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ANTISOCIAL PERSONALITY DISORDER VS. PSYCHOPATHY:
AN ANALYSIS OF THE LITERATURE
Except where reference is made to the work of others, the work described in this thesis ismy own or was done in collaboration with my advisory committee. This thesis does not include proprietary or classified information.
________________________________
David C. Everett, III
Certificate of Approval:
Frank L. Weathers Roger K. Blashfield, Chair Associate Professor Professor Psychology Psychology
___________________________Chris Correia Stephen L. McFarland___________________________ Assistant Professor Dean Psychology Graduate School, Auburn University
ANTISOCIAL PERSONALITY DISORDER VS. PSYCHOPATHY:
AN ANALYSIS OF THE LITERATURE
David C. Everett, III
A Thesis Submitted to the Graduate Faculty of Auburn University in Partial Fulfillment of the Requirements for the Degree of Master of Science
Auburn, AlabamaMay 11, 2006
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THESIS ABSTRACT
ANTISOCIAL PERSONALITY DISORDER VS. PSYCHOPATHY:
AN ANALYSIS OF THE LITERATURE
David C. Everett, III (B.S., Tennessee Technological University, 2001)Master of Science, May, 11, 2006 74 Typed Pages Directed by Roger K. Blashfield
Antisocial Personality Disorder and Psychopathy are disorders related by their associations with criminal behavior. Antisocial Personality Disorder is a pervasive pattern of disregard for the rights of others beginning in childhood and continuing into adulthood. Psychopathy is characterized by a variety of affective and behavioral traits, such as impulsivity, lack of remorse or empathy, and irresponsibility. Although their histories are intertwined, some researchers, such as Hare, have considered the disorders separate since 1980 and the inclusion of Antisocial Personality Disorder in the DSM-III. Yet there are some researchers who still consider these disorders linked, such as being two measurement criteria of the same construct, or two sides of the same coin, so to speak. Assuming ASPD and Psychopathy were separate disorders, it could be expected for the research literature of each to be also distinctly separate from one another.
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This study was an attempt to analyze and define the possible differences between the research literatures for Antisocial Personality Disorder and Psychopathy. Seventy-seven articles were selected from eight top psychological journals for four specific years covering the last three decades of research to be used for this study. The articles were separated into categories by diagnostic focus and split by their country of origin (American or other country) as well as the association of the publication in which they appeared (American vs. International). Results indicated that there was some overlap between the two research literatures due to the presence of articles using both diagnoses as well as articles using other, alternative diagnoses, such as Sociopathy. Also, it was expected that the ASPD literature would mostly be associated with American entities, such as authors and journals, and that Psychopathy would be concentrated in International journals by International authors. Results showed that, again, there was overlap in this area, as well.
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TABLE OF CONTENTS
- INTRODUCTION LIST OF TABLES viii
- METHOD
- Overview
- SampleMeasures ....................................................................................ÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖ
- Procedure ÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖ
- RESULTS
- DISCUSSION
- Limitations Ö...ÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖ.
- Summary ÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖÖ
- REFERENCES
- APPENDIX
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LIST OF TABLES
- Number of articles published by year for key word and databaseÖ............................
