International Journal of Law and Psychiatry 31 (2008) 394–406

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International Journal of Law and Psychiatry

A five-factor model perspective on psychopathy and comorbid Axis-II

disorders in a forensic–psychiatric sample
Mieke Decuyper a,⁎, Filip De Fruyt a, Jos Buschman b
a
Ghent University, Belgium
b
Dr. S. van Mesdagkliniek, Groningen, The Netherlands

a r t i c l e i n f o a b s t r a c t

Keywords: The validity of DSM-IV predictions [Widiger, T. A., Trull, T. J., Clarkin, J. F., Sanderson, C. J., & Costa,
FFM P. T., (2002). A description of the DSM-IV personality disorders with the five-factor model of
Antisocial Personality Disorder personality. In Costa, P. T. & Widiger, T. A. (Eds.), Personality disorders and the five-factor model
Psychopathy
of personality (2nd ed.). Washington DC: American Psychological Association] concerning
Forensic population
Comorbidity
Antisocial Personality Disorder and the validity of the hypothesized associations between the
Five-Factor Model and psychopathy were examined in 48 male forensic–psychiatric patients.
Prevalence of psychopathy and comorbid personality pathology was also investigated, as well as
the convergent validity of two Dutch personality disorder inventories. Patients provided self-
descriptions on the NEO-PI-R [Costa, P. T., & McCrae, R. R., (1992b). Professional Manual: Revised
NEO Personality Inventory (NEO-PI-R) and NEO Five-Factor-Inventory (NEO-FFI). Odessa, FL:
Psychological Assessment Resources], and were administered the VKP [Duijsens, I. J., Haringsma,
R., & EurelingsBontekoe, E. H. M., (1999). Handleiding VKP (Vragenlijst voor kenmerken van de
persoonlijkheid). Gebaseerd op DSM-IV en ICD-10. Leiderdorp: Datec] and the ADP-IV [Schotte,
C. K. W., & De Doncker, D. A. M., (1994). ADP-IV Questionnaire. Antwerp Belgium: University
Hospital Antwerp] to assess personality pathology. Psychopathy was assessed using Hare's
Psychopathy Checklist—Revised (PCL-R; [Hare, R. D., (1990). The Hare Psychopathy Checklist
Revised Manual. Toronto: Multi-Health Systems]) based on a semi-structured interview and file
records of psychiatric and psychological evaluations and criminal history. Results underscored
the validity of the FFM Antisocial PD associations, but the hypothesized correlations between
the FFM and Psychopathy were less supported. Results supported the convergent validity of the
ADP-IV and the VKP, both at the dimensional and categorical level. Around 55% met the
diagnostic threshold of psychopathy, and Antisocial PD was the most prevalent disorder in
the psychopathic group, consistent with previous research. Sizeable personality comorbidity
was also observed.
© 2008 Elsevier Inc. All rights reserved.

1. Introduction

1.1. Psychopathy and Antisocial Personality Disorder

Psychopathy was the first personality disorder (PD) to be recognized in psychiatry and has a long historical and clinical tradition.
During the last decade the validity of psychopathy has been supported by a growing body of research (Millon, Simonsen, & Birket-
Smith,1998) although the concept has not been officially recognized as a PD in the last three editions of the Diagnostic and Statistical

⁎ Corresponding author. Department of Developmental, Personality and Social Psychology, Ghent University. H. Dunantlaan, 2, B-9000 Ghent, Belgium. Tel.: +32
9 264 64 19; fax: +32 9 264 64 99.
E-mail address: Mieke.Decuyper@ugent.be (M. Decuyper).

0160-2527/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.ijlp.2008.08.008
 M. Decuyper et al. / International Journal of Law and Psychiatry 31 (2008) 394–406 395

