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Disentangling Psychopathy From Antisocial Personality Disorder An Australian Analysis
Disentangling Psychopathy From Antisocial Personality Disorder An Australian Analysis
Disentangling Psychopathy From Antisocial Personality Disorder An Australian Analysis
To cite this article: James R. P. Ogloff, Rachel E. Campbell & Stephane M. Shepherd (2016)
Disentangling Psychopathy from Antisocial Personality Disorder: An Australian Analysis, Journal
of Forensic Psychology Practice, 16:3, 198-215, DOI: 10.1080/15228932.2016.1177281
ABSTRACT KEYWORDS
The relationship between psychopathy and antisocial personality antisocial personality
disorder (APD) was explored in a sample of Australian mentally disorder; forensic
disordered offenders. Two Hare adult psychopathy measures, the psychology; PCL-R;
Psychopathy Checklist–Revised (PCL-R) and the Psychopathy psychopathy; violence risk
assessment
Checklist: Screening Version (PCL: SV) were employed and a
diagnosis of APD was measured for 136 participants in a secure
forensic psychiatric inpatient facility. Results revealed clear dis-
tinctions between measurements of psychopathy and APD. Over
65% of patients high in psychopathic traits received a diagnosis
of APD while only 5.5% of patients with APD were high in
psychopathic traits, denoting an asymmetric relationship.
Implications for the assessment and treatment of mentally dis-
ordered offenders with psychopathic traits are discussed.
Diagnostic comparisons
APD is diagnosable in up to 3% of the population (APA, 2013; Lenzenweger,
Lane, Loranger, & Kessler, 2007). The rate of APD is much higher in clinical
and forensic settings. Approximately 30% of civil psychiatric patients are
diagnosed with APD, and up to 80% of individuals in forensic or correctional
settings are given the diagnosis (American Psychiatric Association, 2013;
Côté & Hodgins, 1990; Douglas, Ogloff, Nicholls, & Grant, 1999; Hare,
1996, 2003). By contrast, the prevalence of psychopathy is low. It is estimated
that less than 1% of the population will score within the range indicative of a
prototypical psychopath (Forth, Brown, Hart, & Hare, 1996; Hare, 2003;
Monahan et al., 2001). On the other hand, approximately 15.7% of male
offenders, 10% of forensic-psychiatric patients and 7.4% of female offenders
in North America achieve PCL-R scores above 30 (Hare, 2003). These
estimates are modest compared to those for APD.
Research has reliably found an asymmetric association between APD and
psychopathy. While most psychopathic offenders meet criteria for APD, the
majority of offenders with APD will not achieve instrument scores indicative of
psychopathy (Hare & McPherson, 1984; Hart & Hare, 1989; Hildebrand & de
Ruiter, 2004; Meloy, 1988; Pham & Saloppe, 2010). Poythress et al. (2010)
200 J. R. P. OGLOFF ET AL.
Methodology
Sample
The current study drew a random sample of 136 patients (men n = 98; women
n = 38) from a larger sample of all 265 forensic-psychiatric patients from
Thomas Embling Hospital (TEH) in Melbourne, Australia, between August
2000 and November 2003
The hospital is operated by the Victorian Institute of Forensic Mental Health
(Forensicare) and is Victoria’s only secure forensic mental health facility. TEH
provides assessment and treatment to men and women with serious mental
illnesses requiring secure inpatient psychiatric hospitalization. Most patients
who go through TEH are transferred from prison when they require involuntary
psychiatric hospitalization, and are returned to prison once stabilized. The
largest number of patients held long-term in the TEH are those found not guilty
by reason of mental impairment and who require hospitalization.
Demographics
Almost three quarters of the sample were male (72.1%), and the mean age at
discharge was 32.2 years (SD = 9.4; Mdn = 30.2; range 17–62). The majority
of patients in the sample were Caucasian (78.7%, n = 107). The vast majority
of patients were admitted to TEH from prison (87.5%). In the study sample,
72% had been diagnosed with either psychotic or affective disorders (with
psychotic features) at discharge. In contrast, few patients received a primary
diagnosis of personality disorder at admission or discharge (7.4% and 8.8%
respectively). A considerable number of patients (64.7%; n = 88) had been
previously hospitalized in a civil psychiatric facility. Just over half (54.4%)
had a previous conviction for a violent offense, while the large majority had
been convicted of a past nonviolent offense (73.5%, n = 100). The most
frequent index offense category was theft or robbery (47.1%), followed by
assault (33.1%), possessing or carrying a weapon (19.9%), and property
damage (19.1%).
Ethics
The research project was approved by the Victorian Institute of Forensic
Mental Health, the Ethics Committee of the Department of Human Services,
202 J. R. P. OGLOFF ET AL.
Measures
Psychopathy Checklist–Revised (PCL-R)
The PCL-R (Hare, 1991, 2003) was developed as a measure of psychopathic
personality traits. The PCL-R has traditionally been divided into two mod-
erately correlated factors (r = .50; Hare et al., 1990; Harpur, Hakstian, &
Hare, 1988). Factor 1 represents the affective or interpersonal features and
Factor 2 captures the behavioral aspects of psychopathy. Factor analyses have
shown that Factors 1 and 2 may be further divided into two facets each: Facet
1 (Interpersonal) and Facet 2 (Affective) fall under the original Factor 1, and
Facet 3 (Lifestyle) and Facet 4 (Antisocial) are aligned with Factor 2. The 20
PCL-R items and Hare’s four-facet structure are presented in Figure 1
(Hare, 2003).
