A five-factor model perspective on psychopathy and comorbid Axis-II disorders in a forensic–psychiatric sample

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Abstract

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

Introduction

Psychopathy was the first personality disorder (PD) to be recognized in psychiatry and has a long historical and clinical tradition. During the last decade the validity of psychopathy has been supported by a growing body of research (Millon, Simonsen, & Birket-Smith, 1998) although the concept has not been officially recognized as a PD in the last three editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, DSM-III-R, DSM-IV; APA, 1980, APA, 1987, APA, 1994). Cleckley, 1941, Cleckley, 1964, Cleckley, 1988 was the first to describe the psychopathic individual as seemingly sane, intelligent, and competent, but clearly disordered. These individuals were said to wear ‘masks of sanity’. Other clinicians and researchers have described psychopathy consistently as a form of PD, characterized by traits such as lack of remorse, manipulativeness, egocentricity, superficial charm and shallow affect. Behaviorally, the psychopath is an impulsive risk-taker involved in a variety of criminal activities. Interpersonally, the psychopath has been described as grandiose, egocentric, manipulative, forceful and cold-hearted. Affectively, the psychopath displays shallow emotions, is unable to maintain close relationships, and lacks empathy, anxiety and remorse (Lynam & Gudonis, 2005).

Psychopathy is distinct from, but related to the more behaviorally based description of the Antisocial Personality Disorder (APD) described in DSM-IV (APA, 1994), consisting of ‘a pervasive pattern of disregard for and violation of the rights of others’. It is based almost solely on behavioral descriptors and is nearly synonymous with persistent criminal offending. The APD diagnosis reflects whether the subject has participated in a number of antisocial and criminal acts during childhood and adulthood.

In forensic populations the prevalence of APD is two or three times higher than the prevalence of psychopathy, as measured by the PCL-R. Empirically the relationship between both disorders is asymmetric: most offenders with a high PCL-R score meet the criteria for APD, but most of those diagnosed as having APD do not meet the PCL-R criteria of psychopathy (Hare & Neumann, 2006).

Many personality psychologists agree that general personality can be best described in terms of the dimensions of the Five-Factor Model (FFM; Costa and McCrae, 1992b, Digman, 1990, Widiger and Costa, 1994). The FFM had a strong appeal to personality psychologists because a series of studies demonstrated that virtually all personality constructs identified in major models of personality description could be represented within this FFM framework (Markon et al., 2005, O'Connor, 2002). The FFM provides a dimensional description of personality on five broad factors, these are Neuroticism, Extraversion, Openness to experience, Agreeableness, and Conscientiousness.

Recently several researchers (Miller et al., 2003, Miller and Lynam, 2003, Widiger and Lynam, 1998) have argued that psychopathy can be understood as a constellation of personality traits from this general model of personality functioning (FFM; McCrae & Costa, 1990). They claimed that the understanding of the relations between the basic dimensions of personality on one hand and psychopathy and APD / antisocial behavior on the other hand can make a substantial contribution to the field of criminology (Miller & Lynam, 2001). One benefit of this approach is its ability to resolve several important issues in the psychopathy literature, such as the underlying structure of the PCL-R (Hare and Neumann, 2005, Johansson et al., 2002, Vitacco et al., 2005) and the patterns of comorbidity surrounding psychopathy (Miller & Lynam, 2003). With regard to the factor structure of the PCL-R, the FFM description of psychopathy shows that the structure is related to different personality dimensions. A similar logic explains the comorbidity of psychopathy with other PDs; psychopathy will co-occur with other PDs to the extent that they share common FFM facets. Based on the facet overlap, psychopathy is expected to be highly comorbid with APD (Lynam & Widiger, 2001). Several studies have examined the associations between the FFM on the one hand and psychopathy (Lynam, 2002, Lynam and Widiger, 2001) and APD (Saulsman and Page, 2004, Widiger et al., 2002).