Manual of Mental Disorders (DSM-III, DSM-III-R, DSM-IV; APA, 1980, 1987, 1994). Cleckley (1941, 1964, 1988) was the first to describe
the psychopathic individual as seemingly sane, intelligent, and competent, but clearly disordered. These individuals were said to
wear ‘masks of sanity’. Other clinicians and researchers have described psychopathy consistently as a form of PD, characterized by
traits such as lack of remorse, manipulativeness, egocentricity, superficial charm and shallow affect. Behaviorally, the psychopath is
an impulsive risk-taker involved in a variety of criminal activities. Interpersonally, the psychopath has been described as grandiose,
egocentric, manipulative, forceful and cold-hearted. Affectively, the psychopath displays shallow emotions, is unable to maintain
close relationships, and lacks empathy, anxiety and remorse (Lynam & Gudonis, 2005).
Psychopathy is distinct from, but related to the more behaviorally based description of the Antisocial Personality Disorder (APD)
described in DSM-IV (APA, 1994), consisting of ‘a pervasive pattern of disregard for and violation of the rights of others’. It is based
almost solely on behavioral descriptors and is nearly synonymous with persistent criminal offending. The APD diagnosis reflects
whether the subject has participated in a number of antisocial and criminal acts during childhood and adulthood.
In forensic populations the prevalence of APD is two or three times higher than the prevalence of psychopathy, as measured by
the PCL-R. Empirically the relationship between both disorders is asymmetric: most offenders with a high PCL-R score meet the
criteria for APD, but most of those diagnosed as having APD do not meet the PCL-R criteria of psychopathy (Hare & Neumann, 2006).
Many personality psychologists agree that general personality can be best described in terms of the dimensions of the Five-
Factor Model (FFM; Costa & McCrae, 1992b; Digman, 1990; Widiger & Costa, 1994). The FFM had a strong appeal to personality
psychologists because a series of studies demonstrated that virtually all personality constructs identified in major models of
personality description could be represented within this FFM framework (Markon, Krueger, & Watson, 2005; O'Connor, 2002). The
FFM provides a dimensional description of personality on five broad factors, these are Neuroticism, Extraversion, Openness to
experience, Agreeableness, and Conscientiousness.
Recently several researchers (Miller, Lynam, & Leukefeld, 2003; Miller & Lynam, 2003; Widiger & Lynam, 1998) have argued that
psychopathy can be understood as a constellation of personality traits from this general model of personality functioning (FFM;
McCrae & Costa, 1990). They claimed that the understanding of the relations between the basic dimensions of personality on one
hand and psychopathy and APD / antisocial behavior on the other hand can make a substantial contribution to the field of
criminology (Miller & Lynam, 2001). One benefit of this approach is its ability to resolve several important issues in the
psychopathy literature, such as the underlying structure of the PCL-R (Hare & Neumann, 2005; Johansson, Andershed, Kerr, &
Levander, 2002; Vitacco, Neumann, & Jackson, 2005) and the patterns of comorbidity surrounding psychopathy (Miller & Lynam,
2003). With regard to the factor structure of the PCL-R, the FFM description of psychopathy shows that the structure is related to
different personality dimensions. A similar logic explains the comorbidity of psychopathy with other PDs; psychopathy will co-
occur with other PDs to the extent that they share common FFM facets. Based on the facet overlap, psychopathy is expected to be
highly comorbid with APD (Lynam & Widiger, 2001). Several studies have examined the associations between the FFM on the one
hand and psychopathy (Lynam, 2002; Lynam & Widiger, 2001) and APD (Saulsman & Page, 2004; Widiger et al., 2002).
Saulsman and Page (2004) meta-analytically reviewed the relationships between the FFM domains and the 10 DSM-IV PDs. This
meta-analysis showed that APD is characterized by little association with Neuroticism and negative relationships with Agreeableness
and Conscientiousness. Widiger, Trull, Clarkin, Sanderson, and Costa (2002) described the hypothesized relations between the FFM
facets and PD constructs, including APD, based on a review of the DSM-IV PD criteria. They predicted that a person diagnosed with APD
scores high on Angry Hostility (N2) and Excitement Seeking (E5), low on Straightforwardness (A2), Altruism (A3), Compliance (A4),
Tendermindedness (A6), Order (C2), Self-Discipline (C5) and Deliberation (C6). Concerning the prototypical psychopath, Miller et al.
(2001) provided an expert-based description using the NEO-PI-R that was generated by 15 psychopathy experts. None of these experts
were FFM theorists or researchers; they were selected on the basis of their work in the psychopathy domain. Miller et al. (2001) showed
that there was a substantial agreement between this expert-based NEO-PI-R description and the preliminary FFM description of
psychopathy proposed by Widiger and Lynam (1998). However there were also some points of disagreement, as the experts included
facets that were not proposed by Widiger and Lynam, such as low Anxiety, Depression and Vulnerability. The fact that Widiger and
Lynam restricted themselves to the description of psychopathy inherent in the PCL-R, whereas the experts did not have that restriction,
is a possible explanation for these discrepancies (Miller et al., 2001). Despite the emphasis on low Anxiousness by Cleckley (1941, 1988)
in the initial description, the PCL-R has no explicit assessment of Anxiety. According to the description of Miller et al. (2001) the
prototypical psychopath scores high on Angry Hostility (N2), Impulsiveness (N5), Assertiveness (E3) and Excitement Seeking (E5); and
scores low on Anxiety (N1), Depression (N3), Self-Conscientiousness (N4), Vulnerability (N6), Warmth (E1), Trust (A1),
Straightforwardness (A2), Altruism (A3), Compliance (A4), Modesty (A5), Tendermindedness (A6), Dutifulness (C3), Self-Discipline
(C5) and Deliberation (C6). Both APD and Psychopathy are thus characterized by low scores on Agreeableness facets and
Conscientiousness facets. There is also no prominent relationship between the Openness to experience facets and both disorders.
However the FFM descriptions of psychopathy and APD show some discrepancies that concern mainly the facets of the Neuroticism
and Extraversion domains. Considering the Neuroticism domain, the psychopath is characterized by low scores on Anxiety, Depression,
Self-Consciousness, Vulnerability, and by high scores on Angry Hostility and Impulsiveness, whereas a person diagnosed with an APD
only by high scores on Angry Hostility. Both the person diagnosed as having APD and the psychopath have high scores on Excitement
Seeking, but a psychopath also scores low on Warmth and high on Assertiveness.
These associations between the FFM domains and facets, psychopathy and APD are mainly examined in non-clinical and
student samples. However, the low prevalence rates of psychopathy and APD in the general population may result in range
restriction, impacting upon the nature and the size of the correlations. Moreover, the majority of these studies have been
conducted in North American samples, and to our knowledge there are no studies examining these FFM-psychopathy/APD
relationships in European forensic populations.
396 M. Decuyper et al. / International Journal of Law and Psychiatry 31 (2008) 394–406

1.2. Psychopathy and comorbid personality pathology

The co-occurrence of one disorder, such as psychopathy, with another disorder is often described as comorbidity, which is the
comorbid presence of two or more disorders. The term comorbidity refers to the co-occurrence of independent disorders, each with
presumably its own, separate etiology, pathology and treatment implications (Feinstein, 1970). Comorbidity is an important
phenomenon because it is rare that a psychiatric patient only meets criteria for just one mental disorder. It is also evident that the
etiology, course, treatment, and outcome of a disorder are influenced heavily by the presence of comorbid conditions. Finally comorbidity
has important and problematic influences on the conceptualization of mental disorders as distinct clinical conditions, posing serious
challenges on the current nosological system and the validity of the diagnostic categories themselves (Widiger, 2006). A major question is
whether the different disorders included in DSM-IV (APA, 1994) constitute distinct clinical entities (Mineka, Watson, & Clark, 1998).
As previously stated, the majority of the PCL-R psychopaths meet the criteria for APD. Correlations between the PCL-R scores
and dimensional diagnoses of APD are usually high, with correlations ranging from .55 to .65 (Hart & Hare, 1989). Several studies
however showed that psychopathy is not only highly comorbid with APD. Hart et al. (1994) demonstrated that PCL-R total scores
correlate positively with Axis-II Cluster B disorders (the dramatic–erratic–emotional cluster) and negatively with Cluster C
disorders (the anxious–fearful cluster). Hart and Hare (1989) investigated the associations between psychopathy and other mental
disorders in 80 male forensic patients. They reported that PCL-R diagnoses were only significantly related to Antisocial and
Histrionic PD, but at the dimensional level PCL-R ratings were positively correlated with Antisocial, Histrionic, and Narcissistic PDs
and negatively correlated with ratings of Avoidant PD. Examining 167 male offenders, Blackburn and Coid (1998) found that
psychopaths were more likely to meet criteria for Paranoid, Histrionic, Narcissistic and Borderline PDs and less likely to meet the
Obsessive–compulsive PD criteria. Finally Hildebrand and de Ruiter (2004) reported similar associations in 98 male forensic
psychiatric patients. At the categorical level, psychopathy was strongly and significantly associated with the diagnosis of APD and
positive correlations were observed with dimensional scores of Antisocial, Paranoid, Borderline and Narcissistic PDs.
It can be concluded that psychopathy, as measured with the PCL-R is associated with several PDs, most clearly with Narcissistic,
Histrionic, Borderline and Paranoid PDs, as well as with APD. Also at the descriptive level, the traits associated with psychopathy
can be distinguished among the criteria for several PDs in addition to APD, particularly Histrionic (superficial charm, insincerity,
egocentricity, manipulativeness), Narcissistic (grandiosity, lack of empathy, exploitiveness), Borderline (impulsivity, suicidal
gestures), and Paranoid (mistrust) PDs (Blackburn & Coid, 1998). At the descriptive and the empirical level, Cleckey's psychopathy
therefore seems to encompass more than one single category and it can be expected that there will be sizeable comorbidity with
the aforementioned PDs in a forensic psychiatric sample. Given the fact that many researchers (Blackburn & Coid, 1998; Blackburn,
Logan, Donnelly, & Renwick, 2003; Hart et al., 1994) reported negative associations with the Avoidant, Dependent, and Obsessive–
compulsive PDs, we also expect a low prevalence of these PDs in this sample.