Each of the 20 items are scored on a 3-point scale (0 = item does not apply,
1 = item applies to a certain extent, 2 = item definitely applies). Although the
PCL-R total score may best be described as dimensional, a score of 30 and
above is considered an appropriate categorical diagnostic cutoff, though
indicative of the prototypical psychopath (Hare, 2003).
The psychometric properties of the PCL-R are well established (Forth,
Kosson, & Hare, 2003; Fulero, 1995; Hare, 2003). A high level of reliability
has been established across varied samples and countries when used by
trained raters; intraclass coefficients (ICC1) around .80 for the single rater
and .90 for the average of raters (ICC2) have been reported.
Table 1. DSM-IV-TR criteria for antisocial personality disorder (American Psychiatric Association, 2000).
(A) 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:
(1) failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly
performing acts that are grounds for arrest
(2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or
pleasure
(3) impulsivity or failure to plan ahead
(4) irritability and aggressiveness, as indicated by repeated physical fights or assaults
(5) reckless disregard for safety of self or others
(6) consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or
honor financial obligations
(7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or
stolen from another
(B) The individual is at least 18 years
(C) There is evidence of conduct disorder with onset before age 15 years
(D) The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic
episode
204 J. R. P. OGLOFF ET AL.
or traits that had been documented in the file (i.e., in past reports, case notes
from prior services).
This information generated three APD variables labeled (a) APD-Met, (b)
APD adult-symptoms, and (c) APD-8. The first of these variables, APD-Met,
is a dichotomous variable comprising patients who clearly met the APD
criteria, and those who did not (1 = APD Yes; 0 = APD No). The second
APD variable, APD adult-symptoms, is a dimensional variable comprising
the sum of the seven Criterion A (adult) items (0–7), prorated for the
number of Don’t Know responses. Finally, a third variable, APD-8, is also a
dimensional variable that comprises the sum of Criterion A (adult) symp-
toms (0–7), plus Criterion C (evidence of conduct disorder, coded Yes, No, or
Don’t Know). This produces an 8-item score encompassing all eight child and
adult items featured in the DSM-IV APD criteria.
Information was also collected pertaining to whether patients, at any point
in the past, had been diagnosed with APD or APD traits. This information
was categorically coded (Diagnosis = 2, Traits = 1, No APD = 0), and created
the fourth APD variable, labeled APD-Past.
Procedure
Each of the patients’ files was retrospectively coded using a broad range of
information collected from clinical and legal files about a patient’s back-
ground. The file information and assessment instruments were coded prior
to the collection or entry of recidivism data.
The file information was used to code the PCL-R (Hare, 2003), the PCL:
SV (Hart et al., 1995), and the APD criteria (APA, 2000) as required by the
test manuals. Where insufficient file information precluded a PCL-R Total
score rating, the patient’s PCL: SV score was used. Due to the quality of file
information available, it was not always possible to complete the study
measures; therefore, the number of participants included in analyses may
vary. The coding of instruments was completed by doctoral-level clinical
forensic-psychology raters. Both coders were trained on the administration of
the PCL measures during a three-day workshop conducted by the measures’
author, Robert Hare, and the third author.
The level of measurement agreement between the PCL-R and PCL: SV was
examined using a median split (above the median and below or equal to the
PCL median). The chi-square test was used to determine differences in
frequency distributions between the measures. In addition, odds ratio and
kappa coefficients were calculated to indicate the association between the
measures.
The level of agreement between the PCL-R and APD variables was evaluated
using a number of statistical methods. First, Pearson’s r was used to perform
intercorrelations between the continuous APD and PCL-R/SV total and sub-
scale scores; point-biserial correlations were employed to compare the con-
tinuous measures with the categorical and dichotomous APD variables.
Second, simple cross-tabulations were used to determine the level of agree-
ment between the measures, and the chi-square test of independence was used
to determine differences in the frequency distributions between the measures.
Results
Interrater reliability
Interrater reliability of file coding was assessed by having the primary rater
and another rater code a randomly chosen subset of 20 (14.7%) files. The
ICC coefficients for the PCL-R total, Factor 1 and 2 scores were high: .94, .81,
and .97, respectively. The PCL: SV Total, Parts 1 and 2 score coefficients,
were also high: .95, .84, and .86 respectively.
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. Agreement
pertaining to the presence of past APD diagnoses or APD traits was high,
generating a kappa value of .92 and achieving 95% total agreement. The four
APD criteria were compared through evaluation of the total percent of
agreement between raters. Overall, the level of agreement between raters on
the APD variables was high (80–100%).
Table 3. Measurement agreement between PCL-R and APD-8 as a function of high and low
scores on the median.
