Management perspective

Current issues in the assessment

and diagnosis of psychopathy (psychopathic personality
disorder)
Stephen D Hart*1 & Alana N Cook1

Practice points
„„ Concepts and operations must be distinguished, recognizing that psychopathic personality disorder (PPD)
comprises a broad range of symptoms, but that any given measurement procedure necessarily focuses on a
limited set of symptoms.

„„ Symptoms of PPD should be broadly assessed using multiple measurement procedures and straying beyond
the limits of standardized diagnostic criteria as necessary and appropriate.

„„ Symptoms of PPD should be assessed along a continuum, either in addition to or instead of making categorical
diagnoses.

„„ The course of PPD symptoms should be assessed, that is, fluctuations over time in trait extremity and
associated functional impairment.

„„ The potential influence of gender, age and culture on the expression of (apparent) symptoms of PPD should be
considered.

„„ The potential influence of acute physical and mental health problems on the expression of (apparent)
symptoms of PPD should be considered.

„„ PPD should be assessed using standardized measurement procedures that integrate information from diverse
sources such as expert rating scales or certain diagnostic interviews.

SUMMARY Few mental disorders are the source of as much fascination on one hand
and confusion on the other hand as psychopathy, also known as psychopathic, antisocial
or dissocial personality disorder. This review focuses first on conceptual issues, clarifying
the nature of psychopathic personality disorder. It then focuses on operational issues,
reviewing some of the most commonly used procedures for measuring features of the
disorder in adult clinical–forensic settings. It concludes by discussing a ‘hot topic’ in
the field: the nature of the association between antisocial behavior and psychopathic
personality disorder.

1
Department of Psychology, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada; Tel.: +1 778 782 3354;
Fax: +1 778 782 3427; [email protected] part of

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Management perspective  Hart & Cook

Mental health professionals are often fascinated (PCL:SV) [14] all differ. Even when measures of
by the concept of psychopathy or psychopathic PPD are broadly similar in content or highly cor-
personality disorder (PPD), yet many are also related at the group level, there may be important
confused by it. The fascination stems primarily differences between them that lead to modest
from the disorder’s association with crime; the diagnostic agreement in individual cases [13,14] .
confusion is caused by its name. This review focuses first on conceptual issues,
The association between PPD and crime has clarifying the nature of PPD. It then focuses
been recognized for almost 200 years. Indeed, on operational issues, reviewing some of the
it was alienists working for the courts who first most commonly used procedures for measur-
identified and described symptoms of what is ing features of PPD in adult clinical–forensic
now called PPD [1] . There is now a large body settings. The overarching goals of this review
of research, including recent meta-analyses [2,3] , are to demystify the disorder and promote best
which confirms that features of PPD are major practice.
risk factors for serious criminality and violence.
For this reason, PPD is an important construct Conceptual issues
in forensic mental health practice. The nature of psychopathic personality
„„
The confusion regarding the disorder’s name is disorder
longstanding [4] and persists to the present time. As histories of the concept reveal [1,4,15] , our
Should we refer to it as PPD [5–7] , or just plain understanding of the nature of PPD has evolved
psychopathy? What about terms such as ‘anti- over the past 200 years. In the last 100 years,
social’, ‘dissocial’ and ‘sociopathic personality and particularly in the last 50 years, there has
disorder’: can they be used synonymously? The emerged a broad consensus that PPD is char-
current authors have often heard it argued that acterized by a syndromal structure, comprising
PPD ‘does not exist’; that is, it is not included symptoms in several major areas of personality
in the DSM‑IV‑TR [8] or the 10th edition of functioning.
the International Classification of Diseases and It is surprisingly uncommon for researchers to
Related Health Problems (ICD‑10) [9] . But the systematically explicate the psychopathological
argument is simply incorrect, the result of con- constructs that they study. To fill the void with
fusing what is being measured (i.e., a concept respect to PPD, Cooke and colleagues developed
with central, core or defining features) with a concept map of PPD based on a systematic
how it is being measured (i.e., an operation or review of the literature [16] . They broke down
method based on specific identification criteria). major clinical descriptions of the disorder into
Put simply, a set of diagnostic criteria for a men- lexical units – trait-descriptive adjectives or
tal disorder is not the same thing as a definition adjectival phrases in the English language – and
of that mental disorder any more than a map is then grouped them rationally into domains
the same thing as the terrain it represents [10] . related to more global aspects of personality
As a concept, PPD is indeed synonymous with functioning. The result was a concept map they
antisocial, dissocial and sociopathic personal- referred to as the Comprehensive Assessment
ity disorder. They are simply different terms for of Psychopathic Personality (CAPP), which is
the same disorder. This is explicitly recognized illustrated in Figure 1. The purpose of the CAPP
in the DSM‑IV‑TR [8] . PPD is included in the is to capture the diversity of views regarding key
DSM‑IV‑TR, where it is referred to as ‘anti­social features of PPD in a way that facilitates research
personality disorder’, and in the ICD‑10, where on PPD as a construct, as well as providing a
it is referred to as ‘dissocial personality disorder’. basis for understanding the associations among
At an operational level, however, the various pro- various measurement procedures, or even the
cedures for assessing and diagnosing PPD are development of new measurement procedures.
definitely not equivalent. Of course, even diag- According to the CAPP, PPD comprises six
nostic criteria with the same name may differ domains of symptoms. First, the attachment
markedly in content. For example, the criteria for domain, which reflects affiliation in inter­
antisocial personality disorder in earlier editions personal relations and includes symptoms such
of the DSM differ from those in the DSM-IV; as detachment, lack of commitment and lack
similarly, the criteria for PPD in the Psychopathy of empathy or concern for others. Second, the
Checklist (PCL) [11] , the revised PCL (PCL-R) behavioral domain, which reflects organiza-
[12,13] and the Screening Version of the PCL-R tion of goal-oriented activities and includes

