Diagnostic labeling in juvenile justice settings: Do psychopathy and conduct disorder findings influence clinicians?

Do provocative diagnostic labels such as psychopathy or conduct disorder influence clinicians who work in juvenile justice settings? Juvenile justice clinicians (N = 109) responded to a mock psychological evaluation of a juvenile, which varied antisocial history, psychopathic personality features, and diagnosis (psychopathy, conduct disorder, or none). Psychopathic personality features and antisocial behavioral history led to higher clinician ratings of the juvenile's risk for future criminality. A psychopathy label also led to higher clinician ratings of risk, but only when there was a minimal history of antisocial behavior. No diagnostic labels influenced clinician ratings regarding treatment. Viewed alongside other research on labeling in the juvenile justice system, clinicians appear to be somewhat more responsive to mention of the psychopathy construct than are nonclinical juvenile justice professionals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical Decision Making About Psychopathy and Violence Risk Assessment in Public Sector Mental Health Settings.

Although there has been extensive research on psychopathy, it is unknown how, or whether, clinicians in public sector mental health settings consider the Psychopathy Checklist (PCL) for assessing violence risk. Mental health clinicians (N = 135) from 4 facilities were interviewed by using multiple methods for collecting data on decision making. Participants considered clinical information most often when assessing violence risk, indicating that these data were most readily available. Clinicians perceived formal testing results (e.g., PCL) to be least available and considered testing least often, especially if clinicians had less clinical experience. Participants did not explicitly report using the PCL but did implicitly rely on psychopathy factors when assessing violence risk. Clinicians in crisis settings reported less availability of historical data typically needed for the PCL. The data point to specific ways to improve the clinical practice of violence risk assessment in public mental health settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Without conscience: The disturbing world of the psychopaths among us.

Reviews the book, Without conscience: The disturbing world of the psychopaths among us by Robert D. Hare (see record 2001-00418-000). Too often we hear about adults, and now more than ever, adolescents, who perpetrate violence so horrific and seemingly meaningless that their actions defy the understanding of professionals, let alone of the perpetrators' families. The republication of Robert Hare's popular work on the psychopathic personality is a testament to the success and importance of this book. Hare paints an intriguing yet scary portrait of this, the most dangerous type of personality disorder. His colourful, but accurate portrayal of the psychopath makes this book equally important alike for parents and clinicians. Without conscience is based on more than 30 years of the author's research on psychopathy. The book is written in a sincere and easily readable fashion for a general audience. The research and clinical literature is described in nontechnical terms with a minimum of jargon, making the work accessible to a wide audience. Much of Hare's research has been devoted to the reliable identification of psychopaths. His development of the Psychopathy Checklist (PCL) may represent the single, most important advancement to date toward what hopefully will become our ultimate understanding of psychopathy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of The psychopath: Theory, research and practice.

Reviews the book, The psychopath: Theory, research and practice edited by Hugues Hervé and John C. Yuille (see record 2006-11788-000). This book begins with an historical overview of the construct of psychopathy and then works its way through a variety of important issues, including measurement, etiology, behavioural manifestations of the disorder, typologies, and practice considerations. A few notable exceptions notwithstanding, this text is a fine primer on psychopathy: It includes a number of outstanding chapters and other important issues in the area of psychopathy receive solid treatment. Although there is occasionally some drop-off in quality, I suspect that even the less outstanding chapters in this book would prove informative for students, lay consumer groups, and clinicians who do not routinely work with psychopaths. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Unsupported Gender Differences on Some Personality Disorder Scales of the Millon Clinical Multiaxial Inventory-III.

Psychologists in many settings work with clients who may have personality disorders, and psychologists need to identify such problems accurately and fairly. The Millon Clinical Multiaxial Inventory-III focuses on attempting to diagnose personality disorders, but a number of its scales manifest gender differences that are not supported by research data. Practitioners should be very cautious about using this measure and be aware that, in some cases, a focus on assessment of relevant patterns of emotion and behavior is preferable to trying to diagnose whether a personality disorder is present. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychopathy and suicide: A multisample investigation.

