653193

research-article2016
IJOXXX10.1177/0306624X16653193International Journal of Offender Therapy and Comparative CriminologyShepherd et al.

Article
International Journal of
Offender Therapy and
Psychopathy, Antisocial Comparative Criminology
2018, Vol. 62(3) 609­–628
Personality Disorder, and © The Author(s) 2016
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DOI: 10.1177/0306624X16653193
https://doi.org/10.1177/0306624X16653193
Sample of Forensic Patients journals.sagepub.com/home/ijo

Stephane M. Shepherd1, Rachel E. Campbell2,

and James R. P. Ogloff1,2

Abstract
This study identified the presence of psychopathy (as measured by the PCL-R/PCL:SV
instruments) and antisocial personality disorder (APD) and their relationship with
future reconviction in an Australian forensic sample (N = 136) of patients with a mental
disorder. Patients were tracked for over 4 years postrelease to determine associations
between a diagnosis of APD/psychopathy and reoffense. Patients with higher
psychopathy scores were found to have an increased likelihood of reincarceration, a
higher rate of reconviction, and were reconvicted earlier compared with patients with
lower psychopathy scores. Patients with APD were more likely to be reconvicted and
reincarcerated during the follow-up period than patients without an APD diagnosis.
Despite demonstrating associations with general reconviction, the PCL instruments did
not exhibit statistically significant relationships with violence. Implications for the clinical
identification of personality disordered patients in forensic settings are discussed.

Keywords
psychopathy, antisocial personality disorder, recidivism, violence risk assessment,
forensic mental health

The rate of major mental disorder in the criminal justice population exceeds the rate
observed in the general community (Fazel & Danesh, 2002; Fazel, Doll, & Langstrom,
2008). Serious mental illness has been found to be a significant risk factor for violence

1Swinburne University of Technology, Clifton Hill, Victoria, Australia

2Forensicare, Fairfield, Victoria, Australia

Corresponding Author:
Stephane M. Shepherd, Centre for Forensic Behavioural Science, Swinburne University of Technology,
505 Hoddle Street, Clifton Hill, Victoria 3068, Australia.
Email: sshepherd@swin.edu.au
610 International Journal of Offender Therapy and Comparative Criminology 62(3)

(Fazel & Grann, 2006; Grann, Danesh, & Fazel, 2008). However, research has shown
criminal behavior is the likely product of personality functioning and sociocontextual
risk markers rather than mental illness alone (Andrews & Bonta, 2010; Shepherd &
Purcell, 2015; Simpson, Grimbos, Chan, & Penney, 2015). High rates of personality
disorder in correctional settings have been internationally documented. In a systematic
review of 62 studies across 12 countries, Fazel and Danesh (2002) found that 65% of
men and 42% of women prisoners had a personality disorder, of which 47% of men
and 21% of women were principally diagnosed with antisocial personality disorder
(APD), which is approximately 10 times greater than that of the general population.
The disproportionate occurrence of APD within these settings is unsurprising given
that the disorder is characterized by problem behaviors including the violation of the
rights of others and repeat criminality (American Psychiatric Association [APA],
2013). The strong emphasis on behaviors associated with criminality has seen up to
80% of individuals in correctional settings being diagnosed with APD (APA, 2013;
Douglas, Ogloff, Nicholls, & Grant, 1999; Hare, 2003) in some studies, while only
15% of prisoners and 10% of forensic-psychiatric individuals are commonly found to
be psychopathic (Hare, 2003).
Psychopathic personality has captured the attention of clinicians, theorists, policy
makers, and the general public alike. Psychopathy is defined as a personality disorder,
which manifests during childhood and persists across the life span (Hare, 2003). What
distinguishes psychopathy from other disorders are specific personality-based symp-
toms such as shallow affect, callousness, and an absence of empathy. The low public
tolerance for antisociality and rule-breaking behaviors that are associated with the
psychopath (see Forsman, Lichtenstein, Andershed, & Larsson, 2010) has sparked sci-
entific interest in unraveling the damaging life course of the psychopath. Despite their
theoretical distinctions, APD and psychopathy are often incorrectly deemed to be
clinically interchangeable (see Ogloff, 2006). Both disorders share antisocial behav-
ioral traits; however, a psychopathic individual’s pronounced lack of empathy and
shallow affect are absent from APD criteria. Most psychopathic offenders meet criteria
for APD; however, the majority of offenders with APD do not satisfy psychopathic
benchmarks (Hart & Hare, 1989; Hildebrand & de Ruiter, 2004; Ogloff, 2006; Pham
& Saloppe, 2010).

Risk Assessment
Research examining psychopathy and violence is well established in North America
and in some areas of Europe. Hare (1980) developed a tool aimed at operational-
izing the construct of psychopathy referred to as the Psychopathy Checklist (PCL;
Hare, 1980). A modified 20-item version, the Psychopathy Checklist–Revised
(PCL-R; Hare, 1991, 2003), a 12-item screening version the Psychopathy Checklist:
Screening Version (PCL:SV; Hart, Cox, & Hare, 1995), and a youth version
(Psychopathy Checklist: Youth Version: PCL:YV; Forth, Kosson, & Hare, 2003)
have since been published. In contemporary forensic settings, the three Hare
Psychopathy instruments—PCL-R, PCL:SV, and PCL:YV—are regularly
Shepherd et al. 611

