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Psychopathy and the DSM - IV Criteria for Antisocial Personality Disorder

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The Axis II Work Group of the Task Force on DSM—IV has expressed concern that antisocial personality disorder (APD) criteria are too long and cumbersome and that they focus on antisocial behaviors rather than personality traits central to traditional conceptions of psychopathy and to international criteria. We describe an alternative to the approach taken in the rev. 3rd ed. of the Diagnostic and Statistical Manual of Mental Disorders ( DSM—III—R ; American Psychiatric Association, 1987 ), namely, the revised Psychopathy Checklist. We also discuss the multisite APD field trials designed to evaluate and compare four criteria sets: the DSM—III—R criteria, a shortened list of these criteria, the criteria for dyssocial personality disorder from the 10th ed. of the International Classification of Diseases ( World Health Organization, 1990 ), and a 10-item criteria set for psychopathic personality disorder derived from the revised Psychopathy Checklist.
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Content Preview
Journal of Abnormal Psychology
© 1991 by the American Psychological Association
August 1991 Vol. 100, No. 3, 391-398
For personal use only--not for distribution.
Psychopathy and the DSM—IV Criteria for Antisocial Personality
Disorder
Robert D. Hare
University of British Columbia
Stephen D. Hart
University of British Columbia
Timothy J. Harpur
University of British Columbia
ABSTRACT
The Axis II Work Group of the Task Force on DSM—IV has expressed concern that
antisocial personality disorder (APD) criteria are too long and cumbersome and that they
focus on antisocial behaviors rather than personality traits central to traditional conceptions
of psychopathy and to international criteria. We describe an alternative to the approach
taken in the rev. 3rd ed. of the Diagnostic and Statistical Manual of Mental Disorders (
DSM—III—R ; American Psychiatric Association, 1987 ), namely, the revised Psychopathy
Checklist. We also discuss the multisite APD field trials designed to evaluate and compare
four criteria sets: the DSM—III—R criteria, a shortened list of these criteria, the criteria for
dyssocial personality disorder from the 10th ed. of the International Classification of
Diseases
( World Health Organization, 1990 ), and a 10-item criteria set for psychopathic
personality disorder derived from the revised Psychopathy Checklist.
The views expressed in this article are those of the authors and do not represent the official positions of
the American Psychiatric Association or its Task Force on DSM—IV.
This work was supported by Grant MT-4511 from the Medical Research Council of Canada and by the
Program of Research on Mental Health and the Law of the John D. and Catherine T. MacArthur
Foundation.
We gratefully acknowledge the substantial contributions of Adelle E. Forth and Sherrie Williamson to
the development of the psychopathic personality disorder criteria. We also appreciate the thoughtful
comments made by Thomas A. Widiger and Scott Lilienfeld on an earlier draft of the article.
Timothy J. Harpur is now at the University of Illinois at Champaign.
Correspondence may be addressed to Robert D. Hare, Department of Psychology, University of British
Columbia, 2136 West Mall, Vancouver, British Columbia, Canada, V6T 1Y7.
Received: July 24, 1990
Revised: October 30, 1990
Accepted: December 17, 1990
The Axis II Work Group of the American Psychiatric Association's Task Force on DSM—IV (the fourth
edition of the Diagnostic and Statistical Manual of Mental Disorders ) has identified antisocial
personality disorder (APD) as "the personality disorder most likely to undergo major changes in
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DSM—IV" ( American Psychiatric Association, 1990 , p. 5). The goals of the work group are to "simplify
the criteria for this disorder and at the same time include more traditional items, typical of psychopathy"
(p. 6). As part of the second goal, the work group hopes to increase "congruency and compatibility"
between the DSM—IV and criteria from the International Classification of Diseases and Related Health
Problems (ICD-10;
World Health Organization, 1990 ). The following four criteria sets have been
developed for evaluation and comparison in field trials: the existing criteria in the revised DSM—III (
DSM—III—R ; American Psychiatric Association, 1987 ) for APD (see Table 1 ); a shortened list of the
DSM—III—R criteria, developed by Lee Robins ( Table 2 ); the ICD-10 criteria for dyssocial personality
disorder ( Table 3 ); and a set of diagnostic criteria for psychopathic personality disorder ( Table 4 )
derived from the Psychopathy Checklist—Revised (PCL—R; Hare, 1985a , 1991 ).
