PCL-R psychopathy and its relation to DSM-IV Axis I and II disorders in a sample of male forensic psychiatric patients in the Netherlands
Introduction
Psychopathy was the first personality disorder to be recognized in psychiatry. According to Schneider (1923), a German psychiatrist, the term psychopathy referred to a variety of personality disorders (psychopathic personalities [PDs]) as extreme variants of normal personality. It has been given many different labels (Hare, 1991) such as psychopathic inferiority, character deficiency, moral insanity, and manipulative personality. The current interest in the disorder is (at least partly) attributable to the development of the Hare Psychopathy Checklist-Revised (PCL-R; Hare, 1991, Hare et al., 1990) and the abundance of empirical research it has generated over the past two decades. PCL-R items are personality traits and behaviors, which are scored on a 3-point scale (2=the item definitely applies to the participant, 1=the item applies to a certain extent, 0=the item does not apply to the participant), yielding a maximum total of 40. A score of 30 or more is recommended by Hare (1991) to identify the prototypical psychopath. PCL-R items define two correlated oblique factors, Factor 1 (callous and remorseless style of relating to other people), primarily at high levels of the construct, and Factor 2 (unstable, socially deviant lifestyle) at low levels of the construct (Cooke & Michie, 1997). Recently, however, Cooke and Michie (2001), using confirmatory factor analysis, identified distinct interpersonal, affective, and behavioral factors of which the measurement is uncontaminated by items reflecting antisocial behavior.
Evidence gathered in the last decade demonstrates that the PCL-R scale is highly reliable when used with trained and experienced raters. Studies in a variety of countries have typically obtained intraclass correlations (ICCs) >.80 for a single rater. Internal consistency (alpha coefficients >.80; mean interitem correlations >.22) is also high. Considerable evidence has accrued attesting to the construct-related validity of the PCL-R. In several (mostly North American) studies Hart & Hare, 1989, Hemphill et al., 1994, Schroeder et al., 1983, Smith & Newman, 1990, an expected pattern of relations with clinical assessments of DSM-III-R Axis I and II disorders American Psychiatric Association, 1980, American Psychiatric Association, 1987 is reported, the interpretation of which is greatly clarified by an analysis of the two-factor structure of the PCL-R (Hart & Hare, 1997). In addition, there is increasing evidence that PCL-R scores are related, in appropriate ways, to so-called psychopathy-related self-report scales, as well as to a variety of behavioral variables Bodholt et al., 2000, Hare, 1991, Hart & Hare, 1997.
The most common finding in studies that have examined the association between PCL-R psychopathy and DSM-III-R Axis I mental disorders is that a diagnosis of PCL-R psychopathy is rarely significantly associated with individual Axis I pathology other than substance-use disorders Hart & Hare, 1989, Nedopil et al., 1998, Rice & Harris, 1995, Stålenheim & von Knorring, 1996. Hart and Hare (1989), for example, reported that patients with a diagnosis of PCL-R psychopathy (total score ≥30) were nine times less likely to receive any Axis I principal diagnosis than were other patients. However, moderate to strong associations between the PCL-R total and Factor 2 scores and substance-related disorders, and weak relationships between Factor 1 scores and substance abuse were found Hart & Hare, 1989, Rutherford et al., 2000. Smith and Newman (1990) assessed substance-use disorder with a structured interview in 360 male prison inmates. Analyses revealed that PCL-R psychopathy was significantly associated with both alcohol and drug abuse/dependence disorders. Other studies Hart et al., 1992, Hemphill et al., 1994 also found significant correlations between PCL/PCL-R scores and drug abuse/dependence diagnoses; however, correlations with alcohol abuse/dependence diagnoses were not significant. Similar associations were found in European samples of prisoners and forensic psychiatric patients Andersen et al., 1999, Stålenheim & von Knorring, 1996.
With regard to the association with PDs, the majority of PCL-R psychopaths meet the criteria for antisocial PD, whereas a large proportion of participants with the antisocial PD diagnosis do not meet the PCL-R criteria for psychopathy Hart & Hare, 1989, Stålenheim & von Knorring, 1996. The correlation between PCL-R scores and (dimensional) diagnoses of antisocial PD is usually quite high, that is, r=.55 to .65 (Hart & Hare, 1989). The prevalence rates of (PCL-R) psychopathy among samples of forensic participants (15–30%), however, are much lower than those for the DSM diagnosis of antisocial PD (50–80%; Hare, 1985, Hart et al., 1994). Results further indicate that the PCL-R score correlates positively with DSM-III-R Axis II Cluster B disorders (“dramatic–erratic–emotional”) and negatively with Cluster C personality, the “anxious–fearful” cluster (Hart & Hare, 1985; Hart et al., 1994). Rutherford, Alterman, Cacciola, and McKay (1997), for example, found strong and significant correlations between the PCL-R total score and the number of symptoms of DSM-III-R APD, borderline, narcissistic, and histrionic PD in a sample of 250 male methadone patients. Hart and Hare (1989) reported positive correlations between PCL-R total scores and categorical diagnoses of DSM-III antisocial and histrionic PD in a sample of 80 North American men remanded by the courts for inpatient assessment of competency to stand trial. PCL-R Factor 1 scores were negatively correlated with the prototypicality ratings of avoidant and dependent PD. A diagnosis of psychopathy was significantly associated with only one DSM-III Axis II disorder, namely, APD (odds ratio=11.32). Finally, examining 61 Swedish male forensic psychiatric patients, Stålenheim and von Knorring (1996) found that PCL-R-defined psychopathy was strongly associated with the presence of Cluster B disorders (t=7.89, P<.0001) and a diagnosis of antisocial personality disorder (χ2=27.9, P<.001) according to DSM-III-R criteria.