administered as part of clinical violence risk assessment. Evolving from these

investigations is an extensive body of research demonstrating the utility of psy-
chopathy as a predictor of reoffense and other negative outcomes across adult
(Douglas, Vincent, & Edens, 2006) and juvenile (Edens, Campbell, & Weir, 2007)
offender samples as well as civil and forensic-psychiatric populations (Doyle &
Dolan, 2006; Edens, Skeem, & Douglas, 2006; Skeem & Mulvey, 2001).
A limitation of the international research on psychopathy risk assessment is that
there remains a paucity of Australian research with forensic populations on this front
(Scott, 2014). McGregor, Castle, and Dolan (2012) found psychopathy to be associ-
ated with violence for patients from Victorian community mental health clinics who
met the criteria for Schizophrenia; however, no Australian study has investigated both
the base rate of psychopathy in forensic settings nor explored its relationship with
violent reoffense. This existing gap in the literature is problematic for several reasons.
Without this data, the interpretation of Psychopathy scores in Australian forensic con-
texts must warrant caution. Different thresholds on psychopathy checklists by geo-
graphical region have been established elsewhere (see Hare, Clark, Grann, & Thornton,
2000). Accurate identification of psychopathic traits is necessary to triage psycho-
pathic patients appropriately, particularly as effective intervention for psychopathy
remains largely elusive. Placing unscreened psychopathic patients into group therapy
may negatively impact group dynamics. As such, regional psychopathy research is
critical in determining local occurrence and refining screening standards. Both adult
versions of the Psychopathy Checklist (PCL-R; PCL:SV) warrant investigation in
Australia. Moreover, given an historic (and misguided) clinical tendency to deem APD
and Psychopathy as analogous constructs, it is necessary to further explore the occur-
rence of both disorders and their relationship with future violence in international
populations.
Available research points to an association between APD and violence (Wormith,
Stevenson, Olver, & Girard, 2007). However, there is still modest evidence for the
disorder as a predictor of violence in correctional samples (see Edens, Kelley, Skeem,
Lilienfeld, & Douglas, 2015). Less is known about the disorder’s relationship with
recidivism for forensic-psychiatric patients. Studying these associations in various
subpopulations is important given the behavioral implications of presenting with
Antisocial Personality Disorder (ASPD) disorder. Efforts to understand the violence
risk levels of forensic patients exhibiting psychiatric comorbidity provide crucial post-
discharge risk management information for forensic services.
This study aims to address these concerns by identifying the base rates of psy-
chopathy and APD in an Australian sample of patients with a mental disorder and
investigate the associations between these personality disorders and postrelease recidi-
vism. In light of previous prevalence estimates, it was anticipated that a higher propor-
tion of the sample would have a diagnoses of APD compared with psychopathy. With
consideration to prior research on the PCL and recidivism and the fact that both disor-
ders are characterized by law-breaking behaviors and a reckless disregard for societal
norms and the safety of others, both APD and psychopathy were expected to be associ-
ated with higher levels of general and violent offending post-hospital discharge.
612 International Journal of Offender Therapy and Comparative Criminology 62(3)

Materials and Method

Participants
The sample comprised 136 randomly selected mentally offenders and forensic-
psychiatric patients (men n = 98; women n = 38) discharged from Victoria’s secure
forensic-psychiatric hospital, Thomas Embling Hospital (TEH) in Melbourne,
Australia, between 2000 and 2003. Participants were randomly selected from a group
originally sourced as part of larger study examining the characteristics of Victorian
mentally ill offenders and forensic-psychiatric patients. All patients admitted to TEH
after August 2000 and discharged before November 2003 were included in the study.
TEH is Victoria’s only secure forensic mental health facility. TEH provides assess-
ment and treatment to men and women with serious mental illnesses requiring secure
inpatient psychiatric hospitalization. Patients include prisoner patients (i.e., prisoners
with serious mental illness who are involuntarily hospitalized at TEH for treatment) as
well as forensic patients (i.e., those found not guilty because of mental impairment,
which is equivalent to a finding of not guilty by reason of insanity). At the time of the
study, TEH included seven inpatient units across three different care programs, total-
ing a capacity of 100 inpatient beds.

Demographics
Table 1 presents sample demographical information including patient ethnicity, pri-
mary diagnosis at admission, previous hospitalizations, and prior convictions. Almost
three quarters of the sample were male, and the mean age at discharge was 32.2 years
(SD = 9.4; median = 30.2; range = 17-62). The vast majority of patients were admitted
to TEH from prison (87.5%). Given the rather small number of forensic patients (less
than 5%), the data that are presented include both prisoner patients and forensic
patients. The incidence of primary diagnoses at discharge was generally similar to
those recorded at admission.
The large majority of TEH patients have psychotic diagnoses. Almost a quarter of
the sample (23.5%) has a prior diagnosis of APD based on preexisting clinical files. The
most common secondary diagnoses on admission and at discharge were alcohol/drug
abuse/dependence and personality disorders. Alcohol/drug abuse/dependence made up
15.4% (n = 21) of secondary diagnoses on admission and 19.1% (n = 26) at discharge.
Personality disorders contributed to 9.6% (n = 13) of secondary diagnoses on admis-
sion; of these, 38.5% (n = 5) were borderline personality disorder. The base rate of
personality disorder as secondary diagnoses was slightly higher at discharge (13.2%;
n = 18) than admission (9.6%, n = 13). It is noteworthy that a very small number of
patients enter the Victorian forensic-psychiatric hospital with a primary diagnosis of
personality disorder. This is partially tied to the Courts’ interpretation of the term men-
tal impairment under the Crimes (Mental Impairment and Unfitness to be Tried) Act,
1997. It is also the result of a vetting process within the Victorian forensic-psychiatric
system, which reserves TEH inpatient beds for only the most severely mentally ill.
Shepherd et al. 613

Table 1. Sample Demographic Characteristics.

