Psychopathic Personality: Analysis of the Concept

Psychopathic Personality:Analysis of the Concept John Callender University of Aberdeen

Acknowledgements Wellcome Trust NHS Grampian Endowments Prof. Eric Matthews

Philosophy and psychiatry • ‘...our essential, if not our only, business is to get a clear view of our concepts and their place in our lives’. P.F. Strawson

Psychopathy- a very brief history • Pinel - manie sans delirie • Henry Maudsley - “moral insanity” • Psychopathy Checklist – Revised (PCL-R) (Robert Hare) • Psychopathy as “one of the most important concepts to ever emerge in forensic psychology and law…” (Nicholls & Petrila (2005, 729).

Psychopathic personality • “Philosophy, as we use the word, is a fight against the fascination which forms of expression exert upon us.”Wittgenstein. The Blue Book

Psychopathic personality and the PCL-R Glibness/ Superficial charm; Grandiose sense of Self Worth; Need for Stimulation/ Proneness to Boredom; Pathological Lying; Conning/ Manipulative; Lack of Remorse or Guilt; Shallow affect; Callous/ Lack of Empathy; Parasitic Lifestyle; Poor Behavioral Controls; .Promiscuous Sexual Behavior; Early Behavioral Problems; Lack of Realistic, Long-Term Goals; Impulsivity; Irresponsibility; Failure to Accept Responsibility for Own Actions; Many Short-Term Marital Relationships; Juvenile Delinquency; Revocation of Conditional Release; Criminal Versatility

Psychopathic personality and the PCL-R Each item scored at 0, 1, or 2 Max. score 40, cut-off for diagnosis, 30 Instrumental violence, said to be “a cardinal feature of psychopathy” 15-25% of male and female incarcerated offenders 0.75% of general male population

PCL-R factor analysis. Factor I (callousness/ unemotionality) Comprised of items relating to glibness and superficial charm, a grandiose sense of self-worth, pathological lying, being conning or manipulative, shallow affect, callousness and lack of empathy, failure to accept responsibility and an incapacity for remorse or guilt. In summary it relates to emotional life and the quality of interpersonal relationships and indicates a history of selfish, callous and remorseless use of other people.

PCL-R factor analysis. Factor II (impulsivity/ antisocial behaviour) Scores impulsive and antisocial behaviour and is comprised of items that indicate need for stimulation and proneness to boredom, a parasitic lifestyle, poor behavioural controls, early behavioural problems, impulsivity, irresponsibility, juvenile delinquency and a history of revocation of conditional release. (Similar to DSM-IV ASPD)

Taxon or dimension? Taxon. A nonarbitrary, latent entity or class. Should entail the demonstration of a distinct pathology and aetiology or causal structure. Dimensional model. Psychopathic personality exists on a dimension or dimensions that are continuous with normal personality and there is no non-arbitrary boundary between the normal and the abnormal

Taxon or dimension? Guay et al, 2007 Full PCL-R scores were obtained on 2300 offenders, whose average age was 31. Study examined total scores and scores on the two factors of callousness/ unemotionality and impulsivity/ antisocial behaviour.

Taxon or dimension? No analysis yielded results consistent with a taxonic structure. Latent structure of psychopathy and its underlying factors have a dimensional distribution. Conclude that someone might be described as scoring highly on measures of psychopathy but not as a “psychopath”.

Unitary entity? “Multi-faceted” entity (blue-eyed blondes) different components covary because of the influence of a common, underlying causal factor “Compound” entity (tall blondes) composite of separable and independent lower-order traits.

Unitary entity? Two psychopathy factors derived from the PCL-R show differing relations with external measures Distinct personality clusters within group of PCL-R-defined psychopaths Psychopathy as assessed by Psychopathic Personality Inventory (PPI). Two underlying factors show no co-variance

Predictive Validity High scores on the PCL-R predict future recidivism, violence and poor response to treatment (in the same way as high blood pressure predicts stroke and heart disease?) Circularity. Factor II relates largely to antisocial acts (behaviour predicts behaviour). Factor I, callousness, lack of empathy etc. High score on the scale is achieved if a person has already exhibited the behaviours that the scale purports to predict

Individual prediction Predictive validity for large groups does not imply predictive utility at the level of the individual patient Confidence interval (usually 95% percent) indicates precision with which a parameter is known by describing the range (or interval) within which it lies in accordance with a given probability (or confidence). CI varies with size of sample

Individual prediction (Hart et al 2007) Suppose that Dealer, from an ordinary deck of cards, deals one to Player. If the card is a diamond, Player loses; but if the card is one of the other three suits, Player wins. After each deal, Dealer replaces the card and shuffles the deck. Player wins 75% of time, loses 25%

Individual prediction 95% CI of winning 10000 deals - 74-76% 1000 deals - 72-78% 100 deals - 66-82% Single deal - 12-99% Measures that provide estimates of population risk (e.g. for suicide or violence) do not provide useful information at the level of an individual Assumes an ideal scale - reality is even worse!