To summarize, previous work has generally supported the construct validity of Hare's PCL-R in relation to assessments of DSM-III-R Axis I and II disorders, based on semistructured interviews. Most of this work, however, has involved North American criminal and forensic samples. We do not know whether the findings reported are generalizable to European forensic psychiatric samples. In addition, to the best of our knowledge, no study has been published that systematically examined the association between PCL-R psychopathy and DSM-IV Axis I and II disorders (American Psychiatric Association, 1994).
Section snippets
Aim of this study
The current study was designed to examine the association between PCL-R scores and (a) assessments of DSM-IV Axis I disorders and (b) diagnoses of DSM-III-R/DSM-IV Axis II disorders, made on the basis of a semistructured interview, the preferred method of assessment in personality disorder research Loranger, 1992, Zimmerman, 1994, in a sample of forensic psychiatric patients. On the basis of earlier findings, we expected PCL-R scores to be negatively correlated with individual Axis I disorders,
Setting
The study was conducted in the Dr. Henri van der Hoeven Kliniek, a Dutch forensic psychiatric facility for the residential treatment of criminal offenders who are sentenced by the court to involuntary commitment because of diminished responsibility for the crimes they committed. In terms of legal status, the patients are sentenced by the court to a maatregel van terbeschikkingstelling (TBS-order). The purpose of the Dutch TBS-order is to protect the society from unacceptably high risks of
Procedure
Since January 1996, newly admitted patients were assessed upon admission (T0; baseline assessment) with a standardized psychological assessment battery. PCL-R psychopathy assessment was implemented in November 1997. To provide information on treatment progress, all patients in our hospital are retested 18–24 months (T1; Follow-up 1) and again 42 months after admission (T2; Follow-up 2). At baseline, PCL-R and SIDP-R/SIDP-IV interviews were administered to assess PCL-R psychopathy and Axis II
Base rate of PCL-R psychopathy
Fig. 1 presents the distribution of PCL-R psychopathy scores in the sample. The mean total PCL-R score (adjusted sum) was 21.4 (S.D.=8.4), with a range from 3 to 38, a median score of 21.1, and a mode of 17. The kurtosis of the PCL-R total score was −.753 (S.E.=−.244). PCL-R scores were normally distributed (Kolmogorov–Smirnov Z=.594, P=.872). The mean Factor 1 score was 9.3 (S.D.=3.8) and the mean Factor 2 score was also 9.3 (S.D.=5.0). When a cutoff point of 30, designated by Hare (1991), was
Discussion
In general, a high prevalence of lifetime DSM-IV Axis I psychiatric morbidity was found in the study sample. Almost 88% of the sample met criteria for at least one Axis I disorder, including any alcohol- or substance-related disorder. The finding that substance-use disorders were the most prevalent type of disorder is consistent with most other studies with forensic participants Hart & Hare, 1989, Stålenheim & von Knorring, 1996, Timmerman & Emmelkamp, 2001. However, only 5% of our patients
Acknowledgements
The authors are grateful to Cécile Vandeputte-van de Vijver and Daan van Beek, who aided in establishing DSM-IV Axis I diagnoses. We also gratefully acknowledge the assistance of Ellen van den Broek, Henriëtte van der Maeden, Cécile Vandeputte-van de Vijver, Vivienne de Vogel, Anke Weenink, Pascalle van der Wolf, Pascal Wolters, and Stefan Zwartjes, who, in addition to the authors, participated as interviewers/raters. Finally, we would like to thank Robert D. Hare and an anonymous reviewer for
References (51)
- et al.
The prevalence of major mental disorders among homicide offenders
International Journal of Law and Psychiatry
(1992) - et al.
The Swedish forensic concept of severe mental disorder as related to personality disorders
International Journal of Law and Psychiatry
(1996) - et al.
Personality disorders, psychopathy, and crime in a Norwegian prison population
International Journal of Law and Psychiatry
(1999) - et al.
Psychopathy, schizophrenia, alcohol abuse, and violent recidivism
International Journal of Law and Psychiatry
(1995) - et al.
Validity of the Psychopathy Checklist—Revised in male methadone patients
Drug and Alcohol Dependence
(1997) Diagnostic and statistical manual of mental disorders
(1980)Diagnostic and statistical manual of mental disorders
(1987)Diagnostic and statistical manual of mental disorders
(1994)- et al.
Psychopathy and psychopathological profiles in prisoners on remand
Acta Psychiatrica Scandinavica
(1999) Psychopathy and personality disorder: Implications of interpersonal theory
Prevalence of personality disorders in a special hospital population
Journal of Forensic Psychiatry
Assessing psychopathy in adults: The psychopathy checklist—Revised and screening version
DSM-III diagnosis in criminal psychopaths: A way forward
Criminal Behaviour and Mental Health
Psychopathy across cultures
An item response theory evaluation of Hare's psychopathy checklist—Revised
Psychological Assessment
Refining the construct of psychopathy: Towards a hierarchical model
Psychological Assessment
Gestructureerd Interview voor de DSM-IV Persoonlijkheidsstoornissen
Personality disorders in a Dutch forensic psychiatric sample: Convergence of interview and self-report measures
Journal of Personality Disorders
The dual nature of forensic psychiatric practice: Risk assessment and management under the Dutch TBS-order
Offenders with major affective disorders
Statistical methods for rates and proportions
The logistic regression analysis of psychiatric data
Journal of Psychiatric Research
Reliability of file-based retrospective ratings of psychopathy with the PCL-R
Journal of Personality Assessment
A comparison of procedures for the assessment of psychopathy
Journal of Consulting and Clinical Psychology
The Hare psychopathy checklist—Revised
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