2. Aims of the study

The current study was designed to examine the associations between psychopathy and APD, and the FFM dimensions in a forensic
psychiatric sample. For APD we based upon the hypothesized relations between PD constructs and the FFM facet traits proposed by
Widiger et al. (2002). Concerning psychopathy we used the expert-based description at the facet level as proposed by Miller et al. (2001).
In a second objective we investigated the comorbidity of psychopathy and DSM-IV Axis-II disorders, broadening the focus from
the APD to all ten DSM-IV Axis-II disorders. Personality pathology was described using the ADP-IV (Schotte & De Doncker, 1994)
and the VKP (Duijsens, Haringsma, & EurelingsBontekoe, 1999), the two most frequently used self-report inventories in the Dutch
language domain to describe personality pathology.

3. Method

3.1. Setting

The study was conducted in a Dutch forensic psychiatric facility for the residential treatment of criminal offenders who are
sentenced by court to involuntary commitment because they are considered irresponsible or diminished responsible for their acts
due to a psychiatric condition. Dutch law uses the term ‘TBS’, which is disposal to be treated on behalf of the state or detention
under a hospital order. The purpose of the Dutch TBS-order is to protect society from unacceptable high risks of recidivism through
involuntary admission, through obligatory treatment in a forensic psychiatric hospital (Hildebrand & de Ruiter, 2004). Legal rights
of the patient under TBS-order are protected by regular evaluations to help the court determine if the patient still poses a danger to
society (Drost, 2006). Most patients serve a limited prison sentence before they are admitted to the forensic psychiatric facility.

3.2. Participants

The sample included 48 male forensic psychiatric inpatients. Patient's age ranged from 19 years to 65 years with an average age
of 37.51 (S.D. = 10.04) and a mean duration of detention of two years (range from 0 to 9 years). Committed crimes included:
indecency offences (20.80%), murder (18.80%), rape (18.80%), arson (10.40%), attempted murder (8.30%), and grievous bodily harm
(8.30%). Recidivism rate was high; 19 out of 48 patients had been convicted more than six times, whereas for only eight patients a
first conviction preceded the admission in the forensic facility. Most (75.55%) of the patients were Caucasian and the rest were
 M. Decuyper et al. / International Journal of Law and Psychiatry 31 (2008) 394–406 397

Surinamese/Antillean (15.56%) or from other descent (13.33%). Thirty-six patients (75.00%) had never been married nor lived in a
common law marriage; eight patients (16.67%) were divorced and did not cohabited, whereas only three patients (6.25%) were
married or lived together. These patients gave permission that their anonymous files and documents could be used in various
research studies. The Ethical Committee at the facility approved the present study and all of its procedures.

3.3. Assessments

3.3.1. FFM traits

FFM traits were described using the Dutch authorized translation of the NEO-PI-R (Costa & McCrae, 1992b; Hoekstra, Ormel, &
De Fruyt, 1996), the most commonly used inventory to assess the five domain traits and their 30 facets. The NEO-PI-R has 240 items
scored on a five-point scale. Neuroticism consists of Anxiety, Angry Hostility, Depression, Self-consciousness, Impulsiveness and
Vulnerability. The facet scales organized under Extraversion are Warmth, Gregariousness, Assertiveness, Activity, Excitement
Seeking and Positive Emotions. Openness to experience includes Fantasy, Aesthetics, Feelings, Actions, Ideas and Values.
Agreeableness groups Trust, Straightforwardness, Altruism, Compliance, Modesty and Tendermindedness. Finally, Conscientious-
ness includes Competence, Order, Dutifulness, Achievement Striving, Self-discipline and Deliberation.
Although the Dutch NEO-PI-R has satisfactory psychometric characteristics, also in clinical and lower educated samples, the
reliabilities of certain facets were sizably lower in this forensic psychiatric sample. Several items appeared to be unsuitable for the
living conditions or social situation of the patients under detention for a long time. Therefore, some items were finally removed,
although preserving the facets' content and improving their reliabilities (see the results section). Cronbach α coefficients for these
shortened facets ranged from .48 (Ideas and Values) to .83 (Vulnerability) with a median value of .66.

3.3.2. Personality pathology

Personality pathology was assessed using the two most frequently used PD self-report inventories in the Dutch language domain,
these are the VKP (Vragenlijst voor Kenmerken van de Persoonlijkheid; Duijsens et al.,1999) and the ADP-IV (Schotte & De Doncker,1994).
The ADP-IV is a Dutch self-report inventory developed by Schotte and De Doncker (1994) and represents the DSM-IV criteria
for the ten recognized PDs. The questionnaire consists of 94 items, each measuring ‘trait’ as well as ‘distress/impairment’
characteristics of a DSM-IV criterion. Only the trait scale was used here. The ADP-IV assesses the self-rated disorder symptoms
on a 7-point scale. The dimensional PD subscales have satisfactory internal consistency coefficients, with lower values of .60 and
.68 respectively for the Schizotypal and the Obsessive–compulsive scales (Schotte, de Doncker, Vankerckhoven, Vertommen, &
Cosyns, 1998). The convergent validity of the ADP-IV was previously examined through comparison with the Wisconsin
Personality Disorder Inventory (WISPI; Klein et al., 1993). Results were satisfactory, with all ADP-IV scales, except the
Schizotypal and the Histrionic scales, displaying the highest correlations with the corresponding WISPI scales (Schotte et al.,
1998). More recent work (Schotte et al., 2004) underscored the differential and the convergent validity with the SCID-II semi-
structured interview. In this sample, Cronbach alpha coefficients ranged from .60 (schizoid) to .89 (antisocial) with a median
value of .80.
The VKP (Duijsens et al., 1999) assesses PD symptoms according to the definitions and criteria of the DSM-IV and the ICD-10.
The VKP is derived from the International Personality Disorder Examination (IPDE), a semi-structured interview developed by
the WHO to diagnose PDs according to both classification systems (Diekstra, Duijsens, EurelingsBontekoe, & Ouwersloot, 1993).
The VKP is a screening instrument consisting of 197 items. The items are scored on a 3-point scale: ‘true’, ‘question mark’, or
‘false’ and reflect what has been typical for the past 5 years. The inventory measures 12 PDs according to the DSM-IV (including
the Passive–Aggressive and the Depressive PD of Appendix A) and 9 disorders according to the ICD-10. Each disorder is
measured at three levels; these are a categorical score, a dimensional score and a categorical diagnosis. The categorical score
reflects the number of confirmed criteria per disorder whereas the dimensional score describes the sum score for each disorder
that takes into account the confirmed items and the items scored with a question mark. For the categorical diagnosis, patients
meeting at least four criteria are given the label ‘positive’, when the patient has one criteria less the label ‘probably’ is given, and
patients receive a ‘negative’ label in all other cases. Regarding the reliability, the Cronbach alpha ranges between .43 (Schizoid)
and .75 (Avoidant) for the DSM-IV PDs with an average alpha of .54 for the total group. These reliabilities are relatively low,
although comparable with the alpha's reported for research with DSM-III-R PDs (mean alpha is .58 ranging from .50 to .73). The
concurrent validity of the VKP was examined through comparison of DSM-III-R and ICD-10 PDs as measured with the IPDE and
the NVM (Dutch version of the MMPI) and the Big Five dimensions of personality (Duijsens et al., 1999). The big five dimensions
were measured with 2 different big five questionnaires, these are the 23 Bipolar Big Five (23BB5; Duijsens & Diekstra, 1995) and
the Five Personality Factor Test (5PFT; Elshout & Akkerman, 1975). In the present forensic–psychiatric sample the Cronbach
alpha reliabilities of the dimensional personality disorder scales ranged from .39 (Obsessive–compulsive) to .85 (Antisocial)
with a median value of .69.