Individual prediction Hart et al (2007) Assessed the ability of two Actuarial Risk Assessment Instruments (ARAIs), the Violence Risk Appraisal Guide (VRAG) and the Static-99, to assess risk at the level of the individual person. (One component of the VRAG is the PCL-R).

Individual prediction VRAG the mean 95% CI for a single person had a width of 85 percentage points. Static-99 revealed a 95% CI width of 86 percentage points at the level of the individual. 95% CIs for scores within each risk category overlapped almost completely with the others “At the individual level, the margins of error were so high as to render the test results virtually meaningless” (ibid. s63).

Construct Validity Cooke et al (2007) Two approaches to the identification of a clinical construct, the “bottom up” and the “top down”. Bottom up approach, one examines a large number of traits in order to obtain a broad and systematic representation of the area of interest. Top down approach, one begins with a more restricted set of traits that are derived from an already-established conceptualisation of the disorder

Construct Validity PCL-R has “operationalized” the concept of psychopathy Cooke et al (2007) argue that the PCL-R conflates operational definition with measurement.

Construct Validity There is one thing of which one can say neither that it is one metre long, nor that it is not one metre long, and that is the standard metre in Paris. – But this is, of course, not to ascribe any extraordinary property to it, but only to remark its peculiar role in the language-game of measuring with a metre-rule. – Let us imagine samples of colour being preserved in Paris like the standard metre. We define: “sepia” means the colour of the standard sepia which is there kept hermetically sealed. Then it will make no sense to say of this sample either that it is of this colour or that it is not. Wittgenstein. Philosophical Investigations

Construct Validity A language-game is comprised of “language and the actions into which it is woven” In the language-game of psychopathy, the PCL-R plays a similar role to the standard metre or standard sepia. The means of measurement contains the definition of what is measured.

Reliability Standard error of measurement (standard deviation of observed scores if the true score is held constant). SEM of PCL-R is 3.0 for single assessments (Hare and Neumann 2006, 66), i.e. if 100 raters assess the same subject at the same time, 68 of the scores would fall within the range of the average total score plus or minus 3.0.

Reliability SEM important if scores are close to cut-off Case reports of trial experts producing disparate scores on either side of cut-off

Psychopathy and court disposal Diagnosis of psychopathy can be an “aggravating factor” in sentencing “Thus, emphasis on protection of the public by confinement of the offender, most frequently employed in the case of the psychopathic or sociopathic offender, tends to lengthen the sentence considerably”Volume 1 of the Canadian Sentencing Digest PCL-R and parole eligibility

Psychopathy and court disposal Death penalty in the U.S.A One factor that is considered is whether the defendant would present “a continuing threat to society” if the death penalty were not applied. “Society” in this criterion includes the prison population

DANGEROUS SEVERE PERSONALITY DISORDER • Michael Stone convicted in October 1998 of the murders of Lyn and Megan Russell, and attempted murder of Josie • ‘Quite extraordinarily for a medical profession, the psychiatric profession has said that it will take on only patients whom it regards as treatable...It is time that the psychiatric profession seriously examined its own practices and tried to modernise them in a way that it has so far failed to do’. Jack Straw, 26 October, 2000

DANGEROUS SEVERE PERSONALITY DISORDER Consultation document was published in 1999 (Home Office, 1999). This stated that there are an estimated 2000 persons in England and Wales with personality disorders whose nature and severity are such as to represent a serious risk to the safety of others. Of these 98% are men. At any one time, most of these persons are incarcerated in prisons and secure hospitals.

DANGEROUS SEVERE PERSONALITY DISORDER Some people used to be thought extremely wicked: today they are classified as cases of mental disorder. Paradoxically, this has the effect that, if you are consistently (in old-fashioned language) wicked enough, you may hope to be excused from responsibility for your misdeeds; but if your wickedness is only moderate, or if you show occasional signs of repentance or reform, then you must expect to take the blame for what you do and perhaps also be punished for it. Wootton, 1959

DSPD- ELIGIBILITY CRITERIA The prisoner is at substantial risk of committing an offence likely to cause serious harm (physical or psychological) to another person He shows a “general disorder of personality” and The risk presented appears to be functionally linked to the personality disorder.