Characteristic n %
Gender
Male 98 72.1
Female 38 27.9
Ethnicity
Caucasian 107 78.7
Aboriginal/TSI 10 7.4
Other 19 13.9
Primary diagnosis (admission)
Schizophrenia 72 52.9
Other psychotic disorder 23 16.9
Major depressive disorder 9 6.6
Adjustment disorder with depressed mood 7 5.1
Other 23 18.5
Any prior civil-psychiatric hospitalizationsa 88 64.7
Number of hospitalizationsb
None 44 32.4
One 20 14.7
2-3 21 15.4
4-5 11 8.1
>5 28 20.6
Any prior forensic-psychiatric hospitalizationsa 46 33.8
Number of hospitalizationsb
None 89 65.4
One 19 14.0
2-3 19 14.0
4-5 3 2.2
>5 3 2.2
Unknown 3 2.2
Prior convictions
Any 102 75
Violent 74 54.5

Note. N = 136.
an = 136.
bn = 124.

TSI = Torres Strait Islander.

Measures
Psychopathy Checklist–Revised (PCL-R). Comprising 20 items, the PCL-R was developed
to capture the extent to which a person epitomizes the prototypical psychopath. Cen-
tral to the PCL-R is a pattern of affective, interpersonal, behavioral, and antisocial
components (Hare, 2003). Factor 1, labeled “interpersonal/affective” or “selfish,
614 International Journal of Offender Therapy and Comparative Criminology 62(3)

callous, and remorseless use of others,” identifies personality features associated with
historical clinical descriptions of psychopathy (Cleckley, 1941/1988). Factor 2, labeled
“social deviance” or “chronically unstable, antisocial, and socially deviant lifestyle,”
captures behaviorally based symptoms and has been likened to the more defining fea-
tures of APD criteria (Ogloff, 2006). Factors 1 and 2 are further divided into four
underlying facets: Facet 1 (Interpersonal) and Facet 2 (Affective) fall under Factor 1,
and Facet 3 (Lifestyle) and Facet 4 (Antisocial) aligned with Factor 2 (Hare, 2003).
Each item is scored on a 3-point scale (totaling a maximum score of 40), which gener-
ates a dimensional measure of traits.
A high level of reliability for the PCL-R has been established across varied samples
and countries when used by trained raters; intraclass correlation coefficients (ICC1)
around .80 for the single rater and .90 for the average of raters (ICC2) have been
reported (Hare, 2003; Harris, Rice, & Cormier, 2013; Hildebrand & de Ruiter, 2012).
In this study, interrater reliability of file coding was assessed by having the primary
rater and a second rater code a randomly chosen subset of 20 (14.7%) files. An ICC
with a one way (rater) random effect model was used as the index of reliability. The
ICC1 coefficients for the PCL-R total, Factors 1 and 2 scores were high: .94, .81, and
.97, respectively. The reliability of the PCL-R facets was also robust (≥.75), with the
exception of Facet 1, which was low in comparison (ICC1 = .55).

Psychopathy Checklist: Screening Version (PCL:SV). Originally developed to screen for

psychopathic traits in noncriminal samples, the Psychopathy Checklist: Screening
Version (PCL:SV; Hart et al., 1995) has since demonstrated predictive validity for
violence in criminal populations (Pedersen, Kunz, Rasmussen, & Elsass, 2010). The
original 20 item PCL-R measure was condensed into a shorter 12-item version to ini-
tially create the PCL:SV for use in the MacArthur Violence Risk Assessment Study
(Steadman et al., 1994). The 12 items are scored on the same 3-point scale as the PCL-
R, producing a total score ranging from 0 to 24.
The measure has demonstrated adequate interrater reliability (mean weighted ICC1
for Total scores .84; Hart et al., 1995) and exhibited high concurrent validity with the
PCL-R total and factor scores (Hart et al., 1995). The PCL:SV Total, Parts 1 and 2
score ICC1 coefficients, were also high: .95, .84, and .86, respectively.

APD. APD was assessed using the criteria from the Diagnostic and Statistical Manual
of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA, 2000), which are unchanged
in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA,
2013). The four criteria that make up the APD diagnostic category are presented in
Table 2. All four criteria must be met to satisfy a diagnosis of APD. Criterion A, how-
ever, specifies that at least three of the seven subitems must be met to fulfill the criteria
(APA, 2013).
Based on information available in the clinical-legal files (e.g., documented past
history, inpatient behavior, staff reports, criminal records) a diagnosis of APD was
objectively made by raters using the above criteria. Depending on the breadth of file
coverage, each of the four criteria were coded Yes, No, or Don’t Know. An overall
Shepherd et al. 615

Table 2. Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) Criteria for
Antisocial Personality Disorder (APA, 2013).

There is a pervasive pattern of disregard for and violation of the rights of others occurring
since age 15 years, as indicated by three or more of the following:
•• failure to conform to social norms with respect to lawful behaviors as indicated by
repeatedly performing acts that are grounds for arrest
•• deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal
profit or pleasure
•• impulsivity or failure to plan ahead
•• irritability and aggressiveness, as indicated by repeated physical fights or assaults
•• reckless disregard for safety of self or others
•• consistent irresponsibly, as indicated by repeated failure to sustain consistent work
behavior or honor financial obligations
•• lack of remorse, as indicated by being indifferent to or rationalizing having hurt,
mistreated, or stolen from another
The individual is at least 18 years
There is evidence of conduct disorder with onset before age 15 years
The occurrence of antisocial behavior is not exclusive during the course of schizophrenia or
a manic episode

diagnosis (i.e., whether collectively all four APD criteria were met) was coded Yes,
No, or Not Enough Information to Make a Diagnosis. This diagnosis was independent
of any preexisting APD diagnosis that had been documented in the file (i.e., in past
reports, case notes from prior services). This information generated two APD catego-
ries labeled APD-Met (Does the patient meet all four APD Diagnostic and Statistical
Manual of Mental Disorders [4th ed.; DSM-IV; APA, 1994] criteria?) and APD-8 (The
total number of Criterion A symptoms met plus a score of one, if evidence of conduct
disorder is present [Criterion C]).
In this study, the two raters demonstrated a high level of agreement in determining
which patients met the APD DSM-IV criteria. A kappa coefficient value of .69 and a
total percentage agreement of 80% were achieved. Overall, the level of agreement
between raters on the APD variables was high (80%-100%).