3.3.3. Psychopathy
Psychopathy was assessed using the PCL-R, a rating scale developed by Hare R.D. in 1985 to measure traits of the
psychopathic PD. The PCL-R is the most frequently used operationalization for the assessment of psychopathy (Hare, 2006). The
Dutch version of the scale has two subscales; these are aggressive narcissism and impulsive/antisocial lifestyle. PCL-R
assessments of patients were based on the results of an interview with the patient on the basis of the Dutch language version of
the semi-structured PCL-R interview designed by Hare. File records of psychiatric and psychological evaluations and criminal
398 M. Decuyper et al. / International Journal of Law and Psychiatry 31 (2008) 394–406

history were reviewed for all patients. According to the PCL-R manual the interrater reliability coefficient ranges for the separate
items from .42 (item 16) to .86 (item 20), what is considered as a satisfactory result. The interrater reliability coefficient of the
total PCL-R score seems to be very high, with coefficients ranging from .91 to .93 in samples of detainees and forensic psychiatric
samples. Test–retest reliability was examined in a very small sample (n = 10), with an interval of one month and independent
raters and yielded a correlation of .94.

4. Procedure

Starting from October 2005 until November 2006, patients of the forensic psychiatric facility were assessed with a standardized
psychological assessment battery, which was administered within the framework of the periodic evaluations on a yearly basis of
the TBS patients. All patients were invited by the assessment psychologists to complete self-report FFM and PD inventories, and
trained psychologists also rated the PCL-R (Hare, 1990) on the basis of an extensive interview and inspection of the forensic record
files. The PCL-R score is a consensus score, which consists of an independent rating provided both by a psychologist of the research
department and a psychologist responsible for the treatment of the patient.

5. Results

5.1. Base rate of PCL-R psychopathy

The mean total PCL-R score was 23.87 (S.D. = 8.72) with a range from 5 to 40 and a median score of 26. PCL-R scores were
normally distributed (Shapiro–Wilk z = .96, p = .14). The mean of the aggressive narcissism scale was 9.53 (S.D. = 3.66) and the mean
of impulsive/antisocial lifestyle scale was 11.19 (S.D. = 4.49). A cut-off of 25 was used to divide the patients into psychopathic and
non-psychopathic groups. Forensic psychiatrists recommend using this lower diagnostic threshold because the PCL-R total, item
and factor scores are lower in European than in North American samples, given equivalent standing on the latent trait of
psychopathy (Cooke, Michie, Hart, & Clark, 2005). Using this diagnostic threshold, 26 patients (55.30%) met the threshold for a
diagnosis of psychopathy. When a cut-off point of 30 was used, as proposed by Hare (1990), only 12 patients (25%) were classified
as psychopaths. The means, standard deviations and ranges of the PCL-R total and factor scores are provided in Table 1.

5.2. Antisocial Personality Disorder

According to the VKP (Duijsens et al., 1999) ten patients (20.80%) met criteria for an APD diagnosis and the mean number of APD
criteria was 4.27 (S.D. = 3.97). Because only the trait scale of the ADP-IV was used in this study – the distress/impairment scale was
omitted – only the dimensional diagnostic evaluations are available preventing categorical PD diagnoses. The means, standard
deviations and ranges of the ADP-IV APD scale and VKP APD dimensional scores are also described in Table 1.

5.3. Shortened version of the NEO-PI-R

The reliabilities of the NEO-PI-R facets were sizably lower in this forensic–psychiatric sample, compared to reliabilities from
other clinical and lower educated samples (Hoekstra et al., 1996). The Cronbach alpha coefficients of the facets typically range from
.70 to .80, with the exception of Openness to Values (O6) and Tendermindedness (A6) with alpha reliabilities of respectively .57 and
.58. Given the small number of items per facet, these values are considered acceptable to very good (Hoekstra et al., 1996). In order
to improve the reliabilities of the facet scales, one or two items of 24 of the 30 facets were removed, preserving the content of the
facet scale as much as possible. For instance, the reliability of the Activity (E4) facet increased from .43 to .61 by excluding items 77
(My work is likely to be slow but steady) and 137 (I'm not as quick and lively as other people). In a similar way the Cronbach alpha of
Compliance (A4) improved from .26 to .63 by eliminating the items 19 (I would rather cooperate with others than compete with them)
and 79 (I hesitate to express my anger even when it's justified). Also the content of the items was considered, because some items
appeared to be unsuitable for the living conditions or social situation of the patients under detention for long time. This was the
case for item 77 of facet Activity (My work is likely to be slow but steady), for item 15 of Dutifulness (I try to perform all the tasks
assigned to me conscientiously), item 230 of Deliberation (I'm something of a ‘workaholic’) and item 25 of Self-discipline (I'm pretty
good at pacing myself so as to get things done in time) because many of the patients did not have a job before the admission in the
facility or did not work for a long time. There were no items excluded from facets of which the reliabilities did not improve by
excluding one or two items or from facets that had already a satisfactory reliability (e.g. N3: Depression). For instance, the facets
Assertiveness (E3) and Deliberation (C6) had a reliability coefficient of .55 and .66 respectively, but no items were excluded since
the reliabilities didn't improve by excluding one or two items. An overview of the excluded items and the reliabilities before and
after removal are provided in Appendix A. Cronbach alpha coefficients for the shortened facets in this sample ranged from .48
(Ideas and Values) to .83 (Vulnerability) with a median value of .66.

5.4. Correlations between FFM traits, psychopathy and APD

The predicted and observed correlations between the FFM, APD and psychopathy are presented in Table 2. Correlations at the
domain level are provided by a meta-analysis of Saulsman and Page (2004) and predictions at the facet level are made by Widiger
 M. Decuyper et al. / International Journal of Law and Psychiatry 31 (2008) 394–406 399

Table 1
Descriptive statistics for the NEO-PI-R, the ADP-IV Antisocial Personality Scale, the VKP Antisocial Personality Disorder Scale and the PCL-R Total and Factor Scores
in a forensic–psychiatric sample

M S.D. Range
NEO-PI-R
Neuroticism 76.31 28.25 10.57–134.76
N1: Anxiety 14.15 6.33 .00–28.57
N2: Angry Hostility 11.02 5.01 1.14–21.71
N3: Depression 14.88 5.81 2.00–30.00
N4: Self-consciousness 12.96 5.84 .00–29.71
N5: Impulsiveness 12.83 5.42 .00–21.33
N6: Vulnerability 10.46 5.26 .00–24.00

Extraversion 99.25 21.79 21.24–141.52

E1: Warmth 19.09 5.93 .00–29.71
E2: Gregariousness 17.05 6.07 4.57–30.86
E3: Assertiveness 13.74 4.18 4.00–22.00
E4: Activity 13.72 4.49 .00–22.67
E5: Excitement seeking 15.48 5.56 .00–25.14
E6: Positive emotions 20.17 5.65 4.00–29.33