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 Current issues in the assessment & diagnosis of psychopathy  Management perspective

Antagonistic
Domineering Detached
Deceitful Dominance Attachment Uncommitted
Manipulative domain domain Unempathic
Insincere Uncaring
Garrulous

Lacks perseverance
Lacks anxiety
Unreliable
Lacks pleasure
Emotional Behavioral Reckless
Lacks emotional depth Psychopathic personality disorder
domain domain Restless
Lacks emotional stability Disruptive
Lacks remorse Aggressive

Self-centered
Self-aggrandizing Suspicious
Sense of uniqueness Lacks concentration
Self Cognitive
Sense of entitlement Intolerant
domain domain
Sense of invulnerability Inflexible
Self-justifying Lacks planfulness
Unstable self-concept

Figure 1. Concept map of psychopathic personality disorder: the Comprehensive Assessment of Psychopathic Personality [16].

symptoms such as lack of perseverance, unreli- this research suggest that the CAPP provides
ability, recklessness, restlessness, disruptiveness a comprehensive concept map of PPD that is
and aggressiveness. Third, the cognitive domain, relatively stable across genders and cultures.
which reflects organization of mental activities The major implication for practice of this
and includes symptoms such as suspiciousness, section is that evaluators should distinguish
inflexibility, intolerance, lack of planfulness and concepts and operations, recognizing that PPD
lack of concentration. Fourth, the dominance comprises a broad range of symptoms, but that
domain, which reflects status in interpersonal any given measurement procedure necessarily
relations and includes symptoms such as antag- focuses on a limited set of symptoms.
onism, arrogance, deceitfulness, manipulative-
ness, insincerity, and glibness or garrulousness. Assessment & diagnosis
„„
Fifth, the emotional domain, which reflects There are two primary approaches to the assess-
the experience and expression of affect and ment and diagnosis of PPD. The first approach
includes symptoms such as lack of anxiety, lack focuses more narrowly on symptoms related to
of remorse, lack of emotional depth and lack impulsivity, irresponsibility and antisociality
of emotional stability. Finally, the self domain, (i.e., those from the behavioral domain of the
which reflects organization of self–concept CAPP). It underlies the DSM‑IV-TR criteria
and self–other relation and includes symptoms for antisocial personality disorder, summarized
such as self-centeredness, self-aggrandizement, in Box 1, which serve as a good example: they
self-justification and a sense of entitlement, require symptoms of conduct disorder with age
uniqueness, and invulnerability. of onset below the age of 15 years and persistence
The CAPP as a concept map has been evalu- of antisocial behavior past the age of 18 years.
ated in several ways. First, it has been translated Diagnostic criteria based on that approach may
into diverse languages [17] . Second, surveys of lack specificity, especially in forensic settings.
forensic mental health professionals and oth- This point is discussed explicitly in DSM‑IV‑TR
ers have asked respondents to rate the proto­ [8] . The second approach includes a broader range
typicality of CAPP symptoms [17,18] . Third, some of symptoms (i.e., those from other domains in
surveys have examined the extent to which pro- the CAPP). It underlies the ICD-10 criteria for
totypicality ratings or symptoms ratings differ dissocial personality disorder, summarized in
as a function of the gender of subjects (i.e., men Box 2, as well as the PCL-R and PCL:SV criteria
vs women with PPD) or the language in which for PPD, summarized in Boxes 3 & 4, respectively.
symptoms were presented [19] . The findings of As a consequence of including more, and more