Saulsman and Page (2004) meta-analytically reviewed the relationships between the FFM domains and the 10 DSM-IV PDs. This meta-analysis showed that APD is characterized by little association with Neuroticism and negative relationships with Agreeableness and Conscientiousness. Widiger, Trull, Clarkin, Sanderson, and Costa (2002) described the hypothesized relations between the FFM facets and PD constructs, including APD, based on a review of the DSM-IV PD criteria. They predicted that a person diagnosed with APD scores high on Angry Hostility (N2) and Excitement Seeking (E5), low on Straightforwardness (A2), Altruism (A3), Compliance (A4), Tendermindedness (A6), Order (C2), Self-Discipline (C5) and Deliberation (C6). Concerning the prototypical psychopath, Miller et al. (2001) provided an expert-based description using the NEO-PI-R that was generated by 15 psychopathy experts. None of these experts were FFM theorists or researchers; they were selected on the basis of their work in the psychopathy domain. Miller et al. (2001) showed that there was a substantial agreement between this expert-based NEO-PI-R description and the preliminary FFM description of psychopathy proposed by Widiger and Lynam (1998). However there were also some points of disagreement, as the experts included facets that were not proposed by Widiger and Lynam, such as low Anxiety, Depression and Vulnerability. The fact that Widiger and Lynam restricted themselves to the description of psychopathy inherent in the PCL-R, whereas the experts did not have that restriction, is a possible explanation for these discrepancies (Miller et al., 2001). Despite the emphasis on low Anxiousness by Cleckley, 1941, Cleckley, 1988 in the initial description, the PCL-R has no explicit assessment of Anxiety. According to the description of Miller et al. (2001) the prototypical psychopath scores high on Angry Hostility (N2), Impulsiveness (N5), Assertiveness (E3) and Excitement Seeking (E5); and scores low on Anxiety (N1), Depression (N3), Self-Conscientiousness (N4), Vulnerability (N6), Warmth (E1), Trust (A1), Straightforwardness (A2), Altruism (A3), Compliance (A4), Modesty (A5), Tendermindedness (A6), Dutifulness (C3), Self-Discipline (C5) and Deliberation (C6). Both APD and Psychopathy are thus characterized by low scores on Agreeableness facets and Conscientiousness facets. There is also no prominent relationship between the Openness to experience facets and both disorders. However the FFM descriptions of psychopathy and APD show some discrepancies that concern mainly the facets of the Neuroticism and Extraversion domains. Considering the Neuroticism domain, the psychopath is characterized by low scores on Anxiety, Depression, Self-Consciousness, Vulnerability, and by high scores on Angry Hostility and Impulsiveness, whereas a person diagnosed with an APD only by high scores on Angry Hostility. Both the person diagnosed as having APD and the psychopath have high scores on Excitement Seeking, but a psychopath also scores low on Warmth and high on Assertiveness.

These associations between the FFM domains and facets, psychopathy and APD are mainly examined in non-clinical and student samples. However, the low prevalence rates of psychopathy and APD in the general population may result in range restriction, impacting upon the nature and the size of the correlations. Moreover, the majority of these studies have been conducted in North American samples, and to our knowledge there are no studies examining these FFM-psychopathy/APD relationships in European forensic populations.

The co-occurrence of one disorder, such as psychopathy, with another disorder is often described as comorbidity, which is the comorbid presence of two or more disorders. The term comorbidity refers to the co-occurrence of independent disorders, each with presumably its own, separate etiology, pathology and treatment implications (Feinstein, 1970). Comorbidity is an important phenomenon because it is rare that a psychiatric patient only meets criteria for just one mental disorder. It is also evident that the etiology, course, treatment, and outcome of a disorder are influenced heavily by the presence of comorbid conditions. Finally comorbidity has important and problematic influences on the conceptualization of mental disorders as distinct clinical conditions, posing serious challenges on the current nosological system and the validity of the diagnostic categories themselves (Widiger, 2006). A major question is whether the different disorders included in DSM-IV (APA, 1994) constitute distinct clinical entities (Mineka, Watson, & Clark, 1998).