- Number of articles published by year for key word and database, part IIÖÖÖÖÖ
- Number of articles identified for journals by key word term and hand searchÖÖÖ
Psychopathy , a disorder similar in some respects to ASPD , has been defined as a constellation of affective, interpersonal, and behavioral characteristics. Some of the traits of a psychopath include, but are not limited to: impulsivity, lack of empathy or guilt, manipulativeness, lack of depth of emotion, and a persistent violation of social norms (Hare, 1993). Although these traits seem similar to those listed above for the diagnosis of ASPD , Robert Hare, a significant contributor to the literature on Psychopathy , has argued that though ìÖmost psychopaths meet the criteria for ASPD Ömost individuals with ASPD are not psychopaths,î (Hare, 1996). Psychopathy has been estimated to occur in about 1% of the population, or in approximately 3 million people (Hare, 1999). Hare recorded in his 1978 book that during the 50ís and 60ís, the terms Sociopathy and Psychopathy were used in the research literature and not Antisocial Personality. The distinction between Psychopathy and ASPD , as he saw it, only began to appear in the late 1970ís and early 1980ís. The histories of Psychopathy and ASPD in their development as diagnoses are somewhat intertwined. Philippe Pinel, a noted 19th^ century physician and early psychiatrist, worked with some patients who displayed explosive and irrational outbursts of violence. These individuals, however, did not exhibit the delusions that were typically associated with ìinsanityî and were, instead, fully aware of their actions and surroundings. Pinel diagnosed these individuals as having manie sans delire or ìmania without deliriumî. He continued to use this term to describe patients with violent outbursts who appeared to have no other underlying or accompanying psychopathology (Robinson, 1977). In 1835, James Prichard, a Scottish physician, coined the term moral insanity to describe those individuals who ìÖappear to be incapable of conducting
themselves with decency and proprietyÖî, but whose intellectual functioning was not impaired due to injury nor showed any other deficits (Black, 1999). German psychiatrists also contributed to this history. In 1891, Koch first used the term ëpsychopathicí to describe a heterogeneous collection of what is now called personality disorders. Then, in the early 1900ís, Kraepelin used the term Psychopathic Personality specifically to describe an immoral or amoral criminal type (Lykken, 1995). In 1923, Schneider, a German psychiatrist, provided a broader definition of Psychopathic Personality. He defined these personalities as ìÖabnormal personalities who either suffer personally because of their abnormality or make a community suffer for it.î In his work, he described ten varieties of abnormal personality, some of which were similar to concepts included in the Diagnostic and Statistical Manual of Mental Disorders, 3 rd^ edition (DSM-III) and the International Classification of Diseases, 10 th revision (ICD-10) ( Livesley et al., 1994). Also at this time, the term Sociopath was introduced by an American psychiatrist, G.E. Partridge, in 1930. Partridge coined the term because he noted that these individuals commonly violated social norms of behavior. Jumping to 1941, Hervey Cleckley originally published The Mask of Sanity (Cleckley, 1941), which he later revised four different times. This book played an important role in the history of Psychopathy. In his book, Cleckley, a professor of psychiatry and neurology at the Medical College of Georgia, catalogued the disorder in a unique fashion. He offered vignette case studies relating the stories of a variety of individuals he identified as psychopaths. Through these case studies as well as other chapters describing how psychopaths may look in the guise of everyday people, he
The DSM-II was published in 1968 and there were some changes to the diagnostic categories. Dyssocial Reaction was moved to be listed under ëconditions without manifest psychiatric disorderí. This was notable because the term ëdyssocialí resurfaces later as a diagnosis, Dyssocial Personality Disorder , in the ICD. Most importantly, Sociopathic Personality Disturbance from the DSM-I was replaced by Antisocial Personality in the DSM-II. This concept was not the same as the current diagnosis of Antisocial Personality Disorder , which was introduced in the DSM-III. At that time, the concepts of Antisocial Personality and Psychopathy were very similar to one another. Antisocial Personality did not, as yet, have any specific diagnostic criteria and instead was still used to refer to individuals who exhibited certain antisocial traits, such as impulsivity and irresponsibility, much like Psychopathy used trait-based criteria for diagnosis. As the 70ís