Evidence suggests that behavioral aspects of psychopathy are associated with suicidal behavior, whereas the affective and interpersonal aspects are not. The authors tested the robustness of this bifurcated association across 1,711 persons and 12 samples of adult and juvenile criminal offenders, forensic psychiatric patients, and civil psychiatric patients. The authors observed a small but significant partial correlation (.13) between the behavioral/impulsive lifestyle features of psychopathy and suicidality, but no effect for affective/interpersonal features. Several method and sample features (mental disorder; psychopathy and suicidality measurement format) significantly strengthened or weakened this association. The authors conclude that it is not possible to speak of "the" association between psychopathy and suicide, but that this relationship appears to be partially dependent on methodological (i.e., self-report vs. clinician-administered psychopathy measures) and sample composition (i.e., age; mental illness) factors. Recommendations for practice are provided, including that clinicians should not consider psychopathy a buffer against suicidal behavior. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The importance of callous–unemotional traits for extending the concept of psychopathy to children.

This study focused on the use of callous–unemotional (CU) traits to identify a subgroup of children with both attention deficit/hyperactivity disorder (ADHD) and a conduct problem diagnosis (oppositional defiant disorder [ODD] or conduct disorder [CD]) who show characteristics similar to adults with psychopathy. In a clinic-referred sample of children aged 6 to 13 years (N?=?154), those with diagnoses of both ADHD and ODD/CD were divided on the basis of teacher ratings of CU traits. Children high on these traits showed features typically associated with psychopathy, such as a lack of fearfulness and a reward-dominant response style. Furthermore, children with CU traits seemed less distressed by their behavior problems. These findings are consistent with research on adults showing that impulsivity and antisocial behavior alone are insufficient to document persons who fit the construct of psychopathy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A taxometric analysis of the latent structure of psychopathy: Evidence for dimensionality.

The taxonomic status of psychopathy is controversial. Whereas some studies have found evidence that psychopathy, at least its antisocial component, is distributed as a taxon, others have found that both major components of psychopathy-callousness/unemotionality and impulsivity/antisocial behavior-appear to distribute as dimensions and show little evidence of taxonicity. In the present study, recent advances in taxometric analysis were added to P. Meehl's (1995) multiple consistency tests strategy for assessing taxonicity, and they were applied to Psychopathy Checklist-Revised (R. D. Hare, 2003) ratings of 4,865 offenders sampled from multiple forensic settings. The results indicated that both the individual components of psychopathy and their interface are distributed dimensionally. Both the implications of these results for research in psychopathy and the integration of these findings with previous taxometric studies of psychopathy are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of comorbid psychopathy on criminal offending and emotion processing in male offenders with antisocial personality disorder.

Antisocial personality disorder (ASPD) and psychopathy are two syndromes with substantial construct validity. To clarify relations between these syndromes, the authors evaluated 3 possibilities: (a) that ASPD with psychopathy and ASPD without psychopathy reflect a common underlying pathophysiology; (b) that ASPD with psychopathy and ASPD without psychopathy identify 2 distinct syndromes, similar in some respects; and (c) that most correlates of ASPD reflect its comorbidity with psychopathy. Participants were 472 incarcerated European American men who met Diagnostic and Statistical Manual (4th ed., American Psychiatric Association, 1994) criteria for ASPD and Psychopathy Checklist criteria for psychopathy, who met the criteria for ASPD but not for psychopathy, or who did not meet diagnostic criteria for either ASPD or psychopathy (controls). Both individuals with ASPD only and those with ASPD and psychopathy were characterized by more criminal activity than were controls. In addition, ASPD with psychopathy was associated with more severe criminal behavior and weaker emotion facilitation than ASPD alone. Group differences in the association between emotion dysfunction and criminal behavior suggest tentatively that ASPD with and ASPD without prominent psychopathic features may be distinct syndromes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clarifying the role of defensive reactivity deficits in psychopathy and antisocial personality using startle reflex methodology.

Prior research has demonstrated deficits in defensive reactivity (indexed by potentiation of the startle blink reflex) in psychopathic individuals. However, the basis of this association remains unclear, as diagnostic criteria for psychopathy encompass two distinct phenotypic components that may reflect differing neurobiological mechanisms—an affective–interpersonal component and an antisocial deviance component. Likewise, the role of defensive response deficits in antisocial personality disorder (APD), a related but distinct syndrome, remains to be clarified. In the current study, the authors examined affective priming deficits in relation to factors of psychopathy and symptoms of APD using startle reflex methods in 108 adult male prisoners. Deficits in blink reflex potentiation during aversive picture viewing were found in relation to the affective–interpersonal (Factor 1) component of psychopathy, and to a lesser extent in relation to the antisocial deviance (Factor 2) component of psychopathy and symptoms of APD—but only as a function of their overlap with affective–interpersonal features of psychopathy. These findings provide clear evidence that deficits in defensive reactivity are linked specifically to the affective–interpersonal features of psychopathy and not to the antisocial deviance features represented most strongly in APD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Identifying persistently antisocial offenders using the Hare Psychopathy Checklist and DSM antisocial personality disorder criteria.

