page, although there are
references throughout the text to anxiety of one form or another. Cleckley (1976) did say,
“Within himself he appears almost as incapable of anxiety as of profound remorse” (p.
340), a statement oft quoted by those who believe that lack of anxiety should have been
included in the PCL-R. However, in the previous sentence, Cleckley had also commented
that psychopaths experience tension or uneasiness but that it “seems provoked entirely
by external circumstances, never by feelings of guilt, remorse, or intrapersonal
insecurity.” This psychodynamic perspective suggests that it is not so much a lack of
anxiety that differentiates psychopaths from others as it is the source of the anxiety
(intra- or extrapsychic).
A good deal of empirical literature has indicated that psychopathy, measured with the
PCL-R or self-report, is at best only weakly related to various measures of anxiousness
(Hare, 2003). Hale, Goldstein, Abramowitz, Calamari, and Kosson (2004) concluded that
the PCL-R was unrelated to contemporary measures of anxiety and that the “finding
raises questions about traditional conceptualizations of psychopathy that posit an
attenuated capacity for anxiety” (p. 705).
The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision
(DSM-IV-TR) states that “individuals with this disorder [ASPD] may also experience
dysphoria, including complaints of tension, inability to tolerate boredom, and depressed
mood” (APA, 2000, p. 702) and notes more specifically that “they may have associated
anxiety disorders [and] depressive disorders” (APA, 2000, p. 702). The suggestion in
DSM-IV-TR that ASPD is associated with anxiety disorders may be attributed in part to
the confinement of many of the ASPD studies to clinical populations (Lilienfeld, 1994).
Anxiousness is common among persons in treatment for mental disorders. However,
increased prevalence rates of panic disorder, agoraphobia, social phobia, and obsessive-
compulsive personality have also been (p. 483) reported among persons diagnosed with
ASPD in the National Institute of Mental Health (Robins, Tipp, & Przybeck, 1991) and
Edmonton (Swanson, Bland, & Newman, 1994) epidemiologic, community studies. Dahl
(1998) suggested that “these findings clearly demonstrate that Cleckley (1941) was
wrong when he stated that psychopaths did not show manifest anxiety” (p. 298). An
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association of ASPD with anxiety disorders could reflect, though, in part, the reliance of
the DSM-IV-TR criteria for ASPD on the epidemiologic studies rather than the PCL-R
criterion set. The callous-unemotional traits of psychopathy have at times correlated
negatively with measures of anxiousness (e.g., Harpur, Hare, & Hakstian, 1989), but
psychopathic persons will also report clinically high levels of anxiousness (Schmitt &
Newman, 1999).
Fearlessness
There is an extensive research literature (to which the first author has contributed)
indicating that the concepts of “low fear arousal” or “fearlessness” (e.g., Lykken, 1995)
may appear to explain the psychopath’s apparent social poise and difficulty in staying out
of trouble. However, in their meta-analytic review of the literature, Sylvers, Lilienfeld,
and LaPrairie (2011, p. 134) commented that the argument by Lykken and others “that
psychopathy is characterized by low trait fear remains controversial,” and that it is
“unclear which, if any, psychopathological syndromes are characterized by low trait
anxiety.” The measures of fearlessness used in this research are often heavily laden with
excitement seeking, sensation seeking, and impulsivity, rather than with a lack of
anxiousness. Fearfulness and anxiousness can appear on the surface to be quite similar
constructs, but they may in fact be very different, or at least they are understood to be
different by some researchers. Fearfulness involves a sensitivity to cues or signs of
impending danger, whereas anxiousness is distress associated with the perception that
impending danger is imminent or inevitable (Frick et al., 2000; Sylvers et al., 2011). The
opposite of fearfulness would perhaps be a fearlessness that some suggest is in fact
central to the construct of psychopathy (Lykken, 1995). Persons who are high in
fearlessness engage in substantial risk taking and may then often experience anxiousness
secondary to their producing and encountering highly stressful events, yet nevertheless
they still engage in the high-risk behavior (Frick et al., 2000; Lilienfeld, 1994). The
assessment of fearlessness often involves measures of thrill seeking, sensation seeking,
and adventure seeking, which generally load on the broad personality domain of
constraint rather than on a negative affectivity domain that would include anxiousness. In
sum, it is not entirely clear whether this fearless, thrill-seeking behavior is best
understood as reflecting fearlessness or an impulsive disinhibition. Furthermore,
Newman et al. (2010) suggest that psychopathy may be characterized less by
fearlessness than by idiosyncrasies in attention that limit the processing of emotion-
related cues associated with response modulation.
There are at least two issues here: the role of anxiety and fearlessness in the
conceptualization of psychopathy; and whether the PCL-R is compromised by not having
items that specifically measure these traits. A recent study by Neumann, Hare, and
Johansson (2012) addressed each issue by adding to the PCL-R items written specifically
to provide clinical ratings of low anxiety and fearlessness (LAF). These items were
administered and scored according to the standard PCL-R protocol. A series of
confirmatory factor analyses revealed that the LAF items could be placed on any of the
four PCL-R factors without any reduction in model fit. Structural equation modeling
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indicated that a PCL-R superordinate factor was able to account for most of the variance
of a separate LAF factor. The results indicate that low anxiety and fearlessness may be
part of the PCL-R psychopathy construct but that they are comprehensively accounted for
by extant PCL-R items.
Antisociality
Some investigators assert that psychopathy can be conceptualized without reference to
antisociality (Cooke & Michie, 2001), largely on the misconception that antisociality is
inconsistent with the conception of psychopathy provided by Cleckley and other early
clinicians (see Hare & Neumann, 2008). However, inspection of the items that comprise
Cleckley’s 1941 and 1976 descriptions of psychopathy clearly conveys the important role
played by antisocial behavior. His patients could not be considered prosocial, or even
simply asocial, without stretching the meanings of these terms. In 1941 Cleckley placed
considerable emphasis on alcohol abuse and the problems it caused for the individual and
for those around him (or her). Later editions also described at length the socially
disruptive behaviors exhibited by psychopathic persons under the effects of alcohol.
Indeed, one can argue that most of the features of psychopathy fundamentally are
antisocial in nature (Hare & Neumann, 2010b). Cleckley (1976) stated that he was “in
complete (p. 484) accord” with the description of the psychopath as “simply a basically
asocial or antisocial individual” (p. 370). “Not only is the psychopath undependable, but
also in more active ways he cheats, deserts, annoys, brawls, fails, and lies without any
apparent compunction. He will commit theft, forgery, adultery, fraud, and other deeds for
astonishingly small stakes, and under much greater risks of being discovered than will
the ordinary scoundrel” (p. 343).
As Patrick (2006) wrote, “there is no question that Cleckley considered persistent