Recidivism. Recidivism was established on records maintained by the Victoria Police

(i.e., no patient interviews, self-reported violence, or collateral information from men-
tal health services/hospitals were obtained). Recidivism was defined as the first new
conviction occurring during the follow-up period (i.e., the date on which the offense
was committed, not the date of conviction in court).
Violence was defined as “actual, attempted, or threatened harm to a person or per-
sons” (Webster, Douglas, Eaves, & Hart, 1997; p. 24). This definition included physical
assaults, fear-inducing actions, clear threats of harm (with or without a weapon), and
acts resulting in criminal sanctions such as arson, kidnapping, and reckless driving.
Reckless driving (Culpable driving) is a criminal offence in Australian jurisdictions
where an offender is found to be culpably negligent of driving that seriously endangers
616 International Journal of Offender Therapy and Comparative Criminology 62(3)

the public (e.g., causing death). Violence did not include destruction of property, self
defense, or acts against animals unless committed with the intent to induce fear in
another person. In addition, offenses were separated into four categories:

Any violence. “Any violence” comprised both physical and fear-inducing violence;
furthermore, all records of violence were established on official criminal records
alone; therefore, a category for criminal violence was redundant.

Physical violence. “Physical violence” included acts such as kicking, hitting, sexual
assault, and robbery with violence.

Fear-inducing violence. “Fear-inducing violence” comprised fear-inducing or

threatening behavior (i.e., armed robbery, arson, stalking, reckless driving, and clear
threats).

Nonviolent. A category for nonviolent crime was also recorded (i.e., theft, drug
offenses, possession of weapons, fraud, property damage, and parole violations).

Procedure
Clinical-legal hospital file material from all admissions (prior and the index hospital-
ization) were used to ascertain historical diagnostic information, and to retrospectively
code the PCL-R/SV and APD criteria. The patient information gathered included legal
status, index offence (obtained from presentence reports, psychiatric or psychological
reports provided to the court, recommendations for fitness, transcripts from the trial,
and official charge sheets), forensic history (e.g., past charges and convictions from
Victorian criminal records, and in some cases, nation-wide criminal records), psychi-
atric history (number of hospitalizations, length of time in hospital, date of first con-
tact, family psychiatric history, diagnoses, community clinical notes), social history,
personal history (employment, living arrangements, marital status), suicidal/self-harm
behavior, and release plans (psychological assessments, occupational therapy reports,
discharge plan summaries).
PCL-R items were summed to yield facet, factor, and total scores. In all analyses
involving the PCL-R and the PCL:SV, prorated scores were used in cases where the
permissible number of items was missing.
The coding of instruments was completed by doctoral level Clinical Forensic-
Psychology raters. Both coders were trained on the administration of the PCL mea-
sures during a 3-day workshop conducted by the measures’ author, Robert Hare and
the third author. Their scoring was supervised by the third author.
Information regarding recidivism post-hospital or prison discharge was retrospec-
tively collected from three sources: the Victorian Department of Justice’s Prisoner
Information Management System (i.e., information on reincarceration), the Victorian
Mental Health Case Management Information System (i.e., information regarding
hospitalization and diagnoses), and the Law Enforcement Assistance Program (i.e.,
criminal charges and corrections), which is maintained by the Victoria Police. Ethical
Shepherd et al. 617

approval was received from the Department of Health, Department of Justice, Victoria
Police, and Monash University.

Statistical Analyses
Data were analyzed using SPSS. PCL-R/SV total and dimension mean scores were calcu-
lated to ascertain the base rates of psychopathy for the overall sample. Patients with and
without APD-MET and Psychopathy were then compared across a number of offending
variables. Using the sample’s PCL-R mean score and one standard deviation above, the
patients were classified into high and low score groups, specific to the current samples
score distribution. This method generated a cutoff score of 22, which identified 20 indi-
viduals (15 men and 5 women), and yielded a base rate of 16.3%. Although the cutoff
score is relative to the sample, it is important to note that a score of 22 is equivalent to the
mean score typically achieved by male offenders (Hare, 2003). Previous PCL-R research
has used similar thresholds with forensic samples (Hildebrand & de Ruiter, 2012)
Chi-square, t tests, and odds ratios were utilized where appropriate to determine the
incidence and strength of group frequency differences across recidivism variables by
presence of disorder.
Rate of reconviction was determined by dividing the number of reconvictions by
the number of days a person was “at risk” in the community (multiplied by 365 to
obtain rate per year). Using an estimate of rate rather than the number of offences
allows the control of time at risk; that is, the actual period of time spent in the com-
munity and thus time available to reoffend.
Predictive validity for general and violent recidivism was assessed using Point bise-
rial correlations and receiver operator characteristic (ROC) analysis and logistic regres-
sion. Point biserial correlations (rpb) were used to examine the association between both
dichotomous (APD-MET) and continuous (APD-8; PCL-R/SV) independent variables
and recidivistic outcome. ROC analysis produces an area under the curve (AUC) index
for interpreting the accuracy of the predictor. It represents the probability that a ran-
domly chosen person who is positive on the dependent measure will score higher on the
predictor measure than a randomly chosen nonviolent person. Sensitivity/specificity
analyses were then conducted to ascertain whether PCL instrument total scores could
correctly identify offenders and nonoffenders at various cutoff points.
Finally, survival analyses were used to examine differences in the length of time to
the first point of failure by psychopathy group, failure being the date of the first new
(reconvicted) offence during the follow-up period. The time variable was calculated
by computing the number of days from the date of the patient’s release to freedom,
until the date of the first new convicted charge.