Early starting, lifetime criminal persistence has been called sociopathy, antisocial personality disorder, and psychopathy. There is, however, disagreement about its core features and which measure is best for identifying such individuals. In the 1st of 2 studies of male offenders (n = 74), we found a large association between scores on the Psychopathy Checklist-Revised (PCL-R; R. D. Hare, 1991) and the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV; American Psychiatric Association, 1994) antisocial personality disorder criteria scored as a scale. The second study (n = 684) replicated this finding and found that, as previously shown for PCL-R scores, a discrete class (or taxon) also underlies scores on items reflecting antisocial personality disorder. The high association among these sets of items and their similarity in predicting violence suggested that the same natural class underlies each. Results indicated that life-course-persistent antisociality can be assessed well by measures of psychopathy and antisocial personality disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A Taxometric Analysis of Psychopathic Personality.

Although a common assumption throughout much of the professional and popular literature is that psychopaths are qualitatively different from others, very few studies have examined the latent structure of psychopathy. Whether psychopathy is a discrete category or a continuous dimension may have implications for research on the assessment, etiology, and treatment of this disorder. This study examined the latent structure of psychopathy in a sample of 309 jail and prison inmates. Three taxometric procedures were used to analyze indicators drawn from the Psychopathic Personality Inventory (S. O. Lilienfeld & B. P. Andrews, 1996), a self-report instrument. Consistent with prior studies that used other measures of psychopathy, none of the analyses was consistent with a taxonic solution, suggesting that psychopathic personality may be best understood as existing on a continuum. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is criminal behavior a central component of psychopathy? Conceptual directions for resolving the debate.

The development of the Psychopathy Checklist—Revised (PCL–R; R. D. Hare, 2003) has fueled intense clinical interest in the construct of psychopathy. Unfortunately, a side effect of this interest has been conceptual confusion and, in particular, the conflating of measures with constructs. Indeed, the field is in danger of equating the PCL–R with the theoretical construct of psychopathy. A key point in the debate is whether criminal behavior is a central component, or mere downstream correlate, of psychopathy. In this article, the authors present conceptual directions for resolving this debate. First, factor analysis of PCL–R items in a theoretical vacuum cannot reveal the essence of psychopathy. Second, a myth about the PCL–R and its relation to violence must be examined to avoid the view that psychopathy is merely a violent variant of antisocial personality disorder. Third, a formal, iterative process between theory development and empirical validation must be adopted. Fundamentally, constructs and measures must be recognized as separate entities, and neither reified. Applying such principles to the current state of the field, the authors believe the evidence favors viewing criminal behavior as a correlate, not a component, of psychopathy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role and relevance of the Psychopathy Checklist-Revised in court: A case law survey of U.S. courts (1991-2004).

The Psychopathy Checklist-Revised (PCL-R; R. D. Hare, 1991, 2003) is the most empirically validated instrument for measuring psychopathy in correctional and forensic psychiatric populations. The PCL-R's predictive utility with criminal justice populations has led to its frequent use by clinicians conducting forensic assessments in criminal and sexually violent predator (SVP) cases. Despite its apparent wide acceptance in U.S. courts, little is known about how often the PCL-R is being introduced, the types of cases in which it is being used, and whether claims made in court regarding psychopathy are empirically defensible and/or relevant to the question at hand. This project documents some uses of the PCL-R in U.S. courts from 1991 through 2004 by year, jurisdiction, type of evaluation, and party. The results suggest that the PCL-R is being used by expert witnesses with increasing regularity across U.S. jurisdictions, primarily to assess risk of future violence. A review of 3 recent cases is also provided that illustrates concerns about the validity of the PCL-R for certain types of legal questions that may arise in criminal and SVP trials. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Alcohol and drug abuse-dependence disorders in psychopathic and nonpsychopathic criminal offenders.

