Psychopath vs. Antisocial Personality Disorder and Sociopathy

Discussion Excerpts: Robert Hare

"When I was working on my Ph.D.," Hare recalls, "I was interested in the effects of punishment on human behavior.  My dissertation looked at the frequency, intensity, duration, and delay effects of punishment.  Of course, I needed to start thinking about people who were resistant to the effects of punishment, so I started reading up on the psychopath.  Hardly any empirical research on psychopathy was going on, so I started to publish some of my own results in 1965."

That led to an opportunity.  At John Wiley & Sons, Inc., Brendan Maher was putting together a series of books on behavior pathology.  He was impressed with Hare's work and asked him to write one of the books, so in 1970, Hare published Psychopathy: Theory and Research, which set forth some ideas that would guide much of the research on psychopaths over the next two decades.  Just the year before, he had received a large grant from the Canadian Mental Health Association, and this provided funds to increase his research efforts.

He noticed throughout the early 1970s that other researchers in the same area were using different classification systems to address psychopathy, such as categories based on the Minnesota Multiphasic Personality Inventory and the California Psychological Inventory.  That was a problem, however, because these were self-report inventories, and it's not difficult for clever psychopaths to figure out the test structures and to lie.  Aside from that, researchers were going in too many different directions.

"Nothing was consistent," Hare says.  "The results were all over the place.  I began to realize that if you can't measure the concept, you can't study it."

He decided to experiment with different systems of assessment and measurement, using ratings based on clinical accounts, such as the detailed case descriptions of psychopaths that he had read in The Mask of Sanity.  "Cleckley was the one who put it all together for me," Hare affirmed.

He and his assistant went through numerous files and did many interviews, trying to determine what makes one person a psychopath and another person not.  He came up with a three-point rating system, and then a seven-point one. Yet neither satisfied him, and journal editors did not understand what he was actually measuring.  Then, as with most discoveries, perseverance and the constant grind of trying different things finally paid off. 

"One day," Hare remembers, "a research assistant who had been with me for a dozen years and I decided to quantify what we thought went into our assessments.  First, we listed all the characteristics we thought are important.  We had about a hundred different features and characteristics.  Then we started to score these on people on whom we already had done the seven-point assessment.  We were able to cut the list down to twenty-two items that we thought were useful for discriminating a psychopathic criminal from a non-psychopathic criminal."

Hare's first published work on this 22-item research scale for the assessment of psychopathy appeared in 1980.

That was the same year that the DSM-III came out.

Then the field began to divide.

Hare was acquainted with people who were on the DSM-III work committees and had some input into their discussions about the criteria they were devising for what they were calling antisocial personality disorder.  However, he diverged significantly from American ideas about the disorder.

Dr. Lee Robins, an eminent sociologist whom Hare knew, was working to focus the antisocial diagnosis strictly on behavior.  Hare recalls that it was her contention that clinicians cannot reliably measure personality traits such as empathy, so it was best just to drop them from the list of criteria and include only overt behaviors.

Hare saw a draft of what the committee was proposing and he spotted real problems.  Of the list of 10 items, which consisted primarily of violations of social norms, a person needed to manifest only a few to be diagnosed with antisocial personality disorder.  To his mind, that would encompass the entire prison population.  Not only that, it would not be congruent with his understanding of a psychopath.  He made suggestions for changes to bring antisocial personality disorder a little closer to psychopathy, but for the most part the committee members went forward with their own ideas.