antisocial deviance to be characteristic of psychopaths. Without exception, all the
individuals represented in his case histories engage in repeated violations of the law—
including truancy, vandalism, theft, fraud, forgery, fire-setting, drunkenness and
disorderly conduct, assault, reckless driving, drug offenses, prostitution, and escape” (p.
608). Lynam and Miller (in press) put it more forcefully by stating, “Antisocial behavior
[ASB] plays a clear and prominent role in psychopathy.…In fact, if there is an essential
behavioral feature in common across the conceptualizations [of psychopathy], it is the
presence of ASB. Any description of psychopathy is incomplete without ASB.” This does
not mean that criminality is essential to the conceptualization or assessment of
psychopathy (Hare & Neumann, 2008, 2010b). Indeed, recent research indicates that
corporate executives manage to obtain high scores on the PCL-R without evidence of
criminal behavior (Babiak, Neumann, & Hare, 2010).
Psychopathy and Crime
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In the past few years there has been a dramatic change in the perceived and actual role
played by psychopathy in the criminal justice system. Formerly, a prevailing view was that
clinical diagnoses such as psychopathy were of little value in understanding and
predicting criminal behaviors. More recently, the importance of psychopathy, particularly
as measured by the PCL-R and its derivatives, is widely recognized, both by forensic
clinicians (Archer, Buffington-Vollum, Stredny, & Handel, 2006; Lally, 2003) and by the
courts (de Boer, Whyte, & Maden, 2008; Walsh & Walsh, 2006; Zinger & Forth, 1998).
This is not surprising, given that many of the characteristics important for inhibiting
antisocial and violent behavior—empathy, close emotional bonds, fear of punishment,
guilt—are lacking or seriously deficient in psychopathic people. Moreover, their
egocentricity, grandiosity, sense of entitlement, impulsivity, general lack of behavioral
inhibitions, and need for power and control constitute what might be described as a
prescription for the commission of antisocial and criminal acts (Hare, 2003; Porter &
Porter, 2007). This would help to explain why psychopathic offenders are
disproportionately represented in the criminal justice system. It also would explain why
they find it so easy to victimize the vulnerable and to use intimidation and violence as
tools to achieve power and control over others. Their impulsivity and poor behavioral
controls may result in “reactive” forms of aggression or violence, but other features (e.g.,
lack of empathy, shallow emotions) also make it relatively easy for them to engage in
aggression and violence that is more predatory, premeditated, instrumental, or “cold
blooded” in nature (Cornell et al., 1996; Hare, 2003; Meloy, 2002; Porter & Woodworth,
2006; Williamson, Hare, & Wong, 1987; Vitacco, Neumann, & Caldwell, 2010; Woodworth
& Porter, 2002).
Assessment of Risk
Extensive discussions of the theories and methodologies of risk assessment are provided
elsewhere (Monahan & Steadman, 1994; Monahan et al., 2001; Quinsey, Harris, Rice, &
Cormier, 2006). The latest generation of risk assessment instruments largely has
dispelled the belief that useful predictions cannot be made about criminal behavior
(Harris & Rice, 2007; Monahan et al., 2001). Empirical evidence indicates that actuarial
risk instruments and structured clinical assessments perform about equally well. The
former are empirically derived sets of static (primarily criminal history, demographic) risk
factors and include the Violence Risk Appraisal Guide (VRAG; Quinsey, Harris et al.,
2006), the Sex Offender Risk Appraisal Guide (SORAG; Quinsey, Rice, & Harris, 1995),
and the Domestic Violence Risk Appraisal Guide (DVRAG; Hilton, Harris, Rice, Houghton,
& Eke, 2008), instruments that improve considerably on unstructured clinical judgments
or impressions. Procedures that include structured clinical decisions based on specific
criteria also are proving to be useful. For example, the Historical-Clinical-Risk 20
(HCR-20; Webster, Douglas, Eaves, & Hart, 1997) assesses ten historical (H) variables,
five clinical (C) variables, and five risk management (R) variables. Because of its
importance in the assessment of risk, psychopathy, as measured by the PCL-R or the PCL:
SV is included in the VRAG, SORAG, DVRAG, and HCR-20, as well as in the Sexual
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Violence Risk 20 (SVR-20; Boer, Hart, Kropp, & Webster, 1997). We note that the PCL-R
and its derivatives reflect static risk factors and are properly used as (p. 485)
supplements to more general risk evaluations. In addition to the instruments described
earlier, there is increasing interest in the role of dynamic (changeable) risk factors in risk
assessment (Quinsey, Jones, Book, & Bar, 2006).
A detailed account of psychopathy as a risk for recidivism and violence is beyond the
scope of this article. However, its significance as a robust risk factor for institutional
problems, for recidivism in general, and for violence in particular, is now well established
(see the large-scale meta-analysis by Leistico, Salekin, DeCoster, & Rogers, 2008; also see
Campbell, French, & Gendreau, 2009). The predictive value of psychopathy applies not
only to adult male offenders but also to adult female offenders (Jackson & Richards, 2007;
Verona & Vitale, 2006); adolescent offenders (Flight & Forth, 2007; Forth et al., 2003;
Gretton, Hare, & Catchpole, 2004; Stafford & Cornell, 2003); forensic psychiatric
patients, including those with schizophrenia (Dolan & Davies, 2006; Doyle, Dolan, &
McGovern, 2002; Heilbrun et al., 1998; Hill, Neumann, & Rogers, 2004; Hill, Rogers, &
Bickford, 1996; Lincoln & Hodgins, 2008; Rice & Harris, 1992; Tengström, Grann,
Långström, & Kullgren, 2000; Tengström, Hodgins, Grann, Långström, & Kullgren, 2004;
Tengström et al., 2006); offenders with intellectual difficulties (Gray, Fitzgerald, Taylor,
MacCulloch, & Snowden, 2007); and civil psychiatric patients (Steadman et al., 2000;
Vitacco et al., 2005). Psychopathy also is increasingly being seen as an important factor in
explaining domestic violence (Spidel et al., 2007; Swogger, Walsh, & Kosson, 2007), with
the PCL-R being an integral component in the DVRAG (Hilton et al., 2008). In some cases,
the predictive utility of the PCL-R and PCL: SV is at least as good as the purpose-built
instruments, including those of which they are a part (Dahle, 2006; Dolan & Davies, 2006;
Doyle et al., 2002; Edens, Skeem, & Douglas, 2006; Hare, 2003; Kroner, Mills, & Reddon,
2005; Pham, Ducro, Maghem, & Réveillère, 2005; Sjöstedt & Långström, 2002;
Tengström, 2001). For example, in the MacArthur Risk Study (Monahan et al., 2001) the
VRAG predicted violence in civil psychiatric patients, but the effect was due entirely to
the inclusion in the VRAG of the PCL: SV (Edens, Skeem et al., 2006).
The last few years have seen a sharp increase in public and professional attention paid to
sex offenders, particularly those who commit a new offense following release from a
treatment program or prison. It has long been recognized that psychopathic sex offenders
present special problems for therapists and the criminal justice system (Knight & Guay,
2006). In general, the prevalence of psychopathy, as measured by the PCL-R, is lower in
child molesters than in rapists or “mixed” offenders (Hare, 2003; Porter et al., 2000;
Porter, ten Brinke, & Wilson, 2009). However, child molesters with high PCL-R scores are
at increased risk for sexual reoffending (Porter et al., 2009). Quinsey et al. (1995)
concluded from their extensive research that psychopathy functions as a general
predictor of sexual and violent recidivism. Although psychopathy appears to be more
predictive of general violence than sexual violence (Hare, 2003; Porter et al., 2009), its
relationship with the latter may be underestimated because many sexually motivated
violent offences are officially recorded as nonsexual violent offences (Rice, Harris, Lang,
& Cormier, 2006). Not only are the offenses of psychopathic sex offenders likely to be
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Psychopathy
more violent than those of other sex offenders, they tend to be more sadistic (Hare, 2003;
Harris et al., 2003; Mokros, Osterheider, Hucker, & Nitschke, 2011; Porter, Woodworth,
Earle, Drugge, & Bower, 2003). In their PCL-R study of murderers, Porter et al. (2003)
concluded that “not only are psychopathic offenders disproportionately more likely to
engage in sexual homicide (than are other murderers), but, when they do, they use
significantly more gratuitous and sadistic violence” (p. 467).
Psychopathy, as measured by the PCL-R, is commonly used in preventative detention

proceedings for sex offenders (Jackson & Hess, 2007; Mercado & Ogloff, 2007) and for
other dangerous offenders (de Boer et al., 2008; Zinger & Forth, 1998). At the same time,
there is evidence that psychopathic sex offenders are more likely to obtain early release
from prison than are other sex offenders, presumably because they are adept at
impression management (Porter et al., 2009).
One of the most potent combinations to emerge from the recent research on sex
offenders is psychopathy coupled with evidence of deviant sexual arousal. Rice and Harris
(1997) reported that sexual recidivism was strongly predicted by a combination of a high
PCL-R score and deviant sexual arousal, defined by phallometric evidence of a preference
for deviant stimuli, such as children, rape cues, or nonsexual violence cues. Several
studies indicate that psychopathy and behavioral or structured clinical evidence of
deviant sexual arousal also is a strong predictor of sexual violence (Harris & Hanson,
1998; Hildebrand, de Ruiter, & de Vogel, 2004; Serin, Mailloux, & Malcolm, 2001).
Gretton, McBride, Hare, O’Shaughnessy, and Kumka (2001) (p. 486) found that this
combination was highly predictive of general and violent reoffending in adolescent sex
offenders. Recently, Harris and colleagues (2003) reported that in a large-sample study
involving four independent sites the psychopathy–sexual deviance combination was
predictive of violent recidivism in general, both sexual and nonsexual. The authors
commented, “Because of the robustness of this (psychopathy × sexual deviance)
interaction and its prognostic significance, its inclusion in the next generation of actuarial
instruments for sex offenders should increase predictive accuracy” (p. 421) of general
violent recidivism. Deviant fantasies no doubt play an important role in facilitating this
psychopathy-deviance pattern (Logan & Hare, 2008; Williams, Cooper, Howell, Yuille, &
Paulhus, 2009).
Structural Equation Modeling and Violence Risk
The literature on psychopathy and violence is compelling, but the emphasis has been on
classical psychometric approaches (i.e., not formally accounting for measurement error),
likely underestimating the role of psychopathy in violence. Modern model-based
approaches, including structural equation modeling (SEM), are beginning to prove
fruitful in elucidating the associations between the PCL scales and violence. For instance,
based on a sample of 149 male psychiatric patients within a maximum security forensic
state hospital, Hill et al. (2004) found that the four-factor model accounted for 31% of the
variance in patients’ aggression across a 6-month follow-up. The Interpersonal (.56) and
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Antisocial (.35) factors were the strongest predictors. Similarly, using a very large sample
(N = 840) of civil psychiatric outpatients, Vitacco et al. (2005) found that the four-factor
model accounted for 21% of violent and aggressive behavior within the community at 20-
week follow-up. In this study, both the Affective (.41) and Antisocial (.40) factors were the
strongest predictors. Noteworthy is that these and other studies (see discussions by Hare
& Neumann, 2008; Hare & Neumann, 2010b) indicate that each of the PCL dimensions
plays an important role in the prediction of aggression and violence.
Based on these previous studies, as well as information about the distribution of

