The concept of psychopathy has undergone more study and refinement in the past 20 years than in the previous 200, and the arc of this research is itself a study in the progress of modern social science. As no fewer than four chapters in the Handbook of Psychopathy (edited by Christopher J. Patrick) point out, the concept was first identified and discussed in scientific literature in the 1800s, with Philippe Pinel's designation in 1801 of manie sans délire (roughly, “insanity without delirium”) being a popular citation for the first formal description of what we now refer to as psychopathy. The disorder has had many labels and many theories since then, with some writers considering it to be an impairment of affect but not reason (Pinel), or moral depravity (Benjamin Rush, 1812), or congenital defects resulting in moral insanity and degeneration (Emil Kraepelin, 1893–1915). Birnbaum (1909) introduced the term “sociopathic” to emphasize the contribution of societal forces to antisocial and delinquent behavior, a well-intentioned effort that set up the confusing interchange of “psychopathy,” “sociopathy,” and “dissocial behavior” through much of the 20th century.
In 1941, Hervey Cleckley's Mask of Sanity was published; in it he theorized that psychopathy was actually a form of “semantic dementia” in which there was an impairment in the appreciation of the emotional meaning of things in the world and a corresponding lack of appreciation for the emotional experience of others (see Ronald Blackburn's Chapter 3 in the Handbook for an excellent, well-organized review of various theoretical views of psychopathy). The description of antisocial personality in the DSM-II (1968) was roughly similar to Cleckley's description of the psychopath, but this description did not lend itself to reliable diagnoses across clinicians. Lee Robins had published her study in 1966 from the records of people treated at a mental health clinic in St. Louis over a span of 30 years, allowing for a truly longitudinal view of antisocial and delinquent characteristics. She developed a set of very behavioral criteria for antisocial personality disorder, 10 of which were combined with criteria developed by Feighner and colleagues (1972, in the Archives of General Psychiatry). The Feighner criteria were the basis for the Research and Diagnostic Criteria (1978, also in the Archives), which in turn became the basis for the much more behaviorally oriented DSM criteria for Antisocial Personality Disorder (see Chapter 8 by Thomas Widiger for a thorough discussion of the relationship between psychopathy as currently conceived and the DSM diagnosis of APD).
As Patrick points out in his Chapter 31, the final chapter, Cleckley's goal was to influence professionals to be more precise in their use of the concept of psychopathy, but the tendency for different writers to use different definitions and labels persisted. By 1988, Blackburn wrote (in the British Journal of Psychiatry) that the concept as commonly used in the profession was little more than a moral judgment masquerading as a clinical diagnosis and that the concept should be discarded due to a lack of demonstrable scientific or clinical utility. Even as he wrote, however, things were evolving in western Canada where Robert Hare and his colleagues had been working since 1980 to define psychopathy in operational terms, an effort that would change the fortunes of the concept of psychopathy dramatically.
Cleckley's semantic dementia idea didn't catch on (though Hare and colleagues did have some interesting experimental data on the emotional versus the non-emotional word; see Chapters 3 (Blackburn) and 17 (Hiatt and Newman)), but what did catch on was his vivid descriptions of individual real-life characters (in the fullest sense of the word) and Cleckley's idea of developing a list of 16 common characteristics of psychopaths. This list was picked up by Hare and colleagues working with the prison population in Canada. Trained originally in psychophysiology and experimental psychology, Hare was interested in making psychopathy measurable. He began by having clinicians and researchers familiarize themselves with the Cleckley characteristics and then rate prison inmates on a seven-point scale. Initial reliabilities were good, but different raters may well have been coming to the same rating using different criteria. So a list of 100 characteristics were generated and then used for ratings, with the items showing the best psychometics being kept and the “weaker” items thrown out. The process was repeated until 22 items were left, which were published as the original Psychopathy Checklist (PCL) in 1980. The PCL was revised to 20 items, with additional validation data, and published as the PCL-R in 1991. Not all of Cleckley's items made it into the PCL-R, and several items not mentioned by Cleckley were added.
This is where the story of psychopathy becomes the science of psychopathy. The PCL-R provided a measure of psychopathy that was quickly found to be reliable and related to other constructs in exactly the right way—increased risk of re-offense and poor response to treatment being the most obvious trends. The underlying concept is the now-familiar glib, remorseless, irresponsible manipulator who is constantly in trouble despite himself, with the two subfactors (Factor 1: selfish, callous, and remorseless use of others; Factor 2: chronically unstable and antisocial lifestyle/social deviance). It is indisputably the publication of the PCL-R that allowed for the subsequent explosion of psychopathy research. Although other methods for measuring psychopathy have always existed, and more are being developed constantly (e.g., Chapter 6 on self-report measures [Lillianfield and Fowler] and Chapter 7 on psychopathy in other personality measures [Lynam and Derefinko]), the PCL-R is often referred to as the gold standard for measuring psychopathy. Chapter 22 (Sullivan and Kosson) in the Handbook, about the occurrence of psychopathy across cultures and ethnicities, is in fact a review of the pattern of measurement with the PCL-R across cultures and ethnicities.
It is this historical background and recent explosion of research that is captured in the Handbook of Psychopathy. Editor Christopher Patrick, himself a well-published researcher in the area of affect in psychopathy, has collected contributions from the leading researchers in a broad array of topical areas, resulting in a comprehensive and well-organized source book for the current state of the science of psychopathy. It is a well-timed volume, given the amount of research done in just the past 20 years, summarizing the progress in various areas of inquiry, and the resultant compilation shows greater advances in some areas than in others. Throughout, the emphasis is on empirical findings in each domain.