With some adjustments, these criteria were continued over the next two decades in the DSM-III-R and the DSM-IV.  Accordingly, clinicians who use these manuals look for symptoms in people over 18 and not otherwise psychotic who since age 15 have shown a pervasive pattern of disregard for, and violation of, the rights of others.  Among these behaviors, the person has done at least three of the following:

• failure to conform to lawful social norms
• deceitfulness
• impulsivity or failure to plan ahead
• irritability and aggressiveness, as indicated by repeated physical fights or assaults
• reckless disregard for safety of self or others
• consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
• lack of remorse, as indicated by being indifferent about having hurt, mistreated, or stolen from another

So while there was now a list of explicit criteria for clinicians to use, APD (Antisocial Personality Disorder) proved to be unworkable for those who were researching psychopathy.  Hare points out, "In forensic populations, diagnoses of APD have far less utility with respect to treatment outcome, institutional adjustment, and predictions of post-release behavior than do careful assessments of psychopathy based on the traditional use of both behaviors and inferred personality traits."   While most psychopaths may fit the criteria for APD, the majority of people with APD are not psychopaths.  In other words, there were now two different diagnostic instruments to assess two different populations that shared some but not all traits in common.

Hare had continued his work with the assessment scale, eventually called the Psychopathy Checklist, and in 1985, he revised it to include only twenty items.  It was now known as the Psychopathy Checklist-Revised (PCL-R), and was completed on the basis of a semi-structured interview with the people being assessed, along with information from files.  Person by person, each trait on the scale was rated on a scale from 0, meaning the person did not manifest it, to 2, meaning he or she definitely did.  The total score was 40, and a person was diagnosed as a psychopath if his or her score fell between 30 and 40. (In some places, a cut-off score of 25 is useful.)

To help others with scoring, Hare put together a brief informal manual consisting of about twenty pages, and this was passed around.  As more people used the scale and sent Hare their ideas and results, the manual grew in thickness.  Finally in 1991, Hare formally published it with Multi Health Systems, which currently distributes it to qualified professionals.  Throughout the rest of the decade, more researchers affirmed the PCL-R's reliability and validity with male forensic populations, and some branched off into work with adolescents and with females.  Cross-cultural studies showed that the concept of psychopathy, as measured by the PCL-R, was generalizable. 

According to Hare in an article published in 1998, "Psychopathy is one of the best validated constructs in the realm of psychopathology." The PCL-R generated a dramatic increase in basic research on the nature of psychopathy and on the implications of the disorder for the mental health and criminal justice systems.

Once it was clear that the PCL-R yielded such solid results, it was time to reach a larger audience than professional diagnosticians—people who might be the victims.

The work of Hare and his associates clarified a set of diagnostic criteria that offers a practical approach to both the assessment and treatment of psychopathy.  The PCL-R items are grouped around two basic factors, affective/interpersonal features and socially deviant lifestyle (both of which have been divided further into four facets, two each for the two factors).  Refocusing the idea of antisocial personality disorder, psychopathy is characterized by such traits as

• lack of remorse or empathy
• shallow emotions
• manipulativeness
• lying
• egocentricity
• glibness
• low frustration tolerance
• episodic relationships
• parasitic lifestyle
• persistent violation of social norms

It remained to translate the academic and professional work into a form that ordinary people could understand, so in 1993, Hare published Without Conscience.  His purpose was to warn people about those predators who walked among them, and to provide a way for those with shattered lives as the result of an encounter with a psychopath to deal with it.  He believes that, for their own protection, it's crucial that people learn to identify a psychopath who may be very close to them. 

Too many people hold the idea that psychopaths are essentially killers or convicts.  The general public hasn't been educated to see beyond the social stereotypes to understand that psychopaths can be entrepreneurs, politicians, CEOs and other successful individuals who may never see the inside of a prison and who don't commit violent crimes.  However, they do often commit violations of another sort: They exploit people and leave them depleted and much the worse for the encounter.  They prove to be treacherous employees, conniving businessmen, or immoral officials who use their position to victimize people and enrich themselves.

Hare says that we know little about these individuals in terms of systematic study about how the disorder manifests in the public at large.  Nevertheless, there are indications that the personality structure and propensity for unethical treatment of others is common to both criminal and noncriminal psychopaths. 

What's missing in psychopaths are the qualities that people depend on for living in social harmony.  In this book, Hare estimated (conservatively) that there were more than two million psychopaths in North America.  "Psychopathy," he insisted, "touches virtually every one of us."[...]