psychopathic features within the general community (Coid, Yang, Ullrich, Roberts, &
Hare, 2009; Neumann & Hare, 2008), we recently examined whether the four-factor
(PCL: SV-based) model of psychopathy could be used to adequately describe a large
sample (N = 514) of people from the general community, as well as predict future violent
behavior (Neumann & Hare, 2008). The results provided excellent support for the model
and indicate that the superordinate psychopathy factor was able to account for 17% of
the variance in future violent behavior in a community sample. Community studies of this
sort are particularly advantageous for examining the biological and psychosocial factors
linked with the development and expression of psychopathic traits, uncontaminated by
the effects of institutionalization and psychiatric morbidity.
As discussed previously, taking into account the type of violence involved—that is,
reactive versus instrumental—facilitates understanding the link between psychopathy
and violent behavior. A more general issue concerns the severity and temporal aspects of
the violence. We have begun to use modern statistical methods of growth modeling to
provide a better sense of how psychopathy might be associated with violent behavior over
time. This approach has the advantage of separating the level of some phenomenon
(violence) at any given time from the rate of change or growth of the phenomenon over
time (Muthen & Muthen, 2001). Neumann and Vitacco (2004), using a latent growth
model, found that the absolute level of violence was primarily explained by the Antisocial
psychopathy factor and a psychotic symptom factor in a sample of civil psychiatric
outpatients. In contrast, the Interpersonal psychopathy factor predicted the growth in
violent acts over a 30-week follow-up. This latent growth modeling research is notably
different from previous prediction research, which has been primarily concerned with
predicting a single event (e.g., the first violent act after release from custody). A more
dynamic picture can be provided by modeling the growth of a phenomenon over time,
rather than simply trying to predict a single event.
Representation of FFM Agreeableness and

Conscientiousness Traits in Terms of the Four-
Factor (PCL-Based) Model of Psychopathy
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The PCL-based four-factor representation of the psychopathy construct has received

considerable empirical support among large and diverse sets of independent North
American samples of offenders (Neumann et al., 2007), psychiatric patients (Hill et al.,
2004; Vitacco et al., 2005), delinquent adolescents (Jones, Cauffman, Miller, & Mulvey,
2006; Kosson et al., in press; Neumann et al., 2006; Vitacco et al., 2010), individuals
within the general population (Neumann & Hare, 2008), as well as corporate (p. 487)
samples (Babiak et al., 2010). Similar support for the four-factor (PCL-based) model of
psychopathy has also been found with European samples (e.g., Žukauskienė,
Laurinavičius, & Čėsnienė, 2010; Mokros, Stadtland, Osterheider, & Nedopil, 2010;
Neumann, 2007), and new research suggests such support with samples from across the
world (Hare, 2010). In addition, a newly revised PCL-based self-report measure (Paulhus
et al., in press; Williams et al., 2007) has also been shown to conform to the four-factor
model in line with the PCL Scales. Thus, the domains of the four-factor model
(Interpersonal, Affective, Lifestyle, and Antisocial) appear to provide an adequate
delineation of psychopathic traits across an impressive range of populations.
The FFM domains of Agreeableness and Conscientiousness are strongly inversely

associated with various PCL-based measures (Lyman & Derefinko, 2006). Also, the FFM
conceptualization of psychopathy has been described by Lynam and Widiger (2007) in
terms that reflect the interpersonal (e.g., “conning and manipulative”), affective (e.g.,
“callous and ruthless”), impulsive lifestyle (e.g., “pan-impulsive”), and antisocial (e.g.,
“greedy and exploitive, oppositional and combative”) PCL domains (p. 171). Within this
context, it seems reasonable to propose that four psychopathy factors, similar to the PCL
factors, could be represented by the FFM traits reflecting (low) agreeableness and (low)
conscientiousness, and that these FFM factors would have some correspondence to the
four PCL-based factors.
In line with this proposal, new research by Neumann (2011), based on independent
community and psychiatric samples, suggests that a four-factor model, composed of FFM
agreeableness and conscientiousness items set to load on specific interpersonal, affective,
lifestyle, and antisocial factors, provides very good fit to the data. Moreover, latent SRP
and PCL: SV-based psychopathy factors show good correspondence in predicting their
respective FFM factors. The results of this research suggests that it may be possible to
provide an integration across the PCL and FFM approaches, one based on clinical
tradition and the other on general personality theory, via a common latent variable model
of psychopathy.
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Psychopathy
APA Diagnostic Manual

The American Psychiatric Association’s (APA) diagnosis of antisocial personality disorder
also traces its history to Cleckley (1941, 1976) but via primarily the work of Lee Robins
(1966) through her follow-up study of 524 children seen at a child guidance clinic for
juvenile delinquents. Robins developed a list of diagnostic criteria for a “sociopathic
personality disturbance” derived in large part on the work of Cleckley. She preferred the
term sociopathy over the DSM-I (APA, 1952) antisocial diagnosis “because it resembles
the older term ‘psychopathic personality’” (p. 79). Thus, it was her intention to identify
persons who would be considered to be psychopathic, as diagnosed by Cleckley. “It is
hoped that Cleckley is correct that despite the difficulties in terminology and definition
there is broad agreement on which kinds of patients are psychopaths” (Robins, 1966, p.
79). Her original criteria for the diagnosis consisted of poor work history, financial
dependency, arrests, inadequate marital history, alcohol problems, inadequate school
history (including truancy), impulsivity, deviant sexual behavior, “wild” adolescence,
vagrancy, belligerence, socially isolated, absence of guilt, somatic complaints, aliases,
armed forces performance, pathological lying, drug abuse, and suicidal attempts.
However, she reported that suicide attempts, drug usage, and multiple somatic
complaints did not prove to be useful in the diagnosis. The most useful features were
poor work history, financial dependency, and multiple arrests.
Robins was among the influential Neo-Kreapelinian psychiatrists working at Washington