In this article we discuss the concerns that led the Axis II Work Group to consider making changes in the
DSM—III—R criteria for APD. Next, we describe alternative approaches to the DSM—III—R criteria,
focusing on the PCL—R. Finally, we comment briefly on the DSM—IV APD field trials, which are
currently underway in five North American sites (and which are described by Widiger, Frances, Pincus,
Davis, & First, 1991 ).
DSM—III—R Criteria for Antisocial Personality Disorder
Four criteria, singly necessary and jointly sufficient, are required for a DSM—III—R diagnosis of APD
(see Table 1 ): (a) the patient is at least 18 years old; (b) there is evidence of conduct problems before age
15 (at least 3 of 12 symptoms); (c) there is evidence of a pattern of antisocial behavior that persists into
adulthood (at least 4 of 10 symptoms); and (d) antisocial behavior is not the result of (i.e., not exclusively
during the course of) certain acute mental disorders, namely, schizophrenia or manic episodes.
One major criticism of the DSM—III—R criteria for APD is that they are too long and cumbersome. The
two inclusion criteria (b and c) take the form of fairly lengthy symptom checklists related to antisocial
and delinquent behavior; in turn, most symptoms are defined in terms of a number of specific behavioral
indicators. Consequently, the number of discrete clinical judgments required to diagnose APD is rather
large. This has led to a concern that some clinicians may ignore the explicit APD criteria and rely instead
on their own, idiosyncratic prototypical criteria ( Widiger, Frances, & Trull, 1989 ). There is some
empirical evidence to justify this concern (e.g., Ford & Widiger, 1989 ; Morey & Ochoa, 1989 ). Also,
because such detailed information is required for a diagnosis, clinicians are generally forced to rely to a
large extent on patients' memories and self-reports of their past conduct ( Widiger et al., 1989 )–a state of
affairs that is particularly problematic, given that untruthfulness is one of the disorder's symptoms (see
Table 1 ). An obvious way to make the DSM—IV criteria for APD more accessible to its users, then, is
merely to shorten and simplify the existing DSM—III—R criteria. This task was undertaken by Lee
Robins, and the resulting criteria set is presented in Table 2 .
The DSM—III—R approach to the diagnosis of APD is based on the assumption that personality traits are
difficult to measure reliably and that it is easier to agree on the behaviors that typify a disorder than on
the reasons why they occur ( Robins, 1978 , p. 256). Although the result has been a diagnostic category
with good reliability, concerns have been expressed about its content- and construct-related validity, in
particular, about its relation to clinical conceptions of psychopathy, in which inferences about affective
and interpersonal processes have long played an important role ( Hare, 1983 ; Millon, 1981 ; Wulach,
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1983 ). This is the second major criticism of the current DSM—III—R criteria for APD: They represent a
rather radical break with clinical tradition (see Cleckley, 1976 ; Karpman, 1961 ; McCord & McCord,
1964 ; Millon, 1981 ), with clinical practice ( Davies & Feldman, 1981 ; Gray & Hutchison, 1964 ), with
earlier versions of the DSM, and with international diagnostic nomenclature ( ICD-9 [ World Health
Organization, 1978 ] and ICD-10 ; Sartorius, Jablensky, Cooper, & Burke, 1988 ). Specifically, the
DSM—III—R criteria exclude, or at least do not explicitly include, such characteristics as selfishness,
egocentricity, callousness, manipulativeness, lack of empathy, and so forth.