approached, though, research began to be conducted that would later provide distinctions between the continuing concept of Psychopathy and the new diagnosis of Antisocial Personality Disorder. The Europeans had their own system of classification and, up to this point, there was not much variation between their system and the American system in the DSM manuals. The World Health Organization in 1948 adopted the Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death. Like the DSM-I , the Europeans had wanted to provide a classification of mental disorders so they added a chapter to the manual and renamed it the International Classification of Diseases, Injuries, and Causes of Death (ICD-6) (WHO, 1948). This section of mental disorders consisted of ten categories of psychosis, nine categories of psychoneurosis, and seven categories of disorders of character and behavior (Gruenberg et al., 2005). The
ICD-7 was published in 1955, but was not internationally accepted so revisions to this text were undertaken by the WHO (Gruenberg et al., 2005). In an effort to improve classification systems, American psychiatrics worked in conjunction with European psychiatrists on the next revision. The ICD-8 was approved by the WHO in 1966 and published in 1968, the same year as the DSM-II. The similarities between the two manuals, such as the inclusion of the diagnostic concept of Antisocial Personality, were a direct result of the collaboration of the American and European scientists to upgrade the mental disorder classification system. However, developments in the field would soon create a split between the two. Lee Robinsí research of deviant children published in 1966 strongly influenced later formulations of Antisocial Personality Disorder. Robinsí study moved away from interpersonal and affective trait-based criteria to a behavioral standard. Robins stated that many in the field thought that these interpersonal and affective traits were difficult to accurately assess, therefore, criteria based on behavior that could be objectively observed was more logical. At the time of the initiation of her research, there were no published diagnostic criteria for the diagnosis of Sociopathic Personality. As previously mentioned, the DSM-I , the diagnostic manual in use at the time, gave a definition of the disorder listing many interpersonal traits or characteristics of someone with the disorder, but no criteria for diagnosis. As a result of the lack of specific criteria, the Robinsí study had to develop a way to accurately assess and diagnose the adults that they interviewed. She identified 19 general life areas of personal behavior representing many facets of life that could be objectively observed for severe or abnormal rates of occurrence and that criteria had to be met in at least five of these areas for a diagnosis to be made. These behaviors
At the same time that Robins was working on her study, another researcher was also making advances in the field, but in a different direction. Robert Hare had been working on Psychopathy during the 1960ís and had written that he noticed there was not much empirical research regarding Psychopathy at that time. In 1970, Hare published his book, Psychopathy: Theory and Research, in which he presented his opinion that there were no assessment tools that could accurately measure Psychopathy, at that time. With this in mind, Hare compiled a twenty-two item list of personality traits that were based on the traits that Cleckley originally deemed characteristic of the psychopath, such as impulsivity and lack of empathy. Cleckleyís work was credited by Robert Hare (1995) as contributing significantly to his work and to the development of Psychopathy as a clinical construct defined by a constellation of interpersonal and affective characteristics. Each item on his list was to be scored on a three-point rating scale: 0 if none of the item applied, 1 if there were some areas where the trait was exhibited, and 2 if the trait were demonstrated in many areas of the individualís life. Hare published this scoring system in 1980 as the Psychopathy Checklist (PCL). This list was meant to provide an empirically derived set of characteristics to be used in the diagnosis of Psychopathy. Meanwhile, in 1972, the Feighner criteria, published by a group of psychiatrists at Washington University in St. Louis, were expanding on Robinsí idea of using a specific set of behaviors for diagnosis, including a childhood component. The Feighner criteria required the early onset of antisocial behavior. Specifically, one type of antisocial behavior before age 15, such as persistent truancy, had to be present in order for a diagnosis of Antisocial Personality to be made. The Research Diagnostic Criteria, RDC (1978), for Antisocial Personality Disorder , developed by Spitzer, Endicott, and E.