Openness 101.25 14.77 72.19–131.16

O1: Fantasy 13.32 5.01 2.29–24.00
O2: Aesthetics 17.18 5.01 6.86–29.71
O3: Feelings 19.72 4.62 8.00–30.67
O4: Actions 14.62 5.04 1.33–29.33
O5: Ideas 16.85 4.22 6.68–26.29
O6: Values 19.56 4.01 9.14–27.43

Agreeableness 125.94 16.53 93.57–168.38

A1: Trust 20.28 4.24 2.00–28.00
A2: Straightforwardness 21.61 5.59 6.68–32.00
A3: Altruism 21.92 4.02 12.00–32.00
A4: Compliance 18.97 5.04 8.00–32.00
A5: Modesty 21.22 3.92 14.86–32.00
A6: Tendermindedness 21.94 4.22 13.33–32.00

Conscientiousness 123.35 18.68 87.95–176.00

C1: Competence 20.96 3.31 12.57–29.71
C2: Order 18.96 4.74 6.86–29.71
C3: Dutifulness 23.04 4.18 14.67–32.00
C4: Achievement striving 19.92 4.51 8.00–28.57
C5: Self-discipline 21.44 5.29 6.86–32.00
C6: Deliberation 19.12 4.25 11.00–32.00

PCL-R
Total score 23.87 8.72 5–40
Factor 1 aggressive narcissism 9.53 3.66 3–16
Factor 2 impulsive/antisocial lifestyle 11.19 4.49 1–18

ADP-IV
Antisocial PD scale 2.09 1.25 1.00–6.63

VKP
Antisocial PD scale 10.35 7.74 2–36

Note In order to make the results of the Dutch/Flemish NEO-PI-R directly comparable to the US means, the scores were re-scaled form a 1 to 5 to a 0 to 4 scoring
format.

et al. (2002). In line with the results of the meta-analysis of Saulsman and Page (2004), APD was negatively correlated with
Agreeableness and Conscientiousness, using both inventories describing personality pathology. No significant associations
between APD and Extraversion, using both the VKP and the ADP-IV, were observed. However, contrary to the results of Saulsman
and Page, the present sample demonstrated a strong relation with Neuroticism using both instruments and a negative association
with Openness, although only with the VKP.
At the facet level, the majority of the predictions made by Widiger et al. (2002) were confirmed for the APD using the
ADP-IV, whereas only 3 out of 9 predictions were confirmed relying on the VKP. Concerning the Neuroticism facets, the high
score on Angry Hostility is replicated using both the VKP and the ADP-IV. The high scores on the facets Depression, Self-
consciousness, Impulsivity and Vulnerability are significant in this forensic–psychiatric sample using both instruments. The
high score on Anxiety was only found using the ADP-IV. However these associations weren't hypothesized by Widiger et al.
(2002). Regarding the Extraversion facets, the predicted high score Excitement Seeking was only replicated with the VKP. The
400 M. Decuyper et al. / International Journal of Law and Psychiatry 31 (2008) 394–406

Table 2
Correlations between NEO scores, the ADP-IV Antisocial Personality Disorder symptoms, VKP Disorder scale and the PCL-R

Domains and facets ADP-IV Antisocial PD VKP Antisocial PD PCL-R total

rMA R rMA R
Neuroticism .09 .52** .09 .47**
Extraversion .04 .07 .04 .02
Openness .05 −.22 .05 −.33*
Agreeableness −.35 −.49** −.35 −.30*
Conscientiousness −.26 −.54** −.26 −.48**

Pred R Pred r Pred r

Neuroticism
N1: Anxiety .36* .26 L −.05
N2: Angry Hostility H .58** H .37* H .14
N3: Depression .43** .38** L .18
N4: Self-consciousness .33* .46** L .07
N5: Impulsiveness .48** .52** H .27
N6: Vulnerability .49** .41** L .11

Extraversion
E1: Warmth −.13 −.18 L − .22
E2: Gregariousness −.13 −.24 − .07
E3: Assertiveness .01 .03 H − .18
E4: Activity .40** .35* .02
E5: Excitement seeking H .29 H .38** H .19
E6: Positive emotions −.05 −.17 − .15

Openness
O1: Fantasy .01 −.29 − .23
O2: Aesthetics .05 −.14 − .10
O3: Feelings −.30* −.29 − .13
O4: Actions −.29* −.33* .00
O5: Ideas .10 −.01 − .10
O6: Values −.29* −.24 − .06

Agreeableness
A1: Trust −.09 −.08 L − .36*
A2: Straightforwardness L −.53** L −.28 L − .10
A3: Altruism L −.32* L −.28 L − .36*
A4: Compliance L −.38** L −.22 L − .27
A5: Modesty −.20 −.10 L .10
A6: Tendermindedness L −.19 L −.13 L − .12

Conscientiousness
C1: Competence −.40** −.41* − .15
C2: Order L −.44* L −.35* − .19
C3: Dutifulness −.29* −.19 L − .14
C4: Achievement striving −.23 −.28 .07
C5: Self-discipline L −.51** L −.50** L − .03
C6: Deliberation L −.42** L −.29 L − .23
Significant predictions facet 7 of 9 3 of 9 2 of 18
Significant nonpredictions facets 11 of 21 7 of 21 0 of 12
Significant predictions domain 2 of 2 2 of 2
Significant nonpredictions domain 1 of 3 2 of 3

* p b .05, ** p b .001; H, L = high, low, respectively, based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnostic
criteria, Antisocial PD = Antisocial Personality Disorder. MA = meta-analysis. The correlations at the domain level are provided by the meta-analysis of Saulsman and
Page (2004) Predictions concerning the Antisocial PD are from Widiger et al. (2002). The predictions concerning psychopathy (prototypic profile) are provided by
Miller, Lynam, Widiger and Leukefeld (2001).

high score on Activity was significant using both instruments, although this was not hypothesized. Although we did not
expect significant associations between the Openness facets and the APD, we found a low score on Openness to feelings and
Openness to values using the ADP-IV, and a low score on Openness to actions using both instruments. Regarding the
Agreeableness facets, negative correlations with Straightforwardness, Altruism and Compliance were only confirmed using
the ADP-IV whereas the low score on Tendermindedness was not replicated. As to the Conscientiousness facets, predictions
were confirmed with the exception of the low score on Deliberation using the VKP. The low score on Competence was found
using both instruments, although this association was not proposed by Widiger et al. (2002).
The hypothesized correlations regarding psychopathy were less supported by the data in this forensic–psychiatric sample. Only
two out of 18 predictions were confirmed, these are the low scores on Trust and Altruism. No other correlations between
psychopathy and facets of the NEO-PI-R reached significance in this sample.
 M. Decuyper et al. / International Journal of Law and Psychiatry 31 (2008) 394–406 401

Table 3
Convergent validity: Pearson product-moment correlations between the ADP-IV and VKP dimensional scales