DSPD- DEFINITION PCL-R score of 30 or more (or SV equivalent) or PCL-R score of between 25 and 29 (or SV equivalent) and at least one personality disorder diagnosis using DSM IV or ICD 10 other than anti-social personality disorder or Two personality disorder diagnoses, one of which is anti-social personality disorder (or equivalent using ICD-10 or DSM IV)

DSPD- DEFINITION More likely than not to commit an offence within five years that might be expected to lead to serious physical or psychological harm from which the victim would find it difficult or impossible to recover; The risk presented appears to be functionally linked to the significant personality disorder

DSPD- DEFINITION “…the novel nature of the disorder [DSPD], previously unrecognised in the psychiatric literature…” May include people who do not meet criteria for either psychopathy or antisocial personality disorder

DSPD- PROBLEMS Validity of diagnosis Eligibility (includes ability to estimate future risk and to make link between this and the presence of personality disorder) Reliability:“...the margin for error in assessments was unacceptably high unless there was independent corroboration of the data". Prediction of recidivism

DSPD- PROBLEMS • Four pilot sites, two in prisons, two in special hospitals • Programme has failed in all of its main outcome measures • Cost to date £488m

Personality disorder and mental disorder The European Convention on Human Rights was incorporated into U.K. legislation by the Human Rights Act 1998. This prohibits the detention of anyone who has not been convicted by a competent court unless they are “of unsound mind…” To justify the detention of someone with a personality disorder it is necessary to argue that abnormality of personality of this type is a mental disorder and therefore falls within the category of “unsound mind”.

Personality disorder and mental disorder “Although it is difficult to provide irrefutable arguments that personality disorders are mental disorders, it is equally difficult to argue with conviction that they are not. The fact that they have been included in the two most influential and widely used classifications of mental disorders (the ICD and the DSM) for the past half century is difficult to disregard…”(Kendell, 2002)

Personality disorder and mental disorder “…the evident disturbance of part-functions as well as of general efficiency…Deviant, maladapted, non-conformist behaviour is pathological if it is accompanied by a manifest disturbance of some such functions. It is true…that functions are an artificial construct, and that disorder in any particular function will be commonly accompanied by less conspicuous disorder in many other functions – just as in the body. But for illness to be inferred, disorder of function must be detectable at a discreet or differentiated level that is hardly conceivable when mental activity as a whole is taken as the irreducible datum. If non-conformity can be detected only in total behaviour, while all the particular psychological functions seem unimpaired, health will be presumed, not illness.”Aubrey Lewis (1953)

Link between mental disorder and antisocial behaviour The psychopath “is, in fact, par excellence, and without shame or qualification, the model of the circular process by which mental abnormality is inferred from antisocial behaviour while antisocial behaviour is explained by mental abnormality”. And “…the illness is the behaviour for which it is also the excuse”. Barbara Wootton

Disturbance of “part-functions” Amygdala-VMPFC dysfunction (Blair, 2005) impaired inhibition of violence impaired limbic-prefrontal response to aversive conditioning low frustration tolerance limited “reinforcement expectancies”

Disturbance of “part-functions” Genetic studies heritability of “callous-unemotional” personality traits Neurochemistry serotonin underactivity and impulsivity

Psychopathy - conclusions Dimensional concept - distinction from normality is arbitrary Doubtful construct and predictive validity Social and moral value-judgment May not be a unitary entity No predictive value at the individual level Inadequate reliability Harmful to those so labelled

Psychopathy - conclusions Need to focus research on discrete abnormalities of cognitive and emotional function Rehabilitation, reform, therapy based on delineation of such abnormalities Focus on interaction between innate traits of personality and social environment Focus on reduction of recidivism

Psychopathy - conclusions • “Psychopathy designates not a species of predator out there in the world, but a label, which is as much about the internal fears of the polite as any aspect of the external reality”. (Mullen, 2007) • “…the whole wretched notion of psychopathy. To retain the concept is morally insane; death to it”. (Cavadino, 1998)

Reference • Callender, J.S. (2010). Psychopathic personality disorder. In Free Will and Responsibility. A Guide for Practitioners. Oxford: Oxford University Press.

Psychopathic Personality: Analysis of the Concept