Robins, continued to refine the behavioral referents that were used as criteria. The RDC required the early onset of at least 3 types of antisocial behaviors before age 18, with at least one of these present before age 15. The next step in the evolution of ASPD and Psychopathy proved to be the critical one. The DSM-III (1980) and the DSM-III-R (1987), heavily influenced by the research of Robins, completed the separation from Psychopathy (Hare, 1991). In the DSM - III , Antisocial Personality Disorder required the presence of 3 or more antisocial behaviors before age 15 and focused on persistent violations of social norms, such as lying, stealing, and arrests (Hare, 1996). The connection between childhood and future adult behavior in Robinsí study, as well as the contributions of the Feighner criteria and the RDC, were the impetus for the inclusion of a childhood component as a criterion for Antisocial Personality Disorder (Widiger et al., 1996). Personality disorders as a whole were separated from other disorders and assigned to a different level, Axis II, in the multi-axial system that the APA established in the manual. According to Hare et al. (1991), this represented a significant break from clinical tradition as well as from the international nomenclature. The DSM-III and DSM-III-R now contained specific criteria for the diagnosis of all the disorders therein. The ICD-9 , however, still gave descriptions of abnormal mental experiences or behavior that would act as a frame of reference for clinicians to use in diagnosis. Also occurring during this time, Hare revised his Psychopathy Checklist by reducing it to twenty items and published it in 1985 as the Psychopathy Checklist- Revised (PCL-R) with a later version including an instructional manual being published in 1991. He stated that the diagnostic category provided by the DSM manuals, while
characteristics that have been mentioned previously in this paper. The differences in names for the disorder as well as the constructs as defined by the current criteria for diagnosis of ASPD in the DSM manuals, Psychopathy based on Hareís criteria as defined in the PCL-R, and the Dyssocial Personality Disorder in the ICDs were important to note because they typify some of the differences between America and the rest of the world regarding the diagnosis of ASPD and Psychopathy. The DSM was largely considered to be an American manual for the American mental health system. Hare gave voice to this fact in the 1999 Oxford Textbook of Psychopathology when he stated that there were two diagnostic traditions for the assessment of Psychopathy ; one stemming ìnaturallyî from the ìrich European and North American clinical traditionî and the other, ìclosely associated with research emanating from Washington University in St. Louis.î As has been discussed, the rest of the world has mostly used the International Classification of Diseases in its various editions, as well as also using the DSM. There would seem to be, based on the opinions of some, a point at which the separation of the criteria occurred to create, in fact, two individual disorders and not just two dimensions of the same construct. In other words, the shift towards behaviorally-defined criteria has been argued by some to have actually created a disorder separate from the classical trait-based definition of Psychopathy. The development of the DSM-IV instigated new research into this area as it included some field trials regarding the criteria for ASPD. At that time, there were some proposed changes to the nomenclature. Two proposals were directed specifically at ASPD. The first was to provide more emphasis on the traits of Psychopathy in the criteria for ASPD and the other was to simplify the criteria of ASPD without significantly
changing the diagnosis. The results of the field trial while finding that some items could be deleted from the criteria or combined into one item, only found partial support for the proposal to include more traditional traits consistent with the diagnosis of Psychopathy (Widiger et al., 1996). Specifically, the results showed that the Psychopathy criteria sets as well as the criteria given in the ICD-10 could be assessed as reliably as the DSM-III-R criteria. But, the researchers stated that this would not guarantee that items such as glibness and superficial charm could be reliably assessed in the everyday practice of clinicians without the use of a semi-structured interview. Clinicians would have to use these interviews in order to accurately and reliably assess the construct and that was considered to be unlikely. Ultimately, due to this reliance on the structured interview as well as perceived limitations of the study, such as intersite reliability and the absence of the full criteria list for Psychopathy (only a 10-item list was used), decisions were made not to incorporate more of the Psychopathy traits into the criteria of ASPD (Hare, 1996). In 1999, Rutherford et al. provided further support for the separation of ASPD and Psychopathy as distinct disorders. This study examined how 137 cocaine-dependent women would be diagnosed for ASPD using the five relevant criteria, the RDC, the Feighner criteria, the DSM-III , DSM-III-R , and the DSM-IV criteria. Also included in this study was the Revised Psychopathy Checklist (Hare, 1991) in order to ascertain if these women would qualify for a diagnosis of Psychopathy as well. The study noted important differences between Antisocial Personality Disorder and the Psychopathy diagnosis according to the Revised Psychopathy Checklist. For instance, it is impossible to get a high Psychopathy score on the PCL-R without the presence of such psychopathic personality traits as grandiosity, egocentricity, and lack of empathy. However, none of