VKP PAR SZD SZT APD BDL HST NAR AVD DEP OBC

ADP-IV
PAR .69** .47** .58** .36* .61** .31* .58** .52** .44** .63**
SZD .61** .74** .54** .30* .62** .36* .50** .66** .43** .58**
SZT .55** .44** .48** .31* .63** .37* .52** .58** .54** .62**
APD .39** .15 .10 .51** .62** .32* .29 .37* .62** .39**
BDL .53** .30* .42** .48** .76** .51** .50** .57** .71** .64**
HST .42** .28 .48** .20 .60** .52** .49** .55** .61** .57**
NAR .63** .42** .61** .36* .70** .51** .64** .61** .66** .52**
AVD .56** .61** .45** .31* .67** .46** .41** .80** .67** .57**
DEP .46** .43** .37* .28 .62** .49** .40** .60** .70** .53**
OBC .63** .46** .58** .31* .68** .49** .53** .63** .62** .66**

Note.* p b .05; ** p b .01; PAR = Paranoid, SZD = Schizoid, SZT = Schizotypal, APD = Antisocial, BDL = Borderline, HIS = Histrionic, NAR = Narcissistic, AVD = Avoidant,
DEP = Dependent, OBC = Obsessive–Compulsive, based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnostic
criteria. Correlations on diagonal, assessing the convergence between scales describing the same PDs, are in bold.

Overall, the support for the hypothesized relationships was substantial for the APD, especially when the ADP-IV was used.
Psychopathy was poorly explained by the FFM with only two out of 18 significant predicted correlations.

5.5. Psychopathy and personality disorders comorbidity

Literature showed that psychopathy co-occurred with various personality disorders (Blackburn & Coid, 1998; Blackburn et al.,
2003; Hart & Hare, 1989; Hart et al., 1994; Hildebrand & de Ruiter, 2004). Although two inventories were used to describe
personality pathology in this study, only the VKP generated categorical PD diagnoses because only the trait scale of the APD-IV was
administered. Because both inventories – and especially the VKP – are less widespread in international literature and only the VKP
provided categorical diagnoses, the convergent validity of these inventories was examined before psychopathy and personality
disorder comorbidity was described. To assign patients to a psychopathic versus a non-psychopathic group, a PCL-R total score of
25 was used as a cut-off.
Pearson correlations were computed to assess the convergent validity of the two self-report PD inventories, inspecting
convergence at the dimensional level. The results are described in Table 3. Correlations on the diagonal represent associations
between scales describing the same PDs. All correlations are significant at p b .01 and range from .48 (Schizotypal PD) to .80
(Avoidant PD), with a mean of .65. However, a large proportion of the off-diagonal correlations is also significant at the .01 level.
The values range from .10 (APD measured with the ADP-IV and Schizotypal PD measured with the VKP) to .71 (Borderline PD
measured with ADP-IV and Dependent PD measured with VKP) and have a mean of .50. With the exception of Schizotypal and
Dependent PDs, all disorders showed the largest correlation with the same disorder diagnosed using the other instrument.
At the diagnostic category level, we could not examine concordance for the PD diagnoses, because only the trait scale of the ADP-IV
was used making it impossible to generate categorical diagnoses. Categorical PD diagnoses were only provided by the VKP. To examine
if patients who received a diagnosis according to the VKP also scored higher on the corresponding ADP-IV dimensional scale, we
conducted a number of ANOVA's. The results of the analyses of variance are described in Table 4. For all PDs, we found that patients with
a PD diagnosis on the basis of the VKP scored significantly higher at the corresponding ADP-IV dimensional scales. The Cohen's d effect
sizes ranged from 1.21 to 2.49. For 3 PDs (Histrionic, Narcissistic and Obsessive–compulsive PD) the effect sizes could not be computed
because the prevalence of those disorders was too low. Overall, results underscored the convergent validity of the ADP-IV and the VKP.

Table 4
Convergent validity: categorical diagnosis VKP and ADP-IV dimensional scores

ADP-IV VKP F ES Cohen's d

Mean non-diagnosed Mean diagnosed

PAR 1.93 3.83 22.32*** 2.06
SZD 2.38 4.28 19.45*** 2.08
SZT 2.25 3.52 4.09* 1.21
APD 1.70 3.53 25.89*** 1.81
BDL 2.18 4.13 9.03** 1.79
HST 1.99 3.94 8.45** /
NAR 1.97 4.78 10.22** /
AVD 2.16 4.49 21.31*** 2.18
DEP 2.04 4.15 27.72*** 2.49
OBC 2.46 4.88 9.02** /

Note. * p b .05; **p b .01; ***p b .001. The degrees of freedom for all analyses are (1,46). PAR = Paranoid, SZD = Schizoid, SZT = Schizotypal, APD = Antisocial,
BDL = Borderline, HIS = Histrionic, NAR = Narcissistic, AVD = Avoidant, DEP = Dependent, OBC = Obsessive–Compulsive, based on the fourth edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV) diagnostic criteria.
402 M. Decuyper et al. / International Journal of Law and Psychiatry 31 (2008) 394–406

Table 5
Psychopathy and Axis-II disorders comorbidity

Axis-II diagnosis VKP Psychopathic group Non-psychopathic group Total group

(PCL-R score ≥ 25) (PCL-R score b 25)

% n % n % n
Paranoid PD 15 4 10 2 13 6
Schizoid PD 15 4 5 1 10 5
Schizotypal PD 8 2 5 1 6 3
Antisocial PD 27 7 14 3 21 10
Borderline PD 8 2 5 1 6 3
Histrionic PD 4 1 5 1 4 2
Narcissistic PD 0 0 5 1 2 1
Avoidant PD 15 4 5 1 10 5
Dependent PD 15 4 5 1 10 5
Obsessive–compulsive PD 8 2 0 0 4 2
30 12 42

Table 5 represents frequencies and percentages of categorical DSM-IV PD diagnoses in the psychopathic and the non-psychopathic
group. Analysis at the level of the total sample showed that 27% of all patients met criteria of at least one Axis-II disorder as measured with
the VKP, whereas 35% of the patients that scored above the diagnostic threshold of the PCL-R received at least one PD. Twenty-seven
percent of the psychopaths was diagnosed with the APD. For the Paranoid PD, the Schizoid PD, the Avoidant PD and the Dependent PD
respectively, approximately 15% met the criteria. Eight percent of the psychopaths met the criteria defined for the Schizotypal PD, the
Borderline PD or the Obsessive–compulsive PD while 4% were diagnosed as Histrionic PD. No one met Narcissistic PD criteria. There was
also evidence of comorbidity within Axis-II, that is 8% of the psychopaths met the criteria of a single PD, but 8% met the defining symptoms
of two PDs, 12% met the criteria of three PDs, 8% met the diagnostic thresholds of four PDs and finally 4% met the criteria of seven PDs.