Patrick has organized the chapters into five areas of inquiry (plus his concluding chapter, the only one in the “Conclusions and Future Directions” section). Space limitations preclude a review of each of the 31 chapters, but a few deserve special comment. The first section, “Theoretical and Empirical Foundations,” begins with David Lykken's sweeping conceptual review, which reads more like commentary (and is one of the most purely enjoyable chapters) and includes Blackburn's systematic review of various models in Chapter 3, which reads like a textbook and is the chapter most likely to be assigned in graduate classes for the “History of…” portion of the syllabus.
The second section, “Issues in Conceptualization and Assessment” contains the view of psychopathy from the field of personality research in general (see Chapter 7 by Lynam and Derefinko, Chapter 9 by Poythress and Skeem, and Chapter 10 by Krueger) which is a very different theoretical perspective than that of most forensic mental health practitioners. The material is very interesting, in an academic, research-oriented way.
“Etiological Mechanisms” (Section III) is often a tricky area for the topic of psychopathy, since there is almost certainly more than one road leading to psychopathy, and the ultimate answer to the question “What causes this?” is, frankly, “We don't really know.” A common limitation on studies concerning family background, genetics, neurochemistry, and brain imaging is that much of the work is done in relation to antisocial or violent behavior in general and not to psychopathy or its various factors in particular. There are some tantalizing early results, however, that are well-presented and thoroughly discussed in these chapters. It is also in this section that the research on the patterns of performance in learning experiments and cognitive tests are compiled (Chapters 15 [Blair], 16 [Rogers], and 17 [Hiatt and Newman]), material absolutely crucial to the clinician who wants a comprehensive understanding of how the psychopath functions (or fails to function) in the world.
Section IV, “Special Populations,” includes chapters on the concept of the “successful” psychopath, psychopathy across cultures and ethnicities, child and adolescent issues, and the area that is likely to be the Next Big Thing in psychopathy, which is psychopathy in the female population. One particular area of interest, as Verona and Vitale discuss in Chapter 21, is whether psychopathy may manifest itself differently in females than in males, which of course raises larger questions about the construct itself.
Section V, “Clinical and Applied Issues,” is likely to be of greatest interest to the forensic mental health practitioner. The research in these areas is particularly rich, and the authors provide excellent summaries, critiques, and discussion. There are chapters mapping the findings on psychopathy and the crucial areas of violence (Porter and Woodworth, Chapter 24) and criminal recidivism (Douglas, Vincent, and Edens, Chapter 27) which describe the strengths and the limitations of measures like the PCL-R for risk assessment. Edens and Petrila's Chapter 29 on legalities and ethics offers the guideline of three “broad domains” in which the assessment of psychopathy may be considered relevant: risk assessment, mental or behavioral abnormality, and treatment amenability (p 578). They also caution against the tendency to consider psychopaths “untreatable,” although the two chapters in this section addressing treatment specifically (Chapter 28 by Harris and Rice and Chapter 30 by Seto and Quinsey) point out the failure of traditional psychotherapeutic approaches in studies with psychopaths and raise the topic that every clinician working with this population must consider: the role of external monitoring and environmental controls to minimize the potential adverse impact of severe psychopaths on society. These chapters successfully take the discussion beyond the simple question of treatability to those of specific roadblocks to treatment.
Like any scientific domain robust enough to produce the amount of research in the wide variety of areas in which psychopathy has been studied, there are also controversies, and the Handbook does not dodge them. Randall Salekin (Chapter 20), for instance, addresses the concerns over attempts to measure psychopathy in children and adolescent populations, while also presenting the relevant research on the topic.
Generating greater heat (with some potential for generating light on the subject) is the question of what second-order factors go together to make up the superordinate construct of psychopathy. Hare's PCL-R consisted of the two familiar factors (described above), and in the latest revision, those two factors are broken down into two smaller “facets”: Factor 1: interpersonal + affective facets; and Factor 2: deviant lifestyle + antisocial facets. Cooke and colleagues (2004, in the Journal of Personality Disorders) have challenged this conception, suggesting that antisocial behavior is more properly conceived of as a consequence of psychopathy (the “consequence hypothesis,” p 97, Chapter 5 in the Handbook) rather than as a factor of the construct itself. They argued for a three-factor model of psychopathy, essentially including Hare's first three facets. The two views are presented side-by-side in the Handbook in Hare and Neumann's Chapter 4 and Cooke and colleagues' Chapter 5. The heat being generated in the controversy is reflected in these chapters' footnotes. Each chapter notes that the authors of the other chapter declined to share details of their chapters before publication. This controversy is not, however, a paradigm-threatening one, but more of a paradigm-tweaking one. While views of the theoretical construct are likely to expand, the place of the Psychopathy Checklist in the identification of a particularly troublesome sort of offender is safe.
Patrick's Handbook of Psychopathy is a thorough and comprehensive compilation of the findings of research on psychopathy that have emerged after the recent 20- to 25-year burst of work on the topic. The focus is on empirical findings with just enough historic background to set the context for the more recent trends in research. Psychodynamic views, for instance, are relegated to passing mention in discussion of diagnostics. Methodological approaches to the assessment and investigation of psychopathy and measurable results are in the forefront. The forensic mental health practitioner now has a compendium of the current state of the science of psychopathy.
- American Academy of Psychiatry and the Law