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Management perspective  Hart & Cook

Box 1. DSM‑IV‑TR criteria for antisocial personality disorder.

ƒƒ There is a pervasive pattern of disregard for and violation of the rights of others occurring since 15 years of age, as indicated by three
(or more) of the following:
ƒƒ Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds
for arrest
ƒƒ Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
ƒƒ Impulsivity or failure to plan ahead
ƒƒ Irritability and aggressiveness, as indicated by repeated physical fights or assaults
ƒƒ Reckless disregard for safety of self or others
ƒƒ Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
ƒƒ Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated or stolen from another
ƒƒ The individual is at least 18 years of age
ƒƒ There is evidence of conduct disorder (see diagnostic criteria for conduct disorder) with onset before 15 years of age
ƒƒ The occurrence of antisocial behavior is not exclusively during the course of a schizophrenic or a manic episode
Information taken from [8].

diverse, symptoms, the second approach tends Regardless of their underlying approach, con-
to yield diagnoses with lower prevalence rates temporary diagnostic criteria for PPD have some
and greater specificity than the first approach. important limitations. First, they have limited
The distinction between these two approaches coverage of symptoms. Second, they conceptu-
is not just semantic; it may also have some alize symptom severity in global terms. Third,
important implications for understanding the they permit only relatively crude, categorical
etiology of psychopathy. Research indicates that diagnoses.
using narrower diagnostic criteria for PPD yields The major implications of this section are
findings that are stronger and more consistent that evaluators should assess symptoms of PPD
than those based on broader diagnostic criteria. broadly, straying beyond the limits of standard-
For example, compared with offenders who meet ized diagnostic criteria as necessary and appro-
DSM-IV diagnostic criteria for PPD, those who priate, and evaluate symptoms of PPD along a
meet the narrower PCL-R diagnostic criteria continuum, either in addition to or instead of
showed evidence of reduced gray matter volume making categorical diagnoses.
in areas of the brain associated with empathy,
moral reasoning, and processing of prosocial Prevalence
„„
emotions such as guilt and embarrassment, in a Prevalence estimates vary according to the
structural MRI study [20] ; blunted processing of nature of the diagnostic criteria used in epide-
negative emotional words on an emotional–lin- miological research. Focusing on research con-
guistic go/no go task, in a study of event-related ducted in the USA and Canada, and using broad
brain potentials [21] ; and better overall perfor- (DSM‑IV‑TR or similar) criteria, the lifetime
mance on measures of executive functions in a prevalence of PPD in the general population is
study of performance on a neuropsychological approximately 1.5–3.5%; in correctional offend-
test battery [22] . ers, the rate is 50–75% [23–25] . By contrast, using

Box 2. International Classification of Diseases (10th Edition) criteria for dissocial personality
disorder.
ƒƒ Callous unconcern for the feelings of others and lack of capacity for empathy
ƒƒ Gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations
ƒƒ Incapacity to maintain enduring relationships
ƒƒ Very low tolerance to frustration and a low threshold for discharge of aggression, including violence
ƒƒ Incapacity to experience guilt and to profit from experience, particularly punishment
ƒƒ Marked proneness to blame others or to offer plausible rationalizations for the behavior bringing the
subject into conflict with society
ƒƒ Persistent irritability
Information taken from [9].