Results
Base Rate of Psychopathy/APD
The available data enabled raters to complete PCL-R Total scores for 90.4% (n = 123)
of the study sample. Total scores for 9.6% (n = 13) could not be produced due to
618 International Journal of Offender Therapy and Comparative Criminology 62(3)

inadequate file information. The mean PCL-R Total score was 15.0 (SD = 6.8; median
= 15.6; range = 1-34). The PCL:SV produced a slightly higher base rate of psychopa-
thy than did the full PCL-R. It was possible to generate PCL:SV total scores for 94.9%
(n = 129) of the sample; 5.1% (n = 7) could not be determined due to limited file
information. The mean PCL:SV score was 10.9 (SD = 4.8; median = 11; range = 1-24).
An APD diagnosis was able to be made for the entire sample (N = 136). The preva-
lence of APD (diagnosed objectively using DSM-IV criteria) was 27.2% (n = 37).
There was not enough information to make a definitive diagnosis in almost a third of
patient cases (31.6%, n = 43). In addition, the dimensional APD-8 yielded large and
significant correlations with the PCL-R (r = .75, p < .01) and PCL:SV total scores
(r = .76, p < .01). Weaker correlations were obtained for Part 1 of the PCL:SV (r = .45,
p < .01) and Factor 1 of the PCL-R (r = .40, p < .01) compared with Part 2 (r = .79,
p < .01) and Factor 2 (r = .45, p < .01), respectively.
Comparison of men and women in the sample yielded no significant differences for
any of the measures on either the total or subscale scores. Furthermore, there was no
statistically significant difference in the base rate of psychopathy or base rate of APD
diagnoses (APD-Met), between genders.

Recidivism
Twenty participants were excluded from the follow-up sample because they had not
been released (n = 17) or were deceased during the follow-up period (n = 3). The fol-
low-up sample for participants with an APD diagnosis comprised 116 patients (n =
83 men; n = 33 women). Due to incomplete file information detailed previously, the
follow-up sample for patients with PCL scores was 107. Patients in the final sample were
retrospectively followed from the date of hospital discharge to the study end date for an
average of 4.36 years (range = 988-2,064 days). Almost half (45.7%) of the 116 were
convicted of a new offense. More than 40% of the sample committed a new nonviolent
offense (n = 49) and 25% (n = 29) committed a new violent offense. Twenty percent of
the sample were reconvicted for both violent and nonviolent offences (n = 25). The
majority of patients who had been reconvicted of a violent offense, had also committed
a nonviolent offense (86.2%, n = 25). Of those who had been reconvicted, the average
number of convictions was 15.9 (SD = 15). Almost a third (31.9%, n = 37) of patients
released into the community were reincarcerated during the study follow-up.

Group Comparisons by Disorder

The mean PCL-R score for the High Psychopathic group was 25.3 (SD = 3.3); Factor 1
= 7.4 (SD = 3.3); Factor 2 = 15.7 (SD = 1.7). The mean PCL-R score for the Low
Psychopathy group was 13.0 (SD = 5.4); Factor 1 = 2.8 (SD = 2.3); Factor 2 = 9.1
(SD = 4.3). Results revealed significant differences between groups after employing the
Bonferroni adjusted alpha of .125 per test. Compared with patients with low psychopa-
thy, those with high psychopathy scores were significantly more likely to be reincarcer-
ated. Patients with high psychopathy scores were also found more likely to be
Shepherd et al. 619

Table 3. Comparison of Reconviction and Reincarceration as a Function of High

Psychopathy (≥22) and Low Psychopathy Group Membership and APD (APD-Met) and No-
APD Group Membership.
High Low
psychopathy (n) psychopathy (n) χ2 OR APD (n) No-APD (n) χ2 OR

Any reconviction 72.2% (13) 42.7% (38) 5.23 3.45 74.2% (23) 35.3% (30) 13.85* 5.27
Violent reconviction 33.3% (6) 23.6% (21) 1.89 2.12 41.9% (13) 18.8% (16) 6.47 3.12
Nonviolent reconviction 66.6% (12) 39.3% (35) 4.54 3.01 67.7% (21) 32.9 (28) 11.28 4.28
Reincarceration 61.1% (11) 27.0% (24) 7.93* 4.26 58.1% (18) 22.4% (19) 13.34* 4.81

Note. Community follow-up groups only. Psychopathy measured with the PCL-R. APD refers to dichotomous APD-Met
variable. APD = antisocial personality disorder; OR = odds ratio; PCL-R = Psychopathy Checklist–Revised.
*p < .0125.

reconvicted for any violent and nonviolent offenses although these findings did not
reach significance (see Table 3). Regarding the rate of reconviction, patients with high
psychopathy scores had a significantly higher mean number of reconvictions by days at
risk (M = 7.64, SD = 8.35) compared with patients with low psychopathy scores (M =
1.76, SD = 3.59; p < .01). In addition, reconvicted patients had significantly higher
PCL-R total scores compared to non-reconvicted patients, t(105) = 4.48, p < .0001.
Compared with patients without APD, those with APD (APD-Met) were signifi-
cantly more likely to be reconvicted and reincarcerated during the follow-up period
(see Table 3). Specifically, patients with APD were more likely to be reconvicted for
both violent and nonviolent offenses compared with patients without APD, though
these particular findings did not reach statistical significance.
The rate of reconviction was significantly higher for patients with APD (M = 5.05,
SD = 6.49) than those without APD (M = 1.66, SD = 3.78; p < .01). For patients who
were reconvicted, their mean APD-8 scores were significantly higher than patients
who were not reconvicted, t(114) = 4.75, p < .00001.