University in St. Louis. Her research and diagnostic criteria had an important impact in
the inclusion of antisocial personality disorder within Feighner et al. (1972), the only
personality disorder to be included within this widely cited, instrumental paper. The
criterion set for antisocial personality disorder in Feighner et al. consisted of school
problems (e.g., truancy, suspension, expulsion, or fighting), running away from home
overnight, troubles with the police (i.e., two or more arrests for nontraffic offenses, four
or more for moving traffic offenses, or one felony conviction), poor work history (e.g.,
being fired, quitting with no new job available, or frequent job changes), marital
difficulties (e.g., two or more divorces, deserting family, repeated infidelity, physical
attacks on spouse or child), repeated outbursts of rage, sexual problems (e.g.,
prostitution, pimping, flagrant promiscuity, or more than one episode of venereal
disease), vagrancy or wanderlust, and persistent lying or use of an alias. The Feighner et
al. criteria were subsequently revised by Spitzer, Endicott, and E. Robins (1978) for their
Research Diagnostic Criteria, which were in turn revised for DSM-III (APA, 1980). Robins
was a member of the DSM-III Personality Disorders Work Group.
(p. 488) The DSM-III criterion set for ASPD proved to be quite successful in obtaining
adequate levels of reliability. In contrast, it was notably difficult to construct behaviorally
specific criterion sets for the complex and broad behavior patterns that constituted the
other personality disorders (Widiger & Trull, 1987). As acknowledged by the authors of
DSM-III-R, “for some disorders…particularly the Personality Disorders, the criteria
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require much more inference on the part of the observer” (APA, 1987, p. xxiii). ASPD was
considered to be an exception to this difficulty, due in large part to the experience and
efforts of Robins (1966), Feighner et al. (1972), and Spitzer et al. (1978). Indeed, ASPD
has been the only personality disorder to be diagnosed reliably in general clinical practice
(Mellsop, Varghese, Joshua, & Hicks, 1982; Spitzer, Forman, & Nee, 1979), the
assessments for which were not facilitated by the support of a semi-structured interview
(Widiger & Boyd, 2009). Nevertheless, the ASPD criterion set also received considerable
criticism, suggesting to many that validity had been sacrificed for reliability (Frances,
1980; Hare, 1983; Millon, 1981) due to its failure to include all of the features of
psychopathy identified by Cleckley (1941, 1976), such as glib charm, arrogance, lack of
remorse, and lack of empathy. The authors of the DSM-III-R ASPD criterion set responded
in part to these criticisms by adding lack of remorse as a criterion (Widiger, Frances,
Spitzer, & Williams, 1988).
The authors of DSM-IV ASPD were concerned with two issues, the complexity of the
criterion set and the apparent preference of many researchers for the PCL-R) (Widiger &
Corbitt, 1993). A commonly reported finding was an overdiagnosis of ASPD within prison
settings and that the ASPD criterion set correlated more highly with PCL-R Factor 2 than
with with PCL-R Factor 1 (e.g., Hare, 2003; Ogloff, 2007; Shine & Hobson, 1997; Sturek,
Loper, & Warren, 2008; Warren & South, 2006), suggesting perhaps that the ASPD
criterion set was not identifying the core, personality features of psychopathy and was
identifying instead simply the tendency to be aimless, impulsive, irresponsible,
delinquent, or criminal (Hare, 1996). “Research that uses a DSM diagnosis of [ASPD] taps
the social deviance component of psychopathy but misses much of the personality
component, whereas each component is measured by the PCL-R” (Hare, 2003, p. 92).
A comparison of the DSM-III-R criteria for ASPD with the PCL-R criteria for psychopathy
was the focus of the DSM-IV field trial, the results of which were mixed (Widiger et al.,
1996). Number of arrests and convictions correlated significantly with both ASPD and
psychopathy in the drug-homelessness clinic, the methadone maintenance clinic, and the
psychiatric inpatient hospital but not with either ASPD or psychopathy within the prison
setting. Items that were unique to the PCL-R (e.g., lacks empathy; inflated and arrogant
self-appraisal; and glib, superficial charm) correlated more highly with interviewers’
ratings of ASPD and psychopathy within the prison setting, but not within the clinical
settings. The PCL-R items that were most predictive of clinician’s impressions of
psychopathy within a drug treatment and homelessness site included adult antisocial
behavior. Within a psychiatric inpatient site, the most predictive items were adult
antisocial behavior and early behavior problems, along with glib, superficial charm. In
contrast, the most predictive items within the prison site were inflated, arrogant self-
appraisal; lack of empathy; irresponsibility; deceitfulness; and glib, superficial charm.
A revision of the criterion set for ASPD to include the additional traits of glib charm, lack
of empathy, and arrogance was also opposed by the authors of the criterion set for
narcissistic personality disorder (Widiger, 2006; Widiger & Corbitt, 1993). These features
are also central to the diagnosis of narcissistic personality disorder, and their inclusion
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Psychopathy
within the criterion set for ASPD would have increased markedly their diagnostic co-
occurrence and undermined their differential diagnosis (Widiger & Corbitt, 1995). The
authors of the DSM-IV criterion set for narcissistic personality disorder (Gunderson,
Ronningstam, & Smith, 1991) considered these personality disorders to be qualitatively
distinct conditions, and they felt that the criterion sets should increase the ability of
clinicians to differentiate among these distinct disorders rather than complicate this
effort through criterion set overlap (Gunderson, 1992). “The high comorbidity of
narcissistic personality disorder with other personality disorders makes differential
diagnosis essential” (Ronningstam, 1999, p. 681).
In the end, no revisions were made to the criterion set for DSM-IV ASPD to increase its
coordination with PCL-R psychopathy. However, the text was modified to indicate that
lack of empathy; callousness; cynicism; contemptuousness; arrogance; and glib,
superficial charm were also important features of ASPD. It was further noted that “lack of
empathy, inflated self-appraisal, and superficial charm are features that have been
commonly (p. 489) included in traditional conceptions of psychopathy that may be
particularly distinguishing of the disorder and more predictive of recidivism in prison or
forensic settings where criminal, delinquent, or aggressive acts are likely to be non-
specific” (APA, 1994, p. 647).
The current proposal for DSM-5 ASPD (also titled “dissocial” personality disorder)
consists of two components: four impairments in self and interpersonal functioning (e.g.,
ego-centrism: self-esteem derived from personal gain, power, or pleasure), and seven
maladaptive personality traits, such as callousness, deceitfulness, and impulsivity (APA,
2011). One concern with respect to this new criterion set is that it is untested and not
clearly tied empirically to any prior criterion set for ASPD or psychopathy. It resembles
prior criterion sets in many respects but given the substantial empirical foundation for
DSM-IV ASPD and PCL-R psychopathy one might have expected a more conservative
approach for this well-established diagnosis by building upon prior research rather than
creating a whole new criterion set. In addition, the distinction between the impairments
of self-interpersonal functioning and the traits is unclear. For example, it would seem that
there will be little difference between the interpersonal impairment of lack of empathy
(suggested by a lack of concern for feelings, needs, or suffering of others; lack of remorse
after hurting or mistreating another) (impairment in interpersonal functioning) and the
personality trait of callousness (suggested by a lack of concern for feelings or problems of
others; lack of guilt or remorse about the negative or harmful effects of one’s actions on
others) (APA, 2011). It might also be worth noting that, at least so far, there is no proposal
to include traits of fearlessness or low anxiousness.
Etiology
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There is increasing evidence that broad genetic factors may account for a substantial
portion of the variance and covariance of diverse sets of psychopathy traits. For instance,
investigators have reported bivariate analyses that suggest that there are genetic
influences on the covariance of psychopathy scales reflecting emotional detachment and
antisocial tendencies (Viding, Blair, Moffitt, & Plomin, 2005). Relatedly, both Minnesota
Personality Questionnaire (MPQ) dimensions (fearless-dominance and impulsive-
antisociality) show genetic covariation with externalizing psychopathology in men
(Blonigen, Hicks, Krueger, Patrick, & Iacono, 2005). In a large sample of 9- to 10-year-old
twins, Baker, Jacobson, Raine, Lozano, and Bezdjian (2007) found that a common
antisocial behavior factor (composed of child psychopathy traits, aggression, and
delinquency) across informants was strongly heritable. Recently, Viding, Frick, and
Plomin (2007) found a common genetic component to the covariation between callous-
unemotional traits and antisocial tendencies in children. Finally, based on a large
adolescent twin sample, Larsson et al. (2007) reported that the same general four factors
present in the four-factor model of psychopathy (e.g., Hare & Neumann, 2005; Neumann
et al., 2006; Vitacco et al., 2005) all loaded onto a single genetic factor. The variance in
the male psychopathic traits in each factor accounted for by the common genetic factor
was 25% for grandiose manipulative, 20% for callous unemotional, 42% for impulsive
irresponsible, 19% for antisocial behavior (ages 13 to 14), and 30% for antisocial
behavior (ages 16 to 17). For females, the variance accounted for by the common genetic
factor was 37% for grandiose manipulative, 22% for callous unemotional, 45% for
impulsive irresponsible, 21% for antisocial behavior (ages 13 to 14), and 41% for
antisocial behavior (ages 16 to 17). Notably, in both sexes the impulsive irresponsible and
antisocial facets showed some of the strongest genetic components, consistent with the
very early conceptions of psychopathy.
The results of twin and adoption studies indicate a strong genetic component for
antisocial-psychopathic behavior. Generally speaking, genetic factors are believed to
account for approximately 50% of variation in antisocial behavior, although this estimate
may be influenced by the interaction among genes, or between genes and environment
(Moffitt, 2005; Raine, 2008; Rhee & Waldman, 2002). However, when additive
(interactive) and nonadditive (singular) genetic contributions are assessed, the genetic
contribution remains resilient. Waldman and Rhee (2006) provided results of a meta-
analysis of 51 twin and adoption studies of antisocial behavior that indicated a substantial
contribution of both additive genetic factors (effect size = .32) and nonadditive genetic
factors (effect size = .09). The heritability of antisocial behavior is also supported by
animal studies of temperament. Selection studies (where brother-sister matings are
carried out over many generations) have been successful in breeding rats for specific
traits, including aggression, indicating that part of what is genetically transmitted is
temperament (Chiavegatto, 2006; DeVries, Young, & Nelson, 1997). These results indicate
that (p. 490) specific, heritable genes may be important contributors to antisocial,
psychopathic behavior.
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Psychopathy
Although no specific genes have been clearly identified as etiological precursors to