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narrow (PCL‑R, PCL:SV or similar) criteria, the Box 3. Items in the Hare Psychopathy
lifetime prevalence rate in correctional offend- Checklist-Revised.
ers and forensic psychiatric patients is approxi-
ƒƒ Glibness/superficial charm
mately 15–25%, or a third of the rate observed
ƒƒ Grandiose sense of self-worth
using broader criteria [5,6,12–14] .
ƒƒ Need for stimulation/proneness to boredom
Course
„„ ƒƒ Pathological lying
Symptoms of PPD typically have an insidi- ƒƒ Conning/manipulative
ous and spontaneous onset sometime between ƒƒ Lack of remorse or guilt
childhood, as young as 6–10 years of age, and ƒƒ Shallow affect
late adolescence or early adulthood, as old as ƒƒ Callous/lack of empathy
16–20 years of age. Perhaps the most easily and ƒƒ Parasitic lifestyle
frequently observed symptoms in childhood and ƒƒ Poor behavioral controls
adolescence are conduct problems; indeed, the ƒƒ Promiscuous sexual behavior
DSM‑IV‑TR diagnostic criteria for antisocial ƒƒ Early behavioral problems
personality disorder require symptoms of con- ƒƒ Lack of realistic, long-term goals
duct disorder with age of onset before 15 years of ƒƒ Impulsivity
age [8] . In middle-to-late adulthood, the course ƒƒ Irresponsibility
of PPD is characterized by relative stability, ƒƒ Failure to accept responsibility for own actions
although symptoms fluctuate with respect to ƒƒ Many short-term marital relationships
extremity or dysfunction. For example, there is ƒƒ Juvenile delinquency
evidence of moderate diagnostic stability across ƒƒ Revocation of conditional release
periods from several months to several years ƒƒ Criminal versatility
[26–28] , persistence of symptoms across adult- Information taken from [12,13].
hood [29] , and long-term risk for negative health
outcomes such as morbidity and mortality [30] . literature reviews and anthropological research,
The major implication for practice of this sec- PPD appears to have conceptual equivalence
tion is that evaluators should assess the course of across genders and cultures. Little attention has
PPD symptoms, that is, fluctuations over time been paid to age.
in trait extremity and associated functional A second explanation is a lack of structural
impairment. equivalence. A disorder’s syndromal struc-
ture – the pattern of associations among its
Gender, age & culture
„„ symptoms – may vary. Put simply, the disorder
The expression and prevalence of PPD varies as a ‘looks different’ across groups, making it difficult
function of demographic characteristics such as or even impossible to develop adequate assess-
gender, age and culture or ethnicity. With respect ment procedures and diagnostic criteria. This
to gender, males are more likely than females also does not seem to be the case with PPD. A
to demonstrate all symptoms of PPD, which
according to epideimiological research, results Box 4. Items in the Screening Version of the
in a male:female sex ratio for lifetime preva- Hare Psychopathy Checklist-Revised.
lence of approximately 3:1 [24,25] . With respect
ƒƒ Superficial
to age, and focusing on adults (aged 18 years
ƒƒ Grandiose
and older), some epidemiological research has
ƒƒ Deceitful
reported a cohort effect, with higher lifetime
ƒƒ Lacks remorse
prevalence rates in younger generations than in
ƒƒ Lacks empathy
older generations [25] . With respect to culture,
ƒƒ Does not accept responsibility
although PPD is found across cultures, there is
some evidence of cross-cultural differences in ƒƒ Impulsive
prevalence [31] . ƒƒ Poor behavioral controls
One explanation for these group differences ƒƒ Lacks goals
is a lack of conceptual equivalence. Sometimes, ƒƒ Irresponsible
a disorder is more apparent, recognized or rel- ƒƒ Adolescent antisocial behavior
evant in one group than in another. This does ƒƒ Adult antisocial behavior
not seem to be the case with PPD. According to Information taken from [14].