Predictive Validity
Correlations. Point-biserial correlations were used to examine the association between
the reconviction criterion variables (dichotomous variables coded 0 or 1, for example,
violence) and the predictor variables (see Table 4). Significant moderate to large effect
sizes were achieved between the Any Reconviction category (general recidivism) and
a number of the PCL instrument subcomponents, specifically Part 2 (PCL:SV) and
Factor 2 (PCL-R). Regarding violence, only Part 2 (PCL:SV) demonstrated a signifi-
cant moderate association.
APD measures demonstrated moderate to strong correlations for any reconviction
and nonviolent reconviction.

Receiver operating characteristic analysis. ROC analyses were used in the present study
to evaluate the predictive accuracy of the PCL-R and PCL:SV. Tables 5 and 6 present
the AUC scores and Sensitivity/Specificity cutoff points for the PCL measures. Both
620 International Journal of Offender Therapy and Comparative Criminology 62(3)

Table 4. Point-Biserial Correlations Between PCL-R Scores, APD Measure, and

Reconviction Categories.
Reconviction category

Any Physical Fear-inducing Violent and

Any violence violence violence Nonviolent nonviolent

PCL:SV total .405** .196* .200* .117 .404** .202*

Part 1 .215* .089 .101 .020 .192 .065
Part 2 .437** .256** .253** .165 .439** .267**
PCL-R total .401** .116 .091 .101 .417** .139
Factor 1 .242* .076 .090 .051 .238* .072
Factor 2 .435** .149 .127 .104 .443** .164
Facet 1 .108 −.101 −.074 −.038 .140 −.069
Facet 2 .234* .114 .107 .086 .243* .129
Facet 3 .389** .132 .054 .165 .430** .187
Facet 4 .392** .130 .160 .050 .361** .097
APD-MET .346** .236* .172 .154 .312** .205*
APD-8 .407** .166 .160 .089 .397** .158

Note. Total n ranges from 99 to 111. APD n = 116. PCL-R: Factor 1 (interpersonal/affective), Factor 2 (social deviance),
Facet 1 (interpersonal), Facet 2 (affective), Facet 3 (lifestyle), Facet 4 (antisocial). APD-MET (dichotomous). APD-8
(continuous). PCL-R = Psychopathy Checklist–Revised; APD = antisocial personality disorder; PCL:SV = Psychopathy
Checklist: Screening Version.
*p < .05. **p < .01.

PCL measures produced strong effects for Any Reconviction. The Factor 2 score on
the PCL:SV produced the strongest association (AUC = .78, p < .05) for Any
Reconviction.
The PCL-R scales were unable to accurately predict violent reconviction. This was
confirmed when the PCL-R was also entered into a logistic regression on its own as a
predictor of Any Violent Reconviction. No statistical association between PCL-R total
score and violent reconviction (p = .233) was detected. These findings were likely to
be influenced by the relatively low presence of psychopathy in the sample in combina-
tion with the low base rate of violence. The PCL:SV Total and Part 2 scores were the
only PCL-R/SV scales to reach significance for the violence categories, and no psy-
chopathy scale produced prediction above 0.5 in the category of fear-inducing vio-
lence. While demonstrating a strong relationship with any reconviction, the APD-8
category was unable to reproduce this result for future violence.
Table 6 indicates that as the sensitivity of the PCL instruments increase, the specific-
ity typically decreases. Both instruments demonstrated stronger sensitivity and weaker
specificity at lower total scores and the inverse was found for higher total scores.

Survival. Finally, survival analyses of scores above and below the cutoff on PCL mea-
sures were conducted as a function of time to first reconviction. Patients scoring above
the cutoff were more likely to be reconvicted earlier. The difference in survival distri-
butions was significantly different for both the PCL-R, χ2log (1) = 14.19, p < .0001; and
the PCL:SV, χ2log (1) = 10.79, p = .001.
 Table 5. AUCs of Receiver Operating Characteristic Analyses for the PCL:SV, PCL-R, and APD-8.

Any Any violent Physically violent Fear-inducing violent

reconviction reconviction reconviction reconviction

Measure AUC SE 95% CI AUC SE 95% CI AUC SE 95% CI AUC SE 95% CI

PCL:SV total .75* .047 [.69, .84] .65* .057 [.54, 76] .66* .058 [.55, .78] .58 .064 [.45, .70]
Part 1 .65* .054 [.54, .75] .59 .062 [.47, .71] .60 .065 [.47, .73] .54 .070 [.41, .68]
Part 2 .78* .046 [.69, .87] .67* .056 [.57, .78] .69* .057 [.58, .80] .61 .065 [.48, .74]
PCL-R total .74* .049 [.64, .83] .59 .058 [.48, .70] .58 .064 [.46, .71] .57 .064 [.45, .70]
Factor 1 .67* .053 [.57, .78] .60 .060 [.48, .71] .61 .065 [.48, .73] .58 .067 [.44, 71]
Factor 2 .75* .047 [.66, .85] .61 .059 [.49, .72] .61 .065 [.48, .73] .58 .068 [.44, .71]
Facet 1 .60 .058 [.48, .71] .44 .065 [.31, .57] .45 .069 [.32, .59] .47 .076 [.32, .62]
Facet 2 .69* .054 [.58, 79] .61 .062 [.49, .74] .61 .068 [.47, .74] .60 .070 [.46, .74]
Facet 3 .71* .053 [.61, 81] .57 .062 [.45, .69] .54 .066 [.41, .67] .61 .068 [.47, .74]
Facet 4 .73* .052 [.63, .83] .60 .061 [.47, .72] .63 .065 [.49, .75] .55 .069 [.41, .68]
APD-8 .73* .046 [.64, .82] .58 .057 [.47, .70] .59 .058 [.48, .71] .54 .069 [.40, .68]