psychopathy, several candidates are being considered, including those that are thought to
underlie the related predisposing disorder of attention-deficit/hyperactivity, and those
that are related to neurotransmitter systems relevant to aggressive and criminal
behavior, such as the dopaminergic and serotonergic systems (Caspi et al., 2002; Delisi,
Beaver, Vaughn, & Wright, 2009; Minzenberg & Siever, 2006; Waldman & Rhee, 2006). In
a review of this research, Minzenberg and Siever suggested several genetic
polymorphisms that are the focus of recent research in antisocial and aggressive behavior
(see also Roussos & Siever, Chapter 15, this volume). Within the serotonergic system,
alleles that are involved in the synthesis (U and LL), transportation (s), reception (5-
HT1B), and metabolism (MAO-A) of neuronal serotonin have all been associated with
anger, aggressive behavior, and impulsivity, as have several receptor polymorphisms
(DRD2, DRD3, DRD4) of the dopaminergic system, and catechol-O-Methyl Transferase
(COMT), a polymorphism associated with the breakdown of dopamine and norepiniphrine.
Again, while these genetic variations have been associated with several of the symptoms
associated with ASPD and psychopathy, these preliminary findings are not yet considered
conclusive evidence of any specific genetic contribution.
Numerous environmental factors have also been implicated in the etiology of antisocial
and psychopathic behavior. Shared, or common, environmental influences account for
15% to 20% of variation in criminality or delinquency (Rhee & Waldman, 2002). This
finding is remarkably robust even when compared to other psychiatric disorders with
known environmental components such as affective and substance use disorders
(Kendler, Prescott, Myers, & Neale, 2003), indicating something distinct about the shared
environmental influence on antisocial, psychopathic behavior. The modeling or learning of
psychopathic behaviors is more likely to occur in environments that have higher incidents
of this type of behavior, or that condone antisociality and violence (Eron, 1997). Not
surprisingly, shared environmental factors such as low family income, inner-city
residence, poor parental supervision, single-parent households, rearing by antisocial
parents, delinquent siblings, parental conflict, harsh discipline, neglect, large family size,
young mother, and depressed mother have all been implicated as risk factors for
psychopathic behavior (Farrington, 2006). The effects of these factors are not limited to
learning, however. For instance, neglect and physical abuse can generate several possible
courses to antisocial and aggressive behavior, such as desensitization to pain, impulsive
coping styles, changes in self-esteem, and early contact with the justice system (Widom,
1994). Nonshared environmental influences are also substantial contributors. Factors
specific to the individual appear to account for fully 30% of antisocial behavior variance
(Moffitt, 2005). In short, this is the remaining variance not accounted for by genetic
(50%) or shared environmental (20%) influences. Nonshared environmental factors may
include delinquent peers, individual social and academic experiences, or physical abuse.
Unfortunately, the interactive effects of genetic and environmental influences are difficult
to tease apart and likely create confusion about what these estimates mean in terms of
causation. For example, the individual who is genetically predisposed to psychopathic
behavior will subsequently elicit environmental factors associated with antisocial
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Psychopathy
outcomes, such as peer problems, academic difficulty, and harsh discipline from parents
(Beaver, Barnes, May, & Schwartz, 2011; Larsson, Viding, Rijsdijk, & Plomin, 2008). In
addition, psychopathic individuals may receive their genes from psychopathic parents
who also exhibit delinquent and irresponsible behavior, thus creating an immediate home
environment that is likely to model instability and criminality. Concerns surrounding the
interaction of environmental and genetic factors have led to research designs that have
focused more directly at making these distinctions. Studies that explicitly address this
issue have found that environmental factors continue to play a large part in etiology of
antisocial behavior beyond genetic factors alone. For instance, after controlling for the
genetic component of physical maltreatment, Jaffee, Caspi, Moffitt, and Taylor (2004)
found that the environmental etiological effect of physical maltreatment remained. Thus,
independent of one another, genes and environment account for important variance in
criminal and delinquent outcomes. However, due to the strong interaction between these
components, the significance of either etiological course remains difficult to quantify.
Epidemiology
The prevalence of ASPD in the general population indicates strong gender differences,
with higher incidence in men than in women. Using the (p. 491) Diagnostic Interview
Schedule, the Epidemiologic Catchment Area (ECA) study estimated ASPD prevalence to
be 4.5% in men and 0.8% in women (Robins & Regier, 1991). Similarly, the National
Comorbidity Survey (NCS) indicated substantial gender differences, with 5.8% of men
and only 1.2% of women meeting ASPD criteria (Kessler et al., 1994). In addition, ASPD
prevalence rates tend to be similar across race. For example, ECA estimates
demonstrated little difference between African American and Caucasian races (2.3% vs.
2.6%, respectively), suggesting that ASPD tends to present with equal incidence across
race and ethnicity (see also Oltmanns & Powers, Chapter 10, and Torgersen, Chapter 9,
this volume).
In contrast to the substantial epidemiological research conducted for ASPD, studies of the
prevalence of psychopathy in the community are more limited. The results of several
community studies suggest that perhaps 1% of males and 0.5% of females meet PCL: SV
research criteria for psychopathy (Neumann & Hare, 2008). That is, the community ratio
of ASPD to psychopathy appears to be about 4 or 5 to 1. This is similar to the ratio of
ASPD (about 50% to 60%) to psychopathy (about 15%) in correctional settings (Hare,
2003). These prevalence differences between ASPD and psychopathy may be indicative of
a confound between the ASPD diagnostic criteria and the correctional setting. It has been
suggested that the heavy weighting of the DSM-IV-TR ASPD criteria toward criminal and
delinquent behavior inflates ASPD prevalence in prison settings (Hare, 2003; Widiger,
2006). In addition to the behavioral elements of ASPD, the diagnosis of psychopathy is
contingent on the presence of several personality traits (e.g., glib charm, grandiosity, lack
of empathy) that are specific to correctional populations. Because of this asymmetric
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criterion overlap, it is not surprising that perhaps 90% of incarcerated offenders who
meet the PCL-R research criteria for psychopathy also meet the behavioral criteria for
ASPD, but as few as 30% of those with ASPD also meet the criteria for psychopathy
(Hare, 2003).
At this point, there is little evidence that there are significant ethnic differences in the
prevalence of psychopathy (Cooke, Kosson, & Michie, 2001; Hare, 2003; Skeem, Edens,
Camp, & Colwell, 2004; Sullivan & Kosson, 2006). Item response theory (IRT) analyses
indicate that PCL-R scores in the upper range (around 30) appear to reflect much the
same level of psychopathy in North American male offenders as they do European male
offenders and forensic psychiatric patients (Bolt, Hare, & Neumann, 2007; Bolt, Hare,
Vitale, & Newman, 2004; Cooke, Michie, Hart, & Clark, 2005). Similarly, IRT analyses
(Cooke et al., 2001) and a meta-analytic review (Skeem et al., 2004) indicate that the PCL-
R total scores function similarly in 1990American and Caucasian offenders and patients.
Nonetheless, we note that there are ethnic differences in the functioning of individual
PCL-R items (Bolt et al., 2004, 2007; Cooke et al., 2001, 2005) and in the external
correlates of the PCL-R and other measures of psychopathy (Hare, 2003; Hervé & Yuille,
2007; Kosson, Smith, & Newman, 1990; Patrick, 2006; Sullivan, Abramowitz, Lopez, &
Kosson, 2006). In their report of the use of the PCL-R in the extensive Pittsburgh Youth
Study, Vachon, Lynam, Loeber, and Stouthamer-Loeber (2012, p. 268) concluded that,
“psychopathy behaves similarly across ethnic groups and conviction status. The
implications of these findings are straightforward—research conducted on Caucasian,
African American, convicted, and nonconvicted samples is relevant for a general
understanding of psychopathy. There are also several clinical and forensic implications of
these findings; for example, taking into account race or setting should have little impact
when measuring psychopathy or using it to assess risk. Furthermore, treatment
considerations related to psychopathy will not vary according to the patient’s race or
criminal history.”
Gender differences in the prevalence of psychopathy generally are consistent with the
ASPD findings (Verona & Vitale, 2006), indicating that women are less psychopathic (or at
least have lower psychopathy scores) than men (Bolt et al., 2004; Hare, 2003; Vitale,
Smith, Brinkley, & Newman, 2002). IRT analyses indicate that a given PCL-R score has
much the same meaning, with respect to the underlying trait of psychopathy, in female as
in male offenders (Bolt et al., 2004). There are gender differences in the functioning of
individual PCL-R items (Bolt et al., 2004, 2007), mostly confined to the lifestyle and
antisocial components. There also are similarities and differences in external correlates of
the PCL-R and other measures of psychopathy (Hare, 2003; Hervé & Yuille, 2007;
Kennealy, Hicks, & Patrick, 2007; Patrick, 2006; Sullivan et al., 2006), in part because of
the influence of cultural and biological factors that influence sex-role expectations and
behaviors.
Gender differences in personality disorder have often been attributed to some form of
gender bias in diagnosis or assessment (see Oltmanns & Powers, (p. 492) Chapter 10).
However, well-established gender differences in the facets of the Five-Factor Model of
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general personality structure (Costa, Terracciano, & McCrae, 2001) support the gender
differences obtained for psychopathy and ASPD. For example, Costa et al. (2001) report
that women score much higher on all facets of agreeableness and neuroticism than men,
as well as on the warmth facet of extraversion and the dutifulness facet of the
conscientiousness. Additionally, women score lower than men on the excitement seeking
and assertiveness facets of extraversion. In sum, the facets in which the psychopath is
low are precisely those facets in which men tend to score lower than women (e.g., all
facets of agreeableness; the anxiety, depression, self-consciousness and vulnerability
facets of neuroticism; the warmth facet of the extraversion domain; and the dutifulness
facet of the conscientiousness domain). Likewise, the facets in which the psychopath is
high are facets in which men score higher than women (e.g., the excitement seeking and
assertiveness facets of extraversion). That is, the facets of general personality structures
involved in psychopathy are ones that are more characteristic of men than women. Thus,
from a general personality standpoint large gender differences in psychopathy are to be
expected.
Course
Several studies have supported the temporal stability of psychopathic and antisocial
traits. Frick, Kimonis, Dandreaux, and Farell (2003) found that APSD trait dimensions
were stable over a 4-year period in a sample of nonreferred children in the third, fourth,
sixth, and seventh grades at first assessment. In this study, baseline antisocial behavior,
socioeconomic status, and quality of parenting were significant predictors of stability.
Using a large sample of inner-city boys assessed annually from ages 8 to 16 years and
items from a child behavior checklist to model interpersonal callousness, Obradovic,
Pardini, Long, and Loeber (2007) found evidence of significant stability across a 9-year
period, as well as longitudinal invariance. The latter finding is important because it
suggests that the same construct was being modeled across time. In related research,
Burke, Loeber, and Lahey (2007) reported that the same behavior checklist-based
interpersonal-callousness measure significantly predicted PCL-R scores at age 19 years in
a clinic-referred sample of boys assessed at ages 7 to 12 years.
Loney, Taylor, Butler and Iacono (2007) used a large sample of twins and found that the
Minnesota Temperament Inventory (MTI) detachment and antisocial tendencies showed
good stability (see also Neumann, Wampler, Taylor, Blonigen, & Iacono, 2011). Lynam,
Caspi, Moffitt, Loeber and Stouthamer-Loeber (2007) also found moderate stability from
ages 13 to 24 years, respectively, using the Child Psychopathy Scale (CPS; Lynam, 1997)
and the PCL: SV. This latter study is notable for its use of a hetero-method approach.
Also, Lynam et al. (2007) found that in addition to CPS scores, family structure and SES
also predicted PCL: SV scores, consistent with the Frick et al. (2003) findings.
Importantly, across many of these studies there appear to be fundamental longitudinal
relations between the antisocial-tendencies component of psychopathy and other
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psychopathic traits. Similarly, Larsson et al. (2007) found that prior (ages 13 to 14 years)
antisocial tendencies were significantly positively associated with later (ages 16 to 17
years) interpersonal, affective, and impulsive lifestyle psychopathic traits via cross-twin
cross-trait biometric data. In sum, across a diverse set of psychopathy or psychopathy-
related instruments and samples, there is good evidence for the stability of psychopathic
traits from childhood and adolescence into adulthood. At the same time, family factors,
socioeconomic status, and unique environmental factors may also play important roles in
the stability and change of psychopathic traits over time (Neumann et al. 2011).
Although psychopathy and ASPD are considered to be chronic, lifelong disorders, many of
the specific antisocial behaviors associated with these diagnoses do tend to decrease
significantly with age (Cleckley, 1941). Robins’s (1966) longitudinal study of delinquent
children similarly indicated that approximately 40% of antisocial youths show a reduction
in antisocial activity in adulthood, and that the median age of clinical improvement was
35 years. Comparable findings have been reported in the psychopathy research, albeit
with slightly higher age estimates for remission of symptoms (Hare, 2003). In addition,
cross-sectional prevalence estimates in prisoners reflect this trend with a linear decline in
PCL-R and ASPD scores beginning at age 20 years (Hare, 2003; Harpur & Hare, 1994).
Simply put, there appears to be a higher prevalence of ASPD and psychopathy in
prisoners between the ages of 20 to 40 years than after age 40 years. However, the
clinical improvement documented is relative to the group; before the drop in criminal
behaviors, psychopathic individuals participate in more criminal activity, have higher
conviction rates, and serve longer sentences than nonpsychopathic offenders, and
(p. 493) after age 40 years, conviction rates drop but remain comparable for psychopathic
and nonpsychopathic criminals (Hare, 2003; Hare, McPherson, & Forth, 1988; Harpur &
Hare, 1994). Thus, while the reduction of criminal behaviors over time is significant for
the psychopath, this “improvement” merely renders them comparable in criminality to
their nonpsychopathic counterparts.
Interestingly, while the psychopath appears to “age out” of his (or her) criminal activity
over time, there is evidence that the personality characteristics that accompany
psychopathy remain remarkably stable. In their cross-sectional study, Harpur and Hare
(1994) demonstrated that the psychopathy factors were differentially related to age;
while Factor 2, which assesses the “traits and behaviors associated with an unstable and
antisocial lifestyle” (p. 605) was found to have the predicted negative relation with age,
Factor 1, which describes the “affective and interpersonal traits central to the classical
clinical descriptions of the psychopath [including] egocentricity, manipulativeness,
callousness, and lack of empathy” (pp. 604–605) was unrelated to age. In fact, Factor 1
scores of the 15- to 20-year-old age group were strikingly similar to Factor 1 scores of the
46- to 70-year-old age group, indicating that the personality characteristics present in
Factor 1 show no significant age reduction. Thus, although criminal behaviors become
less prevalent over the life course, the traits associated with psychopathy appear to
continue to cause problems for the psychopath long after his criminal career ends. Hare
(2003) reported similar findings for larger samples of offenders. It is likely that this
pattern of age-related changes in psychopathy applies in the general population, based on
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the personality literature, for which similar findings have been reported. Longitudinal
studies of the Five-Factor Model indicate that the factors of agreeableness and
conscientiousness tend to increase across age (Costa, & McCrae, 1992; Soto, John,
Gosling, & Potter, 2011). Importantly, these domains are those particular important to
psychopathy, ASPD, and antisocial behavior in general (Lynam & Widiger, 2007). Thus,
independently of the psychopathy and ASPD research, predictions about the course of
these disorders are supported from the broad personality literature.
Treatment
Unlike most other offenders, psychopaths appear to suffer little personal distress, see
little wrong with their attitudes and behavior, and seek treatment only when it is in their
best interests to do so, such as when seeking probation or parole. They appear to derive
little benefit from prison treatment programs that are emotion based, involve “talk
therapy,” are psychodynamic or insight oriented, or are aimed at the development of
empathy, conscience, and interpersonal skills (Blair, 2008; Harris & Rice, 2006, 2007;
Thornton & Blud, 2007; Wong & Burt, 2007). This is hardly surprising, given recent
findings from behavioral genetics, developmental psychopathology, and neurobiology
(Frick, 2009; Gao et al., 2009; Harenski, Hare, & Kiehl, 2010; Harris & Rice, 2006; Harris,
Skilling, & Rice, 2001; Juárez, Kiehl, & Calhoun, 2012; Kiehl, 2006; Larsson, Viding, &
Plomin, 2008) that psychopathy is characterized by personality and behavioral
propensities that are strongly entrenched and presumably difficult to change. Some
authors recently have argued for programs primarily geared toward a reduction in risk
for recidivism and violence. Wong and colleagues (Wong & Burt, 2007; Wong, Gordon, &
Gu, 2007; Wong & Hare, 2005) have proposed that such risk management and “harm
reduction” programs should involve an integration of relapse-prevention techniques and
risk/needs/responsively principles (Andrews & Bonta, 2003) with elements of the best
available cognitive-behavioral correctional programs. The programs should be less
concerned with developing empathy and conscience or effecting changes in personality
than with convincing participants that they alone are responsible for their behavior, and
that there are more prosocial ways of using their strengths and abilities to satisfy their
needs and wants. Early indications are that such programs may help to reduce the
seriousness of postrelease offending (Wong et al., 2007). There also is some recent
evidence that therapeutic progress in cognitive-behavioral programs (Doren & Yates,
2008; Langton, Barbaree, Harkins, & Peacock, 2006; Olver & Wong, 2011), as well as
successful completion of such programs (Caldwell, 2011; Caldwell, McCormick, Umstead,
& Van Rybroek, 2007; Catchpole & Gretton, 2003; Forth & Book, 2007; Olver & Wong,
2011), may be predictive of reduced recidivism rates among adolescent and adult
offenders, including some with many psychopathic features. Yet to be determined are the
long-term efficacy of such programs and the extent to which their outcomes can be
replicated and generalized to other jurisdictions and populations.
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(p. 494) Cognitive/Affective Neuroscience