6. Discussion

In a first objective the associations between psychopathy, APD symptoms and FFM facets were examined in a forensic–
psychiatric sample. These associations have been mainly examined in non-clinical and especially student samples. The patients of
this sample have committed one or more serious crimes but are considered irresponsible for their acts due to a severe psychiatric
condition. Given the nature of their conviction and criminal offences, externalizing pathology can be expected to be highly prevalent
is this sample. Hence, this sample offered a unique opportunity to examine the associations between the FFM, psychopathy and APD.
Concerning APD we corroborated on the predictions of Widiger et al. (2002) and for psychopathy we used the expert-based
NEO-PI-R description of the prototypical psychopath as proposed by Miller et al. (2001). The predictions at the domain level for
APD were provided by a meta-analysis of Saulsman and Page (2004). The predictions for the APD were partially replicated in this
forensic–psychiatric sample. The low scores on Agreeableness and Conscientiousness described in the meta-analysis of Saulsman
and Page (2004) were confirmed, with both the VKP and the ADP-IV. However there was a noteworthy difference between the
ADP-IV and the VKP in the number of predictions of Widiger et al. (2002) that was replicated. Using the ADP-IV seven out of nine
predictions were confirmed whereas only three out of nine were replicated using the VKP. Nevertheless the correlations between
the FFM facets and the VKP dimensional scales were in the predicted direction but not large enough to reach significance in this
rather small sample. The correlation analysis further demonstrated a large number of non-predicted relationships between facets
and APD. Previous studies (De Clercq & De Fruyt, 2003; Dyce & O'Connor, 1998) reported a similar amount of significant non-
predicted relationships between facets and PDs. Dyce and O'Connor (1998) suggest that, although there is strong support for the
predicted relationships, some associations may need to be added. De Clercq and De Fruyt (2003) recommended that the proposed
predictions between the facets and disorders by Widiger et al. (2002) would best be interpreted as a minimal set that should be
empirically examined and may eventually be extended relying on a meta-analysis of FFM facet–PD relationships.
Not predicted, but clearly manifested in the present sample was the association between APD and Neuroticism and its facets. Apart
from the high score on Angry Hostility, we did not expect high scores on Neuroticism facets. Nevertheless using both the ADP-IV and
VKP, we found significant positive correlations with the domain Neuroticism and its facets Depression, Self-consciousness,
Impulsiveness, Vulnerability and Anxiety (only with the ADP-VI). These high and prominent scores on the Neuroticism facets can be
indicative for internalizing problems beside the APD, which can be specific for the investigated sample. Internalizing problems can also
be seen in the context of the living conditions or social situation of the patients who are deprived of freedom for a long time. A second
unpredicted finding was the fact that APD correlated negatively with three Openness facets, these are Feelings, Actions and Values and
even at the domain level using the VKP. This finding contradicts conclusions of Watson, Clark and Harkness (1994) who stated that only
four out of five factors from the FFM were relevant for the FFM descriptions of personality pathology and Saulsman and Page (2004)
who reported no prominent relationship between Openness to experience and any PD . Dyce and O'Connor (1998) also declared that
Openness to experience was not strongly represented in the PD scores and that none of the PD scales loaded strongly on the Openness
dimension. Although at the facet level they found that Paranoid, Avoidant, Schizoid and Histrionic scores were associated with
Openness facets. Empirical support for the role of Openness in the relevance of the FFM to the PD domain seems thus less consistent.
Costa and McCrae (1992a) take the view that there has been paid little attention to symptoms that reflect inflexible and maladaptive
 M. Decuyper et al. / International Journal of Law and Psychiatry 31 (2008) 394–406 403

traits related to high or low Openness. Excessive or disordered Openness might lead to eccentric thinking, poor integration of the life
structure or weak ego boundaries; excessive closeness might be seen in dogmatic thinking or an inability to adapt to changing social
conditions. These features may be characteristic for the investigated sample. Trull and Widiger (1997) also suggested that elevated
levels of Openness are related to higher levels of schizotypal symptoms. In a similar way Ross, Lutz and Bailley (2002) found that
Openness was the trait that distinguished Schizotypal and Schizoid PD, as schizotypal symptoms were related to higher levels of
Openness, whereas higher levels of schizoid symptoms were related to lower levels of Openness.
The hypothesized correlations between Psychopathy and the FFM facets were far less supported in this sample. Only two out of
18 predictions were confirmed and there were also no non-predicted associations. Both the APD and the adaptive personality traits
were administered with self-report inventories, whereas the PCL-R was administered by a facility staff member. Probably
common-rater variance accounted for the larger correlations between the FFM facets and APD, compared to Psychopathy.
Moreover it might be possible that the NEO-PI-R does not cover the extremes of the adaptive traits to describe psychopathy. Facility
staff members may also overestimate the extent to which a patient meets the diagnostic criteria of the psychopath, based on their
knowledge of the patient's crimes and violent offences.
In a second section we investigated the prevalence of PDs and the comorbidity with psychopathy. Because both inventories used to
describe maladaptive personality were less widespread in international literature, and only the VKP provided a categorical diagnosis,
convergent validity was first examined. At the dimensional level, the correlation matrix between the VKP and the ADP-VI trait scales was
measured. In such matrices convergent validity is reflected by the correlations on the diagonal between the corresponding scales,
whereas the correlations between the non-related scales indicate the degree of divergent validity. Construct validity presupposes higher
correlations on the diagonal compared to the coefficients off-diagonal (Schotte et al., 2004). The correlations on the diagonal were all
significant at the .01 level and ranged from .48 to .80 with a median value of .68. With the exception of Schizotypal and Dependent PDs,
all disorders showed the largest correlation with the same disorder diagnosed using the other instrument. On the other hand there was
also a large proportion of significant off-diagonal correlations. This was not surprising given the well-known deficiencies and limitations
of the categorical system of the DSM-IV (APA, 1994) in which personality disorders are conceived as discrete categories with a
prototypical structure or organization. In psychiatric samples a high rate of overlap is obviously suspected as on average two-thirds of
the patients obtain more than one Axis-II diagnoses (Widiger et al., 1991). In general the correlation matrix offers arguments in favor of
the convergent and – to a lesser extent – divergent validity of the ADP-IV dimensional trait scales and the VKP dimensional scales. At the
diagnostic category level, we could not examine concordance for the PD diagnoses, because only the trait scale of the ADP-IV was used,
preventing categorical diagnoses. Only the VKP provided categorical PD diagnosis. By conducting a number of ANOVA's we could
examine if patients who received a diagnosis based on the VKP also scored higher on the corresponding ADP-IV dimensional scale. For
all PDs, we found that patients with a PD based on the VKP, scored significantly higher on the corresponding ADP-IV dimensional scale.
The effect sizes of the differences on the ADP-IV scale between those with and those without a diagnosis ranged from 1.21 to 2.49. For 3
PDs (Histrionic, Narcissistic and Obsessive–compulsive PD) the effect sizes could not be computed because the prevalence of those
disorders was too low. These results offer again arguments for the convergent validity of the ADP-IV and VKP.
Concerning the psychopathy and PD comorbidity the overall prevalence rate of personality pathology was generally lower than
in other European forensic psychiatric samples, in which prevalence rates of PDs typically range between 60% and 80% (de Ruiter &
Greeven, 2000; Hildebrand & de Ruiter, 2004; Kullgren, Grann, & Holmberg, 1996). Only 27% of all patients in this study met criteria
for at least one Axis-II disorder, using the VKP. PD diagnoses were based exclusively on information obtained from the patient
probably leading to an underestimation of the PD prevalence. Although self-report inventories typically lead to an overestimation
of the number of PD diagnoses (Schotte et al., 1998), the opposite could be true in a forensic population. Cluster B disorders are the
most prevalent disorders in forensic populations but these are the PDs that are more difficult to detect by means of self-reports
instruments, compared to a semi-structured interview, because of the lack of self-insight and defensiveness inherent to these PDs
(Hildebrand & de Ruiter, 2004). Forensic–psychiatric patients may also be inclined to mislead assessors in their self-descriptions,
providing less reliable descriptions. Therefore a number of authors have advised against the use of self-report inventories in
forensic samples, because the issues of defensiveness, social desirability and deception are especially relevant in that context
(Breuk, Clauser, Stams, Slot, & Dorelijers, 2007; de Ruiter & Greeven, 2000; Hare, 1990). Instead a semi-structured interview in
combination with collateral information obtained by informants (e.g. significant others) and file information, would be necessary
for the diagnosis of personality pathology in forensic samples. On the other hand, Blackburn et al. (2003) found that apart from
Antisocial and Narcissistic disorders, the number of PDs in their sample of patients who were considered dangerous as a result of
severe personality disorder (called the psychopathic sample) were relatively few compared to mentally ill patients and prisoners of
the state hospital, casting doubts on the assertion that the men of their sample are uniformly at the severest end of the spectrum of
personality disorder. They conclude that the psychopathic sample may not be radically different from other offenders because the
group seemed quite similar to a representative sample of sentenced prisoners in England. In this context the lower prevalence of
PDs in our sample could also reflect the fact that these forensic psychiatric patients are not situated at the severest end of
personality disorder spectrum, instead of being the result of an underestimation of the PDs due to the use of self-report inventories.
Literature shows that Psychopathy, as measured with the PCL-R, is associated with several PDs and most clearly with Antisocial,
Narcissistic, Histrionic, Borderline and Paranoid PDs. Researchers also reported a low prevalence of Avoidant, Dependent and
Obsessive–compulsive PDs in psychopaths. In this study 55% of the total sample met the diagnostic threshold for a diagnosis of
psychopathy, which is comparable with other European studies (Blackburn & Coid, 1998; Hildebrand & de Ruiter, 2004). Twenty-
seven percent of the patients with a psychopathy diagnosis also had a comorbid APD diagnosis, compared to 14% in the non-
psychopathic group. As expected the APD was the highest prevalent PD in the psychopathic group. The high prevalence rate of APD
in psychopaths is consistent with existing findings on the construct validity of the PCL-R in a variety of forensic and forensic
404 M. Decuyper et al. / International Journal of Law and Psychiatry 31 (2008) 394–406