As previously stated, the majority of the PCL-R psychopaths meet the criteria for APD. Correlations between the PCL-R scores and dimensional diagnoses of APD are usually high, with correlations ranging from .55 to .65 (Hart & Hare, 1989). Several studies however showed that psychopathy is not only highly comorbid with APD. Hart et al. (1994) demonstrated that PCL-R total scores correlate positively with Axis-II Cluster B disorders (the dramatic–erratic–emotional cluster) and negatively with Cluster C disorders (the anxious–fearful cluster). Hart and Hare (1989) investigated the associations between psychopathy and other mental disorders in 80 male forensic patients. They reported that PCL-R diagnoses were only significantly related to Antisocial and Histrionic PD, but at the dimensional level PCL-R ratings were positively correlated with Antisocial, Histrionic, and Narcissistic PDs and negatively correlated with ratings of Avoidant PD. Examining 167 male offenders, Blackburn and Coid (1998) found that psychopaths were more likely to meet criteria for Paranoid, Histrionic, Narcissistic and Borderline PDs and less likely to meet the Obsessive–compulsive PD criteria. Finally Hildebrand and de Ruiter (2004) reported similar associations in 98 male forensic psychiatric patients. At the categorical level, psychopathy was strongly and significantly associated with the diagnosis of APD and positive correlations were observed with dimensional scores of Antisocial, Paranoid, Borderline and Narcissistic PDs.

It can be concluded that psychopathy, as measured with the PCL-R is associated with several PDs, most clearly with Narcissistic, Histrionic, Borderline and Paranoid PDs, as well as with APD. Also at the descriptive level, the traits associated with psychopathy can be distinguished among the criteria for several PDs in addition to APD, particularly Histrionic (superficial charm, insincerity, egocentricity, manipulativeness), Narcissistic (grandiosity, lack of empathy, exploitiveness), Borderline (impulsivity, suicidal gestures), and Paranoid (mistrust) PDs (Blackburn & Coid, 1998). At the descriptive and the empirical level, Cleckey's psychopathy therefore seems to encompass more than one single category and it can be expected that there will be sizeable comorbidity with the aforementioned PDs in a forensic psychiatric sample. Given the fact that many researchers (Blackburn and Coid, 1998, Blackburn et al., 2003, Hart et al., 1994) reported negative associations with the Avoidant, Dependent, and Obsessive–compulsive PDs, we also expect a low prevalence of these PDs in this sample.

Section snippets

Aims of the study

The current study was designed to examine the associations between psychopathy and APD, and the FFM dimensions in a forensic psychiatric sample. For APD we based upon the hypothesized relations between PD constructs and the FFM facet traits proposed by Widiger et al. (2002). Concerning psychopathy we used the expert-based description at the facet level as proposed by Miller et al. (2001).

In a second objective we investigated the comorbidity of psychopathy and DSM-IV Axis-II disorders,

Setting

The study was conducted in a Dutch forensic psychiatric facility for the residential treatment of criminal offenders who are sentenced by court to involuntary commitment because they are considered irresponsible or diminished responsible for their acts due to a psychiatric condition. Dutch law uses the term ‘TBS’, which is disposal to be treated on behalf of the state or detention under a hospital order. The purpose of the Dutch TBS-order is to protect society from unacceptable high risks of

Procedure

Starting from October 2005 until November 2006, patients of the forensic psychiatric facility were assessed with a standardized psychological assessment battery, which was administered within the framework of the periodic evaluations on a yearly basis of the TBS patients. All patients were invited by the assessment psychologists to complete self-report FFM and PD inventories, and trained psychologists also rated the PCL-R (Hare, 1990) on the basis of an extensive interview and inspection of the

Base rate of PCL-R psychopathy

The mean total PCL-R score was 23.87 (S.D. = 8.72) with a range from 5 to 40 and a median score of 26. PCL-R scores were normally distributed (Shapiro–Wilk z = .96, p = .14). The mean of the aggressive narcissism scale was 9.53 (S.D. = 3.66) and the mean of impulsive/antisocial lifestyle scale was 11.19 (S.D. = 4.49). A cut-off of 25 was used to divide the patients into psychopathic and non-psychopathic groups. Forensic psychiatrists recommend using this lower diagnostic threshold because the PCL-R

Discussion

In a first objective the associations between psychopathy, APD symptoms and FFM facets were examined in a forensic–psychiatric sample. These associations have been mainly examined in non-clinical and especially student samples. The patients of this sample have committed one or more serious crimes but are considered irresponsible for their acts due to a severe psychiatric condition. Given the nature of their conviction and criminal offences, externalizing pathology can be expected to be highly

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