Early psychoanalytic conceptualizations of psychopathy referred to a “superego lacunae”
or holes in the conscience (Singer, 1974). This superego pathology was associated with an
“incapacity to experience self-reflective sadness” that ultimately results in callous, tough-
minded behavior (Kernberg, 1984). This classical clinical picture of the psychopath is
reflected in Cleckley’s (1941, 1976) speculations about “semantic dementia” in which a
dissociation of the affective and denotative components of language is a prime feature of
psychopathy. In the mid-20th century several investigators began to integrate clinical
conceptions of psychopathy with theory and paradigms from experimental psychology,
including motivation, learning, cognition, and perception, and with the emerging
discipline of psychophysiology (Hare, 1965, 1968; Lykken, 1957). The latter is based on
the premise that our understanding of the nature of individual differences in personality
and behavior is facilitated by the concomitant measurement of, and associations among,
behavioral, cognitive, and biological domains. The ensuing decades saw a large number
of empirical studies, most of which provided results consistent with clinical conceptions
of psychopathy (see Hare, 2003; Patrick, 2006). For example, a computerized lexical
decision task (does the letter string form a word?) by Williamson, Harpur, and Hare
(1991) provided the first empirical support for Cleckley’s idea that in psychopaths the
affective and connotative components of language are dissociated. For nonpsychopaths
emotional words were associated with faster reaction times and larger, more prolonged
event-related potentials (ERPs) than were neutral words. These effects did not occur in
psychopaths defined by the PCL-R; reaction times and ERPs were virtually the same for
emotional and neutral words.
There now is an extensive literature indicating that some key clinical and behavioral
attributes of psychopathy, including impulsivity, poor executive functioning and response
inhibition, difficulty in processing emotional material, and poor moral decision making,
appear to be related to “anomalies” (some would say deficits) in various autonomic,
electrocortical, biochemical processes, and in brain function and structure. Several
proximal pathways to antisociality and psychopathy have been advanced, including
affective deficits, neuroanotomical abnormalities, psychophysiological arousal system
impairments, deficits in cognitive functioning, personality factors, and genetic and
evolutionary processes. Interestingly, rather than supporting one causal factor, this
extensive research base indicates that the picture is complex and that many factors are
involved in antisociality and psychopathy (Derefinko & Widiger, 2008; Mitchell, & Beech,
2011; Raine, 2008).
Perhaps the most interesting and controversial research on psychopathy has to do with
the use of imaging techniques to investigate brain function and structure. The first study
used single photon computed tomography (SPECT) to study functional differences during
processing of semantic and affective words by psychopathic substance abusers at the
Bronx VA Center (Intrator et al., 1997). Psychopathic individuals showed less anterior
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activation, and less differentiation between neutral and emotional words, than did other
individuals. A curious finding was that when viewing emotional words the psychopathic
substance abusers showed increased activation in lateral prefrontal regions, which have
been implicated in semantic processing. This study was followed at the University of
British Columbia by a series of functional magnetic resonance imaging (fMRI) studies of
processing of neutral and emotional words and pictures (Kiehl et al., 2001, 2004).
Psychopathic offenders showed less activity than did nonpsychopathic offenders in
several brain regions, including the amygdala, dorsal and ventral anterior cingulate,
posterior cingulate, and ventral striatum. However, among the psychopathic offenders
there was increased activity in the lateral prefrontal cortex, a finding similar to that
reported in the SPECT study by Intrator et al. (1997). The authors suggested that the
lateral prefrontal regions were engaged by psychopathic individuals as a compensatory
response to decreased input from limbic regions. That is, what was an emotional task for
most people appeared to be a linguistic one for psychopaths (think Spock on Star Trek).
There now is a large literature on functional brain differences between psychopathic and
other individuals, as well as a rapidly developing literature on differences in brain
structure (see reviews by Blair, 2006; Blair et al., 2005; Gao et al., 2009; Glenn, Raine, &
Schug, 2009; Hare, 2003; Harenski et al., 2010; Kiehl, 2006; Patrick, 2006; Wahlund &
Kristiansson, 2009; Yang & Raine, 2009). The trend is to view psychopathy in terms of
general brain models, rather than as localized problems within single structures (e.g.,
amygdala, hippocampus, frontal cortex). Interestingly, these brain models of psychopathy
bear a strong (p. 495) resemblance to models of the “moral” (De Oliveira-Souza et al.,
2008; Glenn et al., 2009; Moll, Zahn, de Oliveira-Souza, Krueger, & Grafman, 2005) and
the “social” brain (Adolphs, 2001; Harenski et al., 2010). With respect to the latter,
Harenski et al. (2010, p. 141) commented, “A network of brain regions that [is]
consistently implicated in social cognition has been identified. These include the medial
prefrontal cortex, posterior cingulate/precuneus, the amygdala, anterior insula, and the
anterior and posterior temporal cortex (anterior cingulate). Collectively, these regions
demonstrate a remarkable convergence with the brain regions that have been implicated
in psychopathy.” Sarkar, Clark, and Deeley (2011) have provided a recent overview of
brain function and structure in personality disorders and psychopathy, including evidence
that ASPD and psychopathy exhibit abnormalities in the white matter pathway that
connects limbic and ventral frontal brain regions (Sundram et al., 2011).
Although imaging studies have gained a great deal of attention in recent years, the
traditional psychophysiological paradigms continue to add greatly to our understanding
of psychopathy (e.g., Fung et al., 2005; Hare, 2003; Isen et al., 2010; also see the
chapters in Patrick, 2006). Startle probe methodology and ERPs are proving particularly
useful in the elucidation of learning, motivational, emotional, cognitive, and attentional
processes in psychopathy. For example, psychopaths give relatively small startle
responses to loud noises in the presence of negatively valenced pictures (Benning,
Patrick, & Iacono, 2005; Patrick, Bradley, & Lang, 1993; Vaidyanathan, Hall, Patrick, &
Bernat, 2011). These findings typically are interpreted as evidence for a lack of fear
arousal in psychopathy. However, Newman et al. (2010) have provided evidence that
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“higher order cognitive processes” moderate the fear responses of psychopathic