psychiatric samples (Harpur, Hare, & Hakstian, 1989; Hart & Hare, 1989). The PCL-R dimensional scale was also significantly
correlated with the antisocial trait scale of the ADP-IV. Fifteen percent of the psychopaths also received a comorbid Paranoid PD
diagnosis. However the prevalence rates of the Narcissistic (0%), Histrionic (4%) and the Borderline (8%) PDs were rather low among
the PCL-R psychopaths and the high prevalence rates of Avoidant (15%) and Dependent PD (15%) were unexpected.
The present study had a number of strengths, including the use of two instruments to assess personality pathology and the uniqueness
of the sample consisting of forensic psychiatric patients under TBS-order. Moreover, to our knowledge it is the first study examining
psychopathy and maladaptive traits from a FFM-perspective in a European sample. However, there are also a number of limitations that
require attention and constrain the generalizability of the results. First the assessment of Axis-II disorders and adaptive personality relied
exclusively on self-reports provided by the same informants. Consequently, results concerning Axis-II disorders are subject to same-
method and same informant biases inflating the correlation pattern. Furthermore structured interviews in combination with collateral
information are more suited than self-report inventories to assess personality pathology, particularly in forensic samples because the
issues of defensiveness, social desirability and deception are especially relevant in that context (Breuk et al., 2007; de Ruiter & Greeven,
2000; Hare, 1990). Trull et al. (2001) argued that self-reports are suitable to assess a trait's level, but are unable to assess dysfunction
associated with the trait. Secondly the sample size was relatively small, making it impossible to draw generalized conclusions. Also due to
the small sample size the Bonferroni adjustment was not applied in the examination of the hypothesized associations between APD,
psychopathy and the FFM. Therefore the results are in need of replication in larger samples with a better handling of the common-rater
bias. Thirdly our sample includes only men, which precludes generalization of the findings to women. Fourthly, a shortened version of the
NEO-PI-R was administered, using scales with a smaller number of items due to the lower reliability coefficients for some of the facets.
Finally, we used the lower PCL-R cut-off point of 25 because PCL-R total, item and factor scores are lower in European samples compared to
North American samples given equivalent standing on the latent trait of psychopathy. However this makes it more difficult to compare the
prevalence of psychopathy with, for example, populations detained in the UK high secure services for whom the threshold of 30 is
frequently used. In sum, due to these limitations the results and conclusions reported in this study should be seen as preliminary and as a
first step in the development to a more systematic study in larger European forensic–psychiatric populations.

Appendix A. Excluded items of the shortened version of the NEO-PI-R and Cronbach α of the shortened facets

NEO-PI-R Cronbach α Excluded items Number of items shortened facet Cronbach α shortened facet
Neuroticism
N1: Anxiety .76 Item 1 7 .81
N2: Angry Hostility .71 Item 96 7 .75
N3: Depression .80 8 .80
N4: Self-consciousness .72 Item 166 7 .76
N5: Impulsiveness .55 Items 21, 141 6 .67
N6: Vulnerability .83 8 .83

Extraversion
E1: Warmth .74 Item 212 7 .79
E2: Gregariousness .69 Item 97 7 .77
E3: Assertiveness .55 8 .55
E4: Activity .43 Item 77, 137 6 .61
E5: Excitement seeking .63 Item 202 7 .67
E6: Positive emotions .68 Item 57, 207 6 .72

Openness
O1: Fantasy .59 Item 3 7 .65
O2: Aesthetics .60 Item 38 7 .63
O3: Feelings .43 Items 193, 223 6 .61
O4: Actions .54 Items 48, 168 6 .65
O5: Ideas .41 Item 203 7 .48
O6: Values .41 Item 58 7 .48

Agreeableness
A1: Trust .65 8 .65
A2: Straightforwardness .76 Item 129 7 .80
A3: Altruism .66 8 .66
A4: Compliance .26 Items 19, 79 6 .63
A5: Modesty .51 Item 204 7 .56
A6: Tendermindedness .47 Items 89, 119 6 .52

Conscientiousness
C1: Competence .49 Item 125 7 .53
C2: Order .46 Item 160 7 .63
C3: Dutifulness .57 Item 15, 105 6 .66
C4: Achievement striving .55 Item 230 7 .64
C5: Self-discipline .77 Item 25 7 .80
C6: Deliberation .66 8 .66
 M. Decuyper et al. / International Journal of Law and Psychiatry 31 (2008) 394–406 405

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