Co-occurrence of psychopathy (assessed with the Revised Psychopathy Checklist [R. D. Hare, 1985]) and lifetime Diagnostic and Statistical Manual of Mental Disorders (DSM-III) alcohol and drug disorders (assessed with the Diagnostic Interview Schedule; National Institute of Mental Health) was examined in a sample of 360 male inmates. Consistent with previous research that used diagnoses of antisocial personality disorder, psychopaths were more likely than nonpsychopaths to have lifetime diagnoses of alcoholism, any drug disorder, and multiple drug disorder. The relation between substance abuse and the 2 factors of the Revised Psychopathy Checklist was also examined. Substance abuse was significantly related to general social deviance (Factor 2) but was unrelated to core personality features of psychopathy (Factor 1). Two possible models of psychopathy (unitary syndrome vs dual-diathesis model) are presented that may account for the association between psychopathy and substance abuse. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Child psychopathy and protective factors: IQ and motivation to change.

Psychopathy in children and adolescents has received increased attention over the past decade. Researchers have been particularly interested in identifying who tomorrow's chronic and serious offenders might be. In addition, researchers have been increasingly interested in determining the etiology of the disorder so as to inform treatment programs. Despite this interest, few studies to date have investigated the protective factors for psychopathy in youth. The current study investigated 140 adolescent boys and girls and the potential protective mechanisms of intelligence and motivation to change. Findings indicated that motivation to change served as a protective factor for general and violent offending at varying levels of psychopathy. Motivation to change also served as a compensatory factor for psychopathy when examining high rates of violent offending. These findings suggest that the cognitive factor of motivation to change may very well be critical in examining developmental pathways to offending in youth and a key consideration for those youth scoring high on psychopathy scales and considering violence as a means of gain. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Religiously integrated psychotherapy with Muslim clients: From research to practice.

In this paper, we attempt to translate empirical findings from a program of research that developed a Psychological Measure of Islamic Religiousness (PMIR) into practical clinical applications. The findings from this program of research are complemented and illuminated by findings from other empirical research and clinical work with Muslims. Our recommendations can be summarized as follows. First, clinicians should inquire directly about the place of religion in the lives of their Muslim clients. Second, mental health professionals should ask about what Islam means to their clients and educate themselves about basic Islamic beliefs and practices. Third, clinicians should help their Muslim clients draw on Islamic positive religious coping methods to deal with stressors. Fourth, we recommend that clinicians assess for religious struggles, normalize them, help clients find satisfying solutions to these struggles and, if appropriate, refer clients who struggle to a Muslim pastoral counselor or religious leader. Finally, in order to overcome stigma associated with mental health issues, mental health professionals should educate the Islamic public about psychology, psychopathology, and psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Kinds of patients

The basic goal of health outcomes research is to identify the kinds of patients who do (or do not) benefit substantially from specified medical or surgical treatments and procedures. Similarly, clinicians must determine whether particular patients are the kinds of patients who do (or do not) benefit from specified interventions. Such a kinds-based approach to clinical practice is often resisted, however, when physicians are asked to standardize their practices based on the results of health outcome data. In such settings, clinicians often assert that "every patient is unique". The present paper explores the coherence of this claim. In particular, I examine the applicability of the philosophical notion of natural kinds to a kinds-based approach to clinical research and practice. I conclude that the claim of patient uniqueness is misguided. Two key difficulties with a kinds-based approach are examined: the problems associated with (1) assigning single-case probabilities and (2) stereotyping and discrimination.     

One measure does not a construct make: Directions toward reinvigorating psychopathy research—reply to Hare and Neumann (2010).

In our article by J. L. Skeem & D. J. Cooke, (2010), we outlined the dangers inherent in conflating the Psychopathy Checklist—Revised (PCL–R; R. Hare, 1991) with psychopathy itself. In their response, R. Hare and C. Neumann (2010) seemed to agree with key points that the PCL–R should not be confused with psychopathy and that criminal behavior is not central to psychopathy; at the same time, they said we provided no clear directions for theory or research. In this rejoinder, we clarify our argument that progress in understanding the unobservable construct of psychopathy hinges upon setting aside procrustean dependence on a monofocal PCL–R lens to test (a) actual theories of psychopathy against articulated validation hierarchies and (b) the relation between psychopathy and crime. In specifying these conceptual and applied directions, we hope to promote constructive dialogue, further insights, and a new generation of research that better distinguishes between personality deviation and social deviance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)