Note. N ranges from 96 to 116. Any Reconviction = any reconvictions; Any Violent Reconviction = reconviction for any violence; Physical Violent Reconviction
= reconviction for physical violence; Fear-Inducing Violent Reconviction = reconviction for fear-inducing violence. PCL-R: Factor 1 (interpersonal/affective),
Factor 2 (social deviance), Facet 1 (interpersonal), Facet 2 (affective), Facet 3 (lifestyle), Facet 4 (antisocial). APD-8 (continuous). AUC = area under the curve;
PCL:SV = Psychopathy Checklist: Screening Version; PCL-R = Psychopathy Checklist–Revised; CI = confidence interval; APD = antisocial personality disorder.
*p < .05.

621
622 International Journal of Offender Therapy and Comparative Criminology 62(3)

Table 6. Predictive Accuracy of Sensitivity and Specificity Across Various Cutoff Points on
the PCL:SV and PCL-R.

Any reconviction Violent reconviction

Measure and
cutoff score Sensitivity Specificity Sensitivity Specificity
PCL:SV total
4 .981 .186 1.0 .146
8 .865 .475 .862 .378
12 .519 .814 .517 .72
16 .173 .966 .138 .915
PCL-R total
7 .980 .286 1.0 .20
14 .725 .625 .593 .437
21 .255 .911 .222 .812
29 .020 .982 .000 .975

Note. PCL:SV = Psychopathy Checklist: Screening Version; PCL-R = Psychopathy Checklist–Revised.

Discussion
Despite the breadth of research using the PCL-R measures in North America, the
United Kingdom, and increasingly in Europe, no studies have examined the psychopa-
thy construct and its association with violence in Australian forensic samples. As such,
the objectives of the present study were to explore the prevalence of psychopathy and
APD, and recidivistic outcomes in an Australian sample of mentally disordered offend-
ers discharged from a secure inpatient psychiatric facility.

Disorder Base Rates

APD base rates in this sample were generally lower than rates reported in forensic-
psychiatric samples internationally, if viewed in context of the nature of the sample
(i.e., psychotic, not personality disordered). The results suggest that the rate of formal
APD diagnoses made by TEH clinicians at admission/discharge is, at least for second-
ary diagnoses, underidentified in this sample. The described vetting process that pri-
oritizes TEH admission to those with predominantly psychotic disorders may account
for the underidentification of APD.
The base rate of psychopathy in the present sample was lower than the rate observed
in criminal offenders. Mean scores however were in line with studies where forensic-
psychiatric patients were assessed on file review alone (Hare, 2003). Yet, distinct from
previous research the base rate of psychopathy was also lower than typically found in
civil-psychiatric settings. There are several reasons that may account for this observa-
tion. First, as has been discussed, the present sample differs quite considerably from
forensic-psychiatric samples detailed in the research literature. Specifically, due to
stringent screening, the prevalence of personality disorders in TEH is proportionally
Shepherd et al. 623

lower than psychotic disorders. This, in turn, presages a small base rate of psychopa-
thy. More recently, Douglas, Strand, Belfrage, Fransson, and Levander (2005) reported
that psychopathy was significantly and negatively correlated with diagnoses of psy-
chosis. Thus, the observed base rate of psychopathy may be a function of the high
number of individuals with psychotic disorders in the present sample.
Consistent with studies examining the relationship between the PCL-R/SV and
APD variables (Frick, O’Brien, Wootton, & McBurnett, 1994; Hart & Hare, 1989;
Skilling, Harris, Rice, & Quinsey, 2002), results revealed strong correlations between
the PCL-R/SV total scores and the categorical APD-8 variable. This suggests that the
two constructs share a considerable amount of variance. However, additional correla-
tions between the APD variable and the PCL-R/SV subscales revealed the discrete
nature of these constructs. APD was strongly and positively correlated with Factor/
Part 2, but less so with Factor/Part 1 reflecting conceptual distinctions described in
previous literature (Ogloff, 2006).

Predictive Validity
A major finding, which compares favorably with extant research, was the strong pre-
dictive validity of the PCL-R/SV measures to forecast general reconviction post-
hospital discharge. Similarly, an APD diagnosis demonstrated strong associations with
general future reconviction.
Furthermore, an APD diagnosis demonstrated a weak significant correlation with
violent reconviction. Although patients with APD were found to be three times more
likely to violently reoffend than those without APD, this result was not significant. The
small group numbers here may have limited the capacity to detect significant differ-
ences. Previous studies have found that mentally disordered offenders without APD
commit as many violent crimes as mentally disordered offenders with APD (Nilsson,
Wallinius, Gustavson, Anckarsater, & Kerekes, 2011; Hodgins & Côté, 1993a, 1993b).
A diagnosis of APD has also shown to be an unreliable predictor violent institutional
misconduct (Edens et al., 2015).
The PCL-R was unable to predict violent reconviction (any, physical, and fear-
inducing) above chance. This finding is in contrast to previous studies with schizo-
phrenic cohorts (see Bo et al., 2013; Tengstrom, Grann, Långström, & Kullgren, 2000;
Tengstrom, Hodgins, Grann, Långström, & Kullgren, 2004) though several possibilities
might account for this. The most important of these being the paucity of patients who
achieved a PCL-R score more than 30. The small number of patients receiving scores
over this threshold may have distorted sensitivity and specificity scores which are influ-
enced by the base rate of violence. In contrast, the PCL:SV total score demonstrated
moderate predictive validity (AUC: 0.65, p < .05) for violent reconviction. While cor-
relations between violent reconviction and the PCL:SV total and Factor 2 scores were
moderate, the PCL-R failed to yield a significant correlation with violent reconviction.
This finding is unlikely to be a function of poor or inconsistent coding of the PCL-R/
SV. The PCL-R/SV was strongly correlated and interrater reliability was high, suggest-
ing that inconsistency was unlikely. Marginally stronger findings obtained for the
624 International Journal of Offender Therapy and Comparative Criminology 62(3)