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Management perspective  Hart & Cook

large and growing body of research supports the The major implication for practice of this sec-
structural equivalence (i.e., stability, if not strict tion is that evaluators should consider the poten-
invariance) of PPD across gender and culture. tial influence of acute physical and mental health
Once again, little attention has been paid to age. problems, which may mimic symptoms of PPD.
A third explanation is a lack of metric equiva-
lence. Even if a disorder has good conceptual and Operational issues
structural equivalence across groups, procedures A comprehensive review of measurement proce-
for assessing or measuring symptoms of the dis- dures is beyond the scope of this paper. Below,
order may be biased and not directly comparable the discussion is limited to the most commonly
across groups. There is some evidence of bias in used procedures specifically developed to assess
existing procedures for assessing or measuring PPD in clinical–forensic evaluations of adults;
PPD. Specifically, the findings of item response excluded from this review are measures derived
theory analyses indicate that these procedures from those developed to assess normal person-
may underestimate the prevalence of PPD in ality, measures designed for use in research or
European countries compared with Canada and general clinical settings, measures designed for
the USA, and possibly in women compared with use with children or adolescents, or measures
men. Yet again, little attention has been paid to not commonly used. The procedures included
age. But the underestimation is small in mag- in this review may be divided into three basic
nitude and not sufficient on its own to account categories: diagnostic interviews; self-report
for the observed group differences, raising the questionnaires and inventories; and expert
possibility that they are due, at least in part, to rating scales.
cultural facilitation [32,33] . Diagnostic interviews use (semi-)structured
The major implication for practice of this interview schedules to gather information from
section is that evaluators should consider the the person being evaluated to make a diagnosis
potential influence of gender, age and culture, according to fixed and explicit criteria. Two of
which may influence the expression of symptoms the most commonly used structured diagnos-
of PPD. tic interviews in clinical–forensic settings are
the Structured Clinical Interview for DSM-IV,
Comorbidity
„„ Axis II [41] and the International Personality
Three major patterns of comorbidity are Disorder Examination [42] .
observed. First, PPD has a high rate of comor- Self-report inventories require the person
bidity with substance use disorders [24,34–36] . being evaluated to respond to a series of specific
This comorbidity may reflect a common etio- questions using a fixed response format. They are
logical mechanism, or it may be that in some usually administered in written form, although
cases substance use disorders are a consequence it is possible in many cases to administer them
or complication of PPD. It is not plausible that orally or by means of audio cassettes. Multiscale
PPD is a consequence or complication of sub- inventories commonly used to assess psychopa-
stance use disorders, as symptoms of the former thy include the second edition of the Minne-
generally have onset many years before those of sota Multiphasic Personality Inventory [43] and
the latter. Second, PPD also has a high rate of its Restructured Form [44] , the third edition of
comorbidity with other personality disorders. the Millon Clinical Multiaxial Inventory [45]
Comorbidity is highest with borderline (emo- and the Personality Assessment Inventory [46] .
tionally unstable), narcissistic and histrionic per- A number of self-report questionnaires focused
sonality disorders [24,37–39] . This may be due in specifically on assessment of psychopathy have
part to a lack of specificity in the diagnostic cri- been developed, with perhaps the most popular
teria for personality disorders – that is, a failure one being the revised Psychopathic Personality
to carve nature at its joints – but may also reflect Inventory [47] .
common etio­logical factors. Third, low rates of Expert rating scales are multi-item rating
comorbidity are observed between PPD and scales. Trained observers rate the severity of
certain other personality disorders. Comorbid- symptoms based on all available clinical data
ity is lowest with avoidant (anxious/avoidant), (e.g., interview with the respondent, review of
dependent and obsessive–compulsive (anan- case history information and interviews with
kastic) personality disorders [37,38,40] . This may collateral informants). The PCL-R [12,13] falls
reflect divergent etiological factors. into this category, as does the PCL:SV [14] .