individuals. “These findings suggest that psychopaths’ diminished reactivity to fear
stimuli, and emotion-related cues more generally, reflect idiosyncrasies in attention that
limit their processing of peripheral information” (Newman et al., 2010, p. 66).
ERPs have long been used in the study of cognitive and attentional processes in
psychopathy (e.g., Jutai & Hare, 1983; Kiehl, Bates, Laurens, Hare, & Liddle, 2006; Raine,
1989; Williamson et al., 1991). In a recent review Harenski et al. (2010) summarized
some of the more interesting ERP findings and their interpretation. For example, they
described a series of linguistic and target-detection tasks in which “psychopaths showed
an abnormal late negativity across fronto-central sites in the 300–500-ms time
window” (p. 138). Each of the tasks required the participant to attend and respond to a
target stimulus. The authors viewed these ERP findings as an indication that psychopaths
give unusually large orienting responses to stimuli of interest. This interpretation, based
on an unusual ERP waveform, is consistent with the speculation by Hare (1986, p. 13)
that the biological anomalies observed in psychopaths “are more likely a reflection of the
particular motivational and cognitive demands placed on them, than of an autonomic
nervous system that does not function properly…(P)sychopaths may have difficulty in
allocating their attentional and processing resources between competing demands of two
tasks. It appears that rather than distributing resources between tasks they focus
attention on the one that is most interesting to them.” The ERP findings also are
consistent with the influential body of research by Newman and his colleagues on
response modulation in psychopathy (Hiatt & Newman, 2006; Newman et al., 2010;
Newman, Hiatt, & MacCoon, in press; Newman, Patterson, & Kosson, 1987; Zeier,
Maxwell, & Newman, 2009). Newman defines response modulation as a brief and
relatively automatic shift of attention from the organization and implementation of goal-
directed action to its evaluation. The hypothesis is that psychopaths are deficient in
modulation of their attentional responses, a deficit that interferes with their ability to
accommodate the meaning of contextual cues while actively engaged in goal-directed
behavior. That is, they attend selectively to the primary demands of a situation but are
less likely than others to process a range of incidental information that normally provides
perspective on behavior and guides interpersonal interactions and response strategies.
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Evolutionary Psychology
Although many investigators view psychopathy as pathology (abnormality, deficit),