PCL:SV compared with the PCL-R were not unsurprising. Prior research has found the
PCL:SV total score to be a strong predictor of violence for discharged psychiatric
patients (Silver, Mulvey, & Monahan, 1999; Steadman et al., 2000). The screening ver-
sion is also a less conservative measure of psychopathy requiring a reduced amount of
collateral information to score. As such, the PCL:SV may be preferred in forensic set-
tings when both time constraints and limited patient information preclude the use of the
PCL-R. The restricted range of PCL-R scores combined with the low base rate for
violence (25%) potentially reduced the probability of detecting meaningful findings.
Patients with high psychopathy scores spent less time at risk thereby reducing the
opportunity to reoffend violently in the community. Many reoffenders many not have
had the opportunity to commit a future violence offense due to being potentially rein-
carcerated or rehospitalized after a nonviolent reconviction. The large majority of the
sample had also demonstrated a preexisting violent offence, which may have reduced
the unique ability of the psychopathy construct to predict violence postrelease.

Limitations
A number of limitations should be considered in light of the findings. It is possible that
the lack of a relationship between violence and psychopathy is a product of the dichot-
omous classification of violence that was employed. Although some effort was made
to separate violence into more meaningful categories (e.g., any violence, physical vio-
lence, and fear-inducing violence), these were only broad ranging categories based on
the classification of criminal offense type, and did not indicate the severity and/or
frequency of the violent acts. Such broad classification of crime can be misleading;
seemingly minor offenses can be collated into a generalized category with more seri-
ous acts of violence. Thus, although some, or many, of the violent offenses may have
been only very minor, they are indistinguishable from more serious acts of violence.
Moreover, the use of official criminal data to establish recidivistic outcome precludes
criminal behavior that goes undetected by law enforcement. Due to plea bargaining
and the limitations police face gathering complete and compelling evidence, the rate
of convictions is unlikely to be an accurate indication of the true rate of offending.
A larger study sample may have increased the base rate of psychopathy as well as
the power to detect effects. Similarly, some caution is advised when interpreting high
and low psychopathy group findings given the small number of patients in the high
psychopathy group. Another limitation was the inability to conduct gender specific
analyses due to the size of the female sample.
Furthermore, it is worth noting that the frequency of “unknown” ratings for evidence
of conduct disorder was 25.7%. While this may have disadvantaged the APD variable
in the predictive analyses, this is reflective of clinical practice where it is often difficult
to obtain historical evidence for or against the presence of conduct disorder. Moreover,
outcome data were limited to official criminal charges rather than other less conserva-
tive methods (e.g., arrests), which may have detected higher levels of offending.
Finally, a methodological issue to arise from the current study relates to the study
design which was postdictive or a “retrospective follow-up.” As with most studies of
Shepherd et al. 625

this kind, there are certain limitations associated, one of which pertains to the reliance
on file information. There are restrictions associated with classifying disorders solely
from case notes. Unlike interviews, which provide an opportunity to clarify or chal-
lenge a patient on certain details, file reviews are restricted as file/documents may fail
to detail enough or the right information.

Implications
The results indicate that the PCL-R/SV instruments have predictive value with
Australian mentally disordered offenders (MDOs). The measures confirmed their rep-
utation as predictors of general recidivism post-hospital discharge. Although the rela-
tionship with violence postdischarge was weak (psychopathy was found to be, at best,
a moderate predictor of violent recidivism), the direction of the trend was nonetheless
consistent with the research literature. Replications of this study are necessary to iden-
tify whether the weak relationship with violent recidivism was potentially due to the
low psychopathy base rates in the study, or low population validity.
Findings showed that MDOs with an ASPD diagnosis pose a heightened risk of
future recidivism. Forensic mental health workers need to consider the impact of APD
on treatment recommendations for psychotic patients. More importantly, ASPD screen-
ing at discharge is necessary to aid community risk management planning. Mentally
disordered patients with either APD or high psychopathic traits present therapeutic
challenges; however, the psychopathic patient poses a particularly difficult challenge.
It is critical that appropriate efforts are made to identify psychopathy in forensic
settings. Evidence points to poor treatment outcomes for psychopathic individuals par-
ticipating in conventional therapy (see Ogloff & Wood, 2010). As such, despite not
being a strong predictor of future violence in this study, the PCL instruments may be
useful to clinicians by way of considering the relative facet scores on PCL instruments
which can guide intervention in a similar manner to the way items on violence risk
instruments (i.e., the Historical, Clinical, Risk Management–20) inform treatment
strategies (Ogloff & Wood, 2010). For example, patients specifically high on Facets 1
and 2 may threaten the therapeutic alliance and/or be unsuitable for specific forms of
treatment (e.g., addressing empathy deficits; group therapy).
In conclusion, mentally disordered offenders’ risk of recidivism appears to increase
with APD or psychopathic comorbidity underscoring the importance of screening for
personality disorders among patients with Axis I disorders.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of
this article.
626 International Journal of Offender Therapy and Comparative Criminology 62(3)

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