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Box 5 summarizes some of the key features of tend to be sensitive to state factors such as acute
these assessment procedures. psychopathology and mood state. It is unclear
whether they are sensitive to change over time
„„Evaluation in PPD symptomatology.
Diagnostic interviews There is an evidence base that supports
The Structured Clinical Interview for DSM- some aspects of the reliability and validity of
IV, Axis II [41] and the International Personality self-report inventories – in particular, their
Disorder Examination [42] have manuals that structural reliability. However, the evidence
assist administration, scoring and interpretation, base also suggests that self-report inventories
although the manuals have been criticized for have low-to-moderate temporal stability and
lack of detail and a complete lack of normative low-to-moderate concurrent validity with other
data [48] . procedures for assessing PPD, including other
The diagnostic interviews have some major self-report inventories. There is relatively little
limitations in terms of content and format. With evidence that self-report inventories of PPD have
respect to content, they are limited by the diag- good predictive validity with respect to serious
nostic criteria on which they were based, and antisocial behavior.
thus over-focus on antisocial behavior. With
respect to format, their heavy reliance on oral Expert rating scales
self-report by respondents means that they are The PCL-R [12,13] and PCL:SV [14] have detailed
susceptible to distortion and sensitive to state manuals that assist administration, scoring and
factors such as acute psychopathology, although interpretation. Extensive normative data for cor-
these problems can be minimized by integrating rectional and forensic mental health settings are
collateral information in the assessment process. contained in the test manuals and the PCL:SV
Also with respect to format, because these inter- manual also contains normative data for civil
views are designed to assess lifetime presence of psychiatric patients and community residents.
PPD, they tend to be insensitive to changes over With respect to content, expert rating scales
time in symptomatology. have good coverage of PPD symptoms, although
Notwithstanding these problems, there is an the PCL-R and PCL:SV have both been criti-
evidence base that supports at least some aspects cized as being too heavily saturated with items
of the reliability and validity of diagnostic inter- that reflect antisocial or socially deviant behav-
views for PPD – in particular, inter-rater and ior. With respect to format, expert rating scales
test–retest reliability, as well as concurrent valid- are specifically designed to integrate collateral
ity with respect to other diagnostic interviews and interview information, which means that
and clinical diagnoses. they require only limited language skills and
are not susceptible to response distortion. Also,
Self-report inventories they have moderate-to-high temporal stability
The self-report inventories described here all and are relatively insensitive to state factors such
have detailed manuals that assist administra- as acute psychopathology and mood state. One
tion, scoring and interpretation. They all contain major problem is that, because the PCL-R and
extensive normative data for community resi- PCL:SV were designed to assess lifetime pres-
dents but have no, or only limited, normative ence of PPD, they are insensitive to changes over
data for correctional and forensic mental health time in symptomatology.
settings. There is a very large evidence base that sup-
With respect to content, most of the self- ports every major aspect of the reliability and
report inventories are designed to assess a broad validity of expert rating scales. The psychometric
range of problems, so their coverage of PPD properties of the PCL-R and PCL:SV have been
symptoms is limited. The exception here is the evaluated extensively within the framework of
revised Psychopathic Personality Inventory, classical test theory. The findings indicate that
which focuses solely on PPD [47] . With respect the structural, inter-rater and test–retest reliabili-
to format, reliance on written self-report with ties of the tests are good to excellent. The tests
no ability to integrate collateral information have also been evaluated within the framework
means that these inventories require respondents of modern test theory, with similar positive find-
to have basic literacy and language skills, and ings. The concurrent validity of the tests is good.
are susceptible to response distortion. They also They show moderate-to-large correlations with