In a segment of "The Mind," a PBS documentary that looked at many aspects of behavior and the brain, Hare assessed "Al," a middle-aged man with 46 convictions for criminal acts from drugs to bank robbery.  Using a neurological diagnostic test to eliminate obvious brain damage, Hare's team then gave Al tests that measure the processing of language.  The question under investigation was whether or not there is something measurably different about the brain of a person who has been so socially deviant.

In a clinical interview, Al admitted to being extraordinarily good at lying; said he was never diagnosed as hyperactive; grew up in a violent area of Vancouver, BC, in Canada; and recalled incidents in which he had acted out in anger or in irrational ways, just to prove something about his macho self-image.  He felt no concern for his victims, he says, or any remorse. 

By the time he was 15, he was in prison, where he mingled with hardcore prisoners.  He became more sensitive to how others treated him, and more reactive.  He ended up stabbing someone.

Hare first tested Al on a dichotic listening device, through which words came to him via alternating ears.  The results appeared to be consistent with the evidence that psychopaths may not process words primarily by left hemisphere activity, but instead involve both hemispheres equally.

The next test was even more revealing.  Al watched different words come onto a monitor screen.  Some of the words were generally considered to have emotional associations and others were considered neutral.  Whereas most people respond more quickly to emotional words, Al's response time was the same to both emotional and neutral words.

"The impetus for this research," Hare says for the documentary, "is the clinical observation that psychopaths can say one thing and do something else.  This has perplexed a lot of people.  Is it simply lying, dissimulation, or hypocrisy?  Probably not.  There's more than that involved in it."

Hare points out that some people have described psychopaths as somewhat robotic, two-dimensional, emotionally shallow, and lacking in conscience.  They may know intellectually they should not do something, but without the feeling component there could be less motivation to respond to the moral imperative. Their inhibitions for antisocial or violent behavior are much weaker than in normal individuals, and they readily learn and adopt behavior patterns that involve manipulation, deception, and violence to attain their own ends.

  Because they don't understand the feelings of others and don't feel remorseful for harming them, psychopaths can easily rationalize their violence or deception as acceptable behavior. 

Hare and his colleagues continued this research to learn more about the brain's involvement in psychopathic behaviors.  They used whole brain functional magnetic resonance imaging (fMRI) to see if there were neurological manifestations of the way psychopaths process different types of words. When non-psychopaths processed negative emotional words (e.g., rape, death, cancer), activity in the limbic regions of the brain increased.  For psychopaths there was little or no increased activity in these regions.  Curiously, however, there was increased activity in other areas.  In short, the emotional word does not have the same limbic implication for psychopaths that it does for normal people.

Limbic system

"They seemed to be like Spock or Data on Star Trek," Hare explains, "What I thought was most interesting was that for the first time ever, as far as I know, we found that there was no activation of the appropriate areas for emotional arousal, but there was over-activation in other parts of the brain, including parts of the brain that are ordinarily devoted to language.  Those parts were active, as if they were saying, 'Hey, isn't that interesting.'  So they seem to be analyzing emotional material in terms of its linguistic or dictionary meaning."       

Yet Hare does not think that psychopathy is caused by brain damage.  Instead, he says, "there are anomalies in the way psychopaths process information.  It may be more general than just emotional information.  In another functional MRI study, we looked at the parts of the brain that are used to process concrete and abstract words. Non-psychopathic individuals showed increased activation of the right anterior/superior temporal cortex.  For the psychopaths, that didn't happen."

Hare and his colleagues then conducted an fMRI study using pictures of neutral scenes and unpleasant homicide scenes.  "Non-psychopathic offenders show lots of activation in the amygdala [to unpleasant scenes], compared with neutral pictures," he points out. "In the psychopath, there was nothing.  No difference.  But there was overactivation in the same regions of the brain that were overactive during the presentation of emotional words.  It's like they're analyzing emotional material in extra-limbic regions."  