evolutionary behavioral psychologists take the view that psychopathy is not a form of
pathology but an adaptive life strategy (Book & Quinsey, 2003; Harris, Rice, Hilton,
Lalumière, & Quinsey, 2007; Ward & Durrant, 2011; also see Buss, 2009, for a discussion
of personality traits as forms of strategic individual differences in adaptation). This view
is subject to considerable debate, but it is consistent with recent findings from behavioral
genetics, discussed earlier. Here, we take the position that (p. 496) neuroscientists have
uncovered important differences between psychopathic and other individuals, but that
these differences do not necessarily imply clinical deficits or pathology. We do so for
several reasons. First, many researchers and clinicians already consider psychopathy to
be pathological and therefore they interpret cognitive, affective, and biological findings
as evidence of an underlying deficit or dysfunction. But even statistically significant
differences do not necessarily imply a deficit or a function that falls outside of the
“normal” range. In this respect, it is important to note that at present we know little
about the variability in brain structure and function in the general population, and even
less about how such variability relates to differences in personality and behavior. Second,
functional differences observed during performance of a task might reflect the use of
different strategies for performance of the task, while structural differences might be a
case of “use it or lose it.” Third, the number of studies and participants is relatively small,
the selection of participants typically is not random, and the laboratory tasks used in
these studies generally have uncertain ecological validity. Fourth, measurement error in
the assessment of psychopathy, methodological, measurement, and statistical problems in
acquiring and interpreting neuroimaging data, and uncertainty about what such data tell
us about underlying cognitive and affective processes, make it difficult to establish causal
connections between brain function/structure and psychopathic behavior.
This is more than an academic issue. The interpretations placed on the cognitive/affective
neuroscience of criminality and psychopathy will have a major impact on determinations
of legal culpability (e.g., Gazzaniga, 2008; Mobbs, Lau, Jones, & Frith, 2007). Discussions
of the clinical, philosophical, ethical, and legal issues related to the psychopathy and legal
responsibility are available in Malatesti and McMillan (2010).
Conclusions and Future Directions

There is now an impressive body of replicable and meaningful empirical findings on the
measurement, etiology, epidemiology, course, and cognitive/affective nature of
psychopathy, due in no small part to the widespread adoption of the PCL-R and its
derivatives as a common working model. We hope that the next edition of the APA
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diagnostic manual will take a significant step toward the inclusion of traits long
recognized as important in the diagnosis of psychopathy.
Author’s Note
Correspondence concerning this manuscript should be addressed to Robert D. Hare,
Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver,
Canada, V6T 1Z4. E-mail: rhare@interchange.ubc.ca. Robert Hare receives royalties from
the sale of the PCL-R and its derivatives. Portions of this chapter are based on Hare and
Neumann (2008, 2010a). We thank Kylie Neufeld for her assistance in preparation of this
chapter.
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Robert D. Hare
Robert D. Hare, Department of Psychology, University of British Columbia,

Vancouver, Canada
Craig S. Neumann
Craig S. Neumann, Department of Psychology, University of North Texas, Denton, TX
Thomas A. Widiger
Thomas A. Widiger, Department of Psychology, University of Kentucky.
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Psychopathy

Oxford Handbooks Online

Print Publication Date: Sep 2012 Subject: Psychology, Clinical Psychology

Abstract and Keywords

Psychopathy refers to the personality disposition to charm, manipulate, and ruthlessly

Keywords: psychopathy, PCL-R, DSM, antisocial personality disorder

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Description and Diagnosis

The Cleckley Psychopath

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Table 22.1 Items and Factors in the Hare PCL Scales

PCL-R PCL: YV PCL: SV

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Interpersonal Interpersonal Interpersonal

1. Glibness/superficial 1. Impression management 1. Superficial

2. Grandiose sense of self- 2. Grandiose sense of self- 2. Grandiose

4. Pathological lying 4. Pathological lying 3. Deceitful

5. Conning/manipulative 5. Manipulation for

Affective Affective Affective

6. Lack of remorse or guilt 6. Lack of remorse 4. Lacks remorse

7. Shallow affect 7. Shallow affect 5. Lacks empathy

8. Callous/lack of empathy 8. Callous/lack of empathy 6. Doesn’t accept

16. Failure to accept 16. Failure to accept

Lifestyle Behavioral Lifestyle

3. Need for stimulation 3. Stimulation seeking 7. Impulsive

9. Parasitic lifestyle 9. Parasitic orientation 9. Lacks goals

13. Lack of realistic, long- 13. Lack of goals 10. Irresponsibility

14. Impulsivity 14. Impulsivity

15. Irresponsibility 15. Irresponsibility

Antisocial Antisocial Antisocial

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12. Early behavioral 12. Early behavior 11. Adolescent

18. Juvenile delinquency 18. Serious criminal 12. Adult antisocial

19. Revocation of 19. Serious violations of

20. Criminal versatility 20. Criminal versatility

This dimensionality may pose a problem for diagnosing or categorizing a person

as a “psychopath,” a problem shared by other clinical disorders (e.g., antisocial

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traits in terms of the PCL-based four-factor model of psychopathy.

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As Patrick (2006) wrote, “there is no question that Cleckley considered persistent

Psychopathy and Crime

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Psychopathy, as measured by the PCL-R, is commonly used in preventative detention

Structural Equation Modeling and Violence Risk

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Based on these previous studies, as well as information about the distribution of

Representation of FFM Agreeableness and

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The PCL-based four-factor representation of the psychopathy construct has received

The FFM domains of Agreeableness and Conscientiousness are strongly inversely

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APA Diagnostic Manual

Robins was among the influential Neo-Kreapelinian psychiatrists working at Washington

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