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Box 5. Commonly used procedures for assessing psychopathic personality disorder in clinical–forensic evaluations of adults.
SCID-II [41]
ƒƒ Semi-structured diagnostic interview for DSM-IV personality disorders
ƒƒ Relevant to PPD, severity ratings for individual symptoms are used to make diagnoses of DSM-IV antisocial personality disorder
ƒƒ Requires expert evaluators
ƒƒ Requires evaluators to be familiar with the respondent’s psychiatric history; evaluators may also consider other collateral information
ƒƒ Evaluators have the option of administering a self-report questionnaire prior to the interview and then asking questions about those areas
in which respondents admitted problems
ƒƒ Takes approximately 2–3 h to complete
ƒƒ No norms available
IPDE [42]
ƒƒ Semi-structured diagnostic interview for DSM-IV and ICD-10 personality disorders
ƒƒ Relevant to PPD, severity ratings for individual symptoms are used to make diagnoses, symptom counts and dimensional ratings of DSM‑IV
antisocial personality disorder and ICD-10 dissocial personality disorder
ƒƒ Requires expert evaluators
ƒƒ Requires evaluators to be familiar with the respondent’s psychiatric history; evaluators are also encouraged to consider other collateral
information
ƒƒ Takes approximately 2–3 h to complete
ƒƒ No norms available
MMPI-2 [43]
ƒƒ 567-item self-report inventory of personality and psychopathology
ƒƒ Contains several scales related to PPD, including Psychopathic Deviate and Hypomania
ƒƒ Also has scales designed to detect response distortion
ƒƒ Takes approximately 1–1.5 h to complete
ƒƒ Requires eighth grade reading level
ƒƒ Normed in a nationally representative sample of community residents
MMPI-2-RF [44]
ƒƒ 338-item self-report inventory of personality and psychopathology, derived from MMPI-2
ƒƒ Contains several scales related to PPD, including antisocial behavior (RC4 asb) and hypomanic activation (RC9 hpm)
ƒƒ Also contains scales designed to detect response distortion
ƒƒ Takes approximately 45–60 min to complete
ƒƒ Requires fifth grade reading ability
ƒƒ Normed in a nationally representative sample of community residents
MCMI-III [45]
ƒƒ 175-item self-report inventory of personality and psychopathology
ƒƒ Contains one scale (6A) designed to assess PPD
ƒƒ Also contains scales to detect response distortion
ƒƒ Takes approximately 30 min to complete
ƒƒ Requires eighth grade reading ability
ƒƒ Normed in clinical settings and in correctional offenders
PAI [46]
ƒƒ 344-item self-report inventory of personality and psychopathology
ƒƒ Contains one scale of PPD, antisocial features, with three subscales: antisocial behaviors, egocentricity and stimulus seeking
ƒƒ Also contains scales to detect response distortion
ƒƒ Takes approximately 45–60 min to complete
ƒƒ Requires fourth grade reading ability
ƒƒ Normed in a large, representative sample of community residents and in clinical settings
ICD-10: International Classification of Diseases (10th Edition); IPDE: International Personality Disorder Examination; MCMI-III: Millon Clinical Multiaxial Inventory-III;
MMPI‑2: Minnesota Multiphasic Personality Inventory-2; MMPI-2-RF: Restructured Form of the MMPI-2; PAI: Personality Assessment Inventory; PCL-R: Psychopathy Checklist
Revised; PCL:SV: Screening Version of the PCL-R; PPD: Psychopathic personality disorder; PPI-R: Psychopathic Personality Inventory-Revised; SCID-II: Structured Clinical Interview
for DSM-IV, Axis II.

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Box 5. Commonly used procedures for assessing psychopathic personality disorder in clinical–forensic evaluations of adults (cont.).
PPI-R [47]
ƒƒ 154-item self-report measure of PPD
ƒƒ In addition to total scores, yields scores on three factors (self-centered impulsivity, fearless dominance and coldheartedness) and eight
subscales (Machiavellian egocentricity, rebellious nonconformity, blame externalization, carefree nonplanfulness, social influence,
fearlessness, stress immunity and coldheartedness)
ƒƒ Also contains scales to detect response distortion
ƒƒ Takes approximately 20–30 min to complete
ƒƒ Requires approximately fourth grade reading ability
ƒƒ Normed in a large sample of adult community residents and in a small sample of adult male offenders
Hare PCL-R [12,13]
ƒƒ 20-item rating scale of PPD
ƒƒ In addition to total scores, yields scores on two factors (interpersonal/affective and lifestyle/antisocial) and four facets (interpersonal,
affective, lifestyle and antisocial)
ƒƒ Requires expert evaluators
ƒƒ Ratings based on the review of collateral information and an interview; may be based solely on the review of collateral information if an
interview is not possible
ƒƒ Takes approximately 90–120 min to complete
ƒƒ Norms available for offenders and forensic psychiatric patients
PCL:SV [14]
ƒƒ 12-item rating scale of PPD derived from PCL-R
ƒƒ In addition to total scores, yields scores on two factors (interpersonal/affective and lifestyle/antisocial) and four facets (interpersonal,
affective, lifestyle and antisocial)
ƒƒ Ratings based on the review of collateral information and an interview; may be based solely on the review of collateral information if an
interview is not possible
ƒƒ Takes approximately 60–90 min to complete
ƒƒ Norms available for offenders, forensic psychiatric patients, civil psychiatric patients and community residents
ICD-10: International Classification of Diseases (10th Edition); IPDE: International Personality Disorder Examination; MCMI-III: Millon Clinical Multiaxial Inventory-III;
MMPI‑2: Minnesota Multiphasic Personality Inventory-2; MMPI-2-RF: Restructured Form of the MMPI-2; PAI: Personality Assessment Inventory; PCL-R: Psychopathy Checklist
Revised; PCL:SV: Screening Version of the PCL-R; PPD: Psychopathic personality disorder; PPI-R: Psychopathic Personality Inventory-Revised; SCID-II: Structured Clinical Interview
for DSM-IV, Axis II.