At first, most of the research was done on the most obvious population: male prisoners, because it was clear that while not all men who engaged in criminal acts were psychopaths, it seemed probable that psychopaths would make up a good percentage of imprisoned criminals.  The first task was to develop an instrument that proved to be a reliable way to distinguish a psychopath from a non-psychopath, and that took some time.  Once it was clear that the PCL-R was reliable and valid, the focus could be turned on imprisoned females, children at risk for developing into psychopaths, and then on the population at large.

As of this writing, Hare says, "There's been quite a bit of research on female psychopaths.  I have data in the new manual, including percentile tables, for 1200 female offenders in North America, many of whom are African-American.  The scores are a few points lower than for male offenders, but otherwise the distributions of scores are very similar.  The correlates and the predictive power of the PCL-R are much the same for female and male offenders.  For example, female psychopathic offenders re-offend at a high rate compared to other female offenders."

Then there are the children: can we spot budding psychopaths and intervene before they became dangerous adults?  A version of the PCL-R used for adolescents is the Psychopathy Checklist: Youth Version (PVL:YV), developed with Dr. Adelle Forth and Dr. David Kosson.  It has proven to be as reliable and valid as its adult counterpart. For younger children, the Antisocial Process Screening Device (APSD), developed with Dr. Paul Frick, appears to be useful for distinguishing children who show risk factors for the development of psychopathy, such as lying easily and acting without awareness of the consequences, from those who merely have social and emotional problems.

"Identification of these risk factors," says Hare, "is necessary if we are ever to develop early interventions for what might become adult psychopathy."

In addition to developing a scale for younger populations, Hare was also asked by British probation officers to provide something for their use.

"Four years ago," he explains, "a senior probation officer in the UK organized a conference in Sheffield to convince me that probation and parole officers needed a tool to help them assess psychopathic features.  They couldn't use the PCL-R or the 12-item PCL:SV, because these are controlled instruments that require professional qualifications.

"So this group showed me the front page of the London Times, which said that most murders committed in the UK are committed by people out on probation or parole.  The response of the government was that the probation service was in need of close monitoring.  The probation people said that it was the job of the prison service to evaluate risk for violence before release of an offender, and that probation officers didn't have the means to assess their clients for psychopathy, a known risk factor. To do this, they wanted a tool."

Hare came up with the P-Scan.  It is a non-clinical tool for developing general impressions into a hypothesis about whether a particular person might be a psychopath, which would have implications for managing risk for violent or antisocial behavior.  It's a rough guide for law enforcement and parole officers, used to bring the person to the attention of someone who might then give a more formal assessment.

"It consists of 120 characteristics, 30 for impressions about interpersonal traits, like grandiosity and lying, 30 for impressions about affective traits, such as lack of remorse and shallow emotions, 30 for impressions about lifestyle features, such as impulsivity and stimulation-seeking, and 30 for impressions about antisocial behaviors.  So we have four components that match the new factor structure of the PCL-R.  The P-Scan involves scoring items that are simple descriptive statements, like 'His presence makes me feel uncomfortable,' or low-level inferences, such as 'Seems unable to understand the feelings of others.' You don't have to be a clinician, you just have to have some experience with the individual.  We've developed a computer program so qualified professionals can access it on the Web, through Multi Health Systems.  The P-Scan report provides a hypothesis about the extent to which a person of interest might have the interpersonal, affective, lifestyle, and antisocial features of psychopathy.  The information may be helpful in dealing with the individual, but in some cases it will be an impetus for getting a clinical opinion from someone trained on the PCL-R."

In some cases the information can be used to guide law enforcement officers in their dealings with suspects. For example, to get cooperation from psychopaths it would be pointless to appeal to their conscience, or to try to make them feel something for their victims or to feel badly about what they did.  It may be more productive to offer them something that appeals to their self-interest.  Many a psychopath involved in a "deadly duet" has turned on a partner to save his or her own skin.  Education about psychopaths should be a routine part of the training of police officers. 

Not everyone has access to these instruments or has the professional qualifications to use them, so Without Conscience, based on the PCL:SV, offers some rules of thumb for spotting and dealing with the psychopaths whom any of us might encounter.