PCL-R
Low High Total
APD-8 Low 50 (70.4%) 4 (6.7%) 54
High 21 (29.6%) 56 (93.3%) 77
Total 71 60 131
Table 5. Measurement agreement between PCL-R groupings and APD-Past diagnosis and traits.
APD-Past
PCL-R Group No APD Traits Diagnosis Total
Conventional score categories Low < 20 58 16 20 94
Medium 20–29 5 11 10 26
High ≥ 30 1 0 2 3
Total 64 27 32 123
Study-derived cutoff scores Low < 8 18 0 2 20
Medium ≥ 8–< 22 44 17 22 83
High ≥ 22 2 10 8 20
Total 64 27 32 123
Discussion
Base rates of psychopathy and APD
It was hypothesized that the base rate of psychopathy would be lower than
that observed in criminal offenders, but higher than civil psychiatric samples
(Hare, 2003). The base rate of psychopathy in the current sample (using a
cutoff score of ≥ 30) was lower than the rate observed in criminal offenders;
however, distinct from previous research (see Hare, 1991; Hart, Hare, &
Forth, 1994), the base rate of psychopathy (2.2%, M = 15, SD = 6.8) was
also lower than typically found in civil-psychiatric settings. It is important to
note that PCL-R scores, derived from both interview and file review in male
forensic-psychiatric patients, produce higher scores (pooled mean 21.5,
210 J. R. P. OGLOFF ET AL.
SD = 6.9) than studies where the score is based on file review alone (pooled
mean = 17.4, SD = 9.3) (Hare, 2003). Although the PCL-R manual generates
a pooled average for the file review approach from just two samples (mean
scores of 15.5 and 20.1), the trend is consistent with the broader state of
research that has since emerged. Hart and Hare (1989) also found that high
PCL total scores tend to be associated with the absence of an Axis I principal
diagnosis. Douglas, Strand, Belfrage, Fransson, and Levander (2005) also
reported that psychopathy was significantly and negatively correlated with
diagnoses of psychosis. Thus, the observed base rate of psychopathy may be a
function of the high number of individuals with psychotic disorders in the
current sample.
Consistent with previous research, the results of the current study revealed
strong correlations between the PCL-R/SV Total scores and the dichotomous
and categorical APD variables (Frick et al., 1994; Hart & Hare, 1989). As
predicted, APD was strongly and positively correlated with Factor/Part 2, but
less so with Factor/Part 1. Similarly, the dimensional APD variables also
shared large and significant correlations with the PCL-R/SV Total scores.
This is consistent with findings reported by Skilling et al. (2002), who found
large, positive, and significant correlations between a dimensionally coded
APD variable and the PCL-R total and factor scores. While Skilling and
colleagues argue that the two constructs share the same natural class, there
are a number of reasons why this is unlikely.
Factor 2 was found to contribute to a diagnosis of APD more than Factor
1. Notably, the Factor/Part 2 correlations were similar to those of the PCL-R
Total score. This suggests that that antisocial and irresponsible lifestyle traits
(i.e., scores on Factor/Part 2) account for as much of the variance toward a
diagnosis of APD as does the PCL-R/SV Total score. Of note were the
correlations between the APD variables and the facet scores. In particular,
Facet 4 (Antisocial) produced large and strong correlations of a similar level
to those between APD and the PCL-R/SV Total score. This suggests that a
diagnosis of APD can, more specifically, be attributed to antisocial traits such
as poor behavioral controls and criminal versatility. Corroborating this,
Facets 1 and 2 were weakly correlated with APD, suggesting that interperso-
nal and affective features have little bearing on a diagnosis of APD. These
results confirm APD as a function of behavior, and not the interpersonal or
affective features considered the core of the psychopathy construct.
Limitations
A number of limitations and methodological issues must be taken into
account when drawing conclusions from the above research findings. First,
a larger study sample may have increased the base rate of psychopathy as well
as the power to detect effects. It is possible that low power arising from the
small number of individuals identified as psychopathic, plus the low base rate
of violence, obscured any true trends.
A second limitation relates to the postdictive design of the study. As with
most studies of this kind, there are certain limitations associated, one of
which pertains to the reliance on file information. Although a number of
research studies using archival data have observed significant effects
(Douglas & Ogloff, 2003; Harris, Rice, & Quinsey, 1993; Menzies &
Webster, 1995; Nicholls, Ogloff, & Douglas, 2004), the coding of diagnostic
tools or risk measures from files is nevertheless limiting. For example,
research has demonstrated that PCL-R file ratings may underestimate high
scores and overestimate low scores (Grann, Långström, Tengström, &
212 J. R. P. OGLOFF ET AL.
Stålenheim, 1998; Hare, 2003). Despite this restriction, the analyses were able
to meaningfully distinguish both disorders—a distinction that perhaps may
have been more pronounced with direct access to the clientele. A third
limitation is the absence of gender comparisons. The smaller female sample
precluded the conducting of meaningful analyses by gender; however, the
inclusion of women in psychopathy research is presently minimal and there-
fore warranted.
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