clinical diagnoses made using other criteria and from diverse sources, such as expert rating scales
low-to-moderate correlations with self-report or certain diagnostic interviews, especially in
measures of PPD. Their predictive validity is clinical–forensic evaluations.
also good. They are moderately correlated with
serious antisocial behavior, including violence, Conclusion & future perspective
in both institutional and community settings. Research on PPD has burgeoned over the past
Finally, their construct validity is good. They 30 years and there is no indication that interest
have been used to study the course, comorbidity, in the disorder will wane in the near future. That
etiology and treatment of PPD. said, one ‘hot topic’ has attracted considerable
attention in recent years, and it raises fundamen-
Summary
„„ tal questions about the theoretical and clinical
At this time, expert rating scales appear to be utility of PPD. The debate is over the associa-
best suited for assessing PPD as part of clinical– tion between antisocial behavior and PPD. Is
forensic evaluations of adults. The primary use antisocial behavior a primary symptom of PPD,
of diagnostic interviews and self-report invento- a cardinal or defining feature of the disorder? Or
ries would appear to be in general clinical evalu- is it a secondary symptom, an associated feature
ations of adults, as an adjunct to expert rating that has low sensitivity (i.e., is not found in all
scales in clinical–forensic evaluations of adults people diagnosed with the disorder) or low speci-
and for research purposes. ficity (i.e., is found in people diagnosed with
The major implication of this section is that many other disorders)? Or perhaps it is not even
evaluators should assess PPD using standardized a symptom at all, but rather a common sequelae,
assessment procedures that integrate information complication or adverse outcome associated with

future science group www.futuremedicine.com 505

Management perspective  Hart & Cook

PPD – in much the same way that hospitaliza- to ignore. If Cooke and colleagues are correct,
tion or involuntary commitment is a common then it should be possible to develop new diag-
sequelae of schizophrenia? nostic criteria for and measures of PPD that
This topic has been debated intensely in recent include far fewer symptoms or items reflecting
years. Cooke and colleagues have argued on logi- antisocial behavior without suffering any sub-
cal and statistical grounds that antisocial behav- stantial decrease in reliability or validity. There
ior is not central to the concept of psychopathy, is already preliminary evidence that ‘decon-
and should be considered a secondary symptom taminated’ measures of PPD may predict vio-
or consequence [49,50] . Current diagnostic criteria lent recidivism as well as well-established expert
and measures of PPD, in their view, include too rating scales such as the PCL:SV [54] . These new
many symptoms or items reflecting antisocial measures have considerable potential theoreti-
behavior, and in particular official criminality. cal and practical promise. They may help us to
This ‘contamination’ makes it virtually impos- better understand the association between PPD
sible to clarify the association between PPD and and antisocial behavior, and may also assist
antisocial behavior. This view has been hotly clinical–forensic assessments of risk for serious
contested by Hare and colleagues [51,52] . Based on criminality and violence.
their review of clinical descriptions and empiri-
cal research, they argue that antisocial behavior Financial & competing interests disclosure
is central to the concept of PPD. The debate SD Hart receives royalties from sales of the Screening
became so heated that Hare issued a threat of Version of the Hare Psychopathy Checklist-Revised. The
litigation against the authors of an article and the authors have no other relevant affiliations or financial
editor of the journal that had accepted that arti- involvement with any organization or entity with a finan-
cle for publication following peer-review, based cial interest in or financial conflict with the subject matter
on his belief that the article was defamatory and or materials discussed in the manuscript apart from those
misrepresented his views on the issue [53] . disclosed.
It is critical to refocus the debate on substan- No writing assistance was utilized in the production of
tive matters. The issue is simply too important this manuscript.

4 Werlinder H. Psychopathy: A History of the 10 Morey LC, McNamara TP. On definitions,

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