The lack of congruence between the DSM—III—R criteria for APD and other well-established
conceptions of psychopathy does not appear to have been intentional. Rather, this construct drift seems to
have been the unforeseen result of reliance on a fixed (and possibly biased; see Millon, 1981 ) set of
behavioral indicators in the DSM—III and the DSM—III—R. That is, the behavioral indicators do not
provide adequate coverage of the construct they were designed to measure. As S. O. Lilienfeld (personal
communication, September 15, 1990 ) pointed out, a diagnosis of APD is based largely on the use of
closed concepts in which the diagnostician is required to select from a fixed and limited set of indicators
of a trait; other, perhaps better indicators cannot be used. The use of closed concepts ignores the fact that
a given trait can be reflected in a wide variety of behaviors and that a given behavior can reflect more
than one personality trait ( Widiger et al., 1989 ). All of those who fulfill the APD criteria may be
antisocial, but they may differ greatly in their motivations for being so and in significant interpersonal,
affective, and psychopathological features, such as the capacity for empathy, remorse, guilt, anxiety, or
loyalty. Paradoxically, the criteria for APD appear to define a diagnostic category that is at once too
broad, encompassing criminals and antisocial persons who are psychologically heterogeneous, and too
narrow, excluding those who have the personality structure of the psychopath but who have not exhibited
some of the specific antisocial behaviors listed for APD ( Millon, 1981 ). 1 This second concern led to the
inclusion of two criteria sets in the APD field trials that are closer to the the traditional clinical construct
of psychopathy–the dyssocial and psychopathic personality disorder criteria ( Tables 3 and 4 ).
An Alternative to Antisocial Personality Disorder: The Psychopathy
Checklist—Revised
Criticisms of the DSM—III—R criteria for APD would be moot if there were no viable alternatives
available. Over the last 10 years, however, a great deal of empirical evidence indicates that at least one
viable alternative does exist–the PCL—R. The original PCL ( Hare, 1980 ) was a 22-item clinical rating
scale designed to assess the traditional clinical construct of psychopathy, perhaps best exemplified in the
work of Cleckley (1976) . More recently, a 20-item revision of the scale has been developed (PCL—R;
Hare, 1985a , 1991 ).
Description
The 20 items of the PCL—R (see Table 5 ) measure behaviors and inferred personality traits considered
fundamental to the clinical construct of psychopathy. Most of the traits are treated as open concepts (
Lilienfeld, 1990 ). That is, the rater is provided with a description of a trait and with some behavioral
exemplars and is asked to make a judgment about the extent to which a given person has the trait. Each
item is scored on a 3-point scale, for which 0 indicates that it definitely does not apply, 1 that it applies
somewhat or only in a limited sense,
and 2 that it definitely does apply to the person.
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The information needed to score the items is obtained from a semistructured interview and institutional
files. Detailed instructions for scoring the items are contained in the manual for the PCL—R ( Hare, 1991
). Although clinical judgment and inference are required, the scoring criteria are quite explicit, and with
some training, the items are not difficult to score.
Descriptive Statistics and Reliability
PCL—R total scores can range from 0 to 40 and represent the extent to which a person matches the
prototypical psychopath. In most forensic samples the distribution of scores is approximately normal,
with a slight negative skew. Although the total scores are dimensional, they can be used to provide a
categorical diagnosis of psychopathy. A cutoff score of 30 has proven useful for this purpose.
Mean PCL—R scores are relatively consistent across samples of prison inmates and forensic patients
from different institutions and countries. The mean total score for six samples of male prison inmates ( N
= 1,065) and four samples of male forensic patients ( N = 440), described by Hare (1991) , is presented in
Table 6 .
Despite the subjective nature of most of the PCL—R items, each has reasonable interrater reliability (see
Table 5 ). The internal consistency of the scale and the interrater reliability of total scores are high in
samples of inmates and patients (see Table 6 ). (As values for inmates and patients were much the same,
only combined data are presented).
Factors
There is strong evidence that the PCL—R consists of two stable, oblique factors ( Hare et al., 1990 ;
Harpur, Hakstian, & Hare, 1988 ). The correlation between the factors is about the same in samples of
prison inmates (.56 on average) as it is in samples of forensic patients (.53 on average).
The items that define each factor are identified in Table 5 . Both factors are psychologically meaningful
facets of the higher order construct of psychopathy. Factor 1 clearly reflects a set of interpersonal and
affective characteristics, such as egocentricity, lack of remorse, callousness, and so forth, considered
fundamental to clinical conceptions of psychopathy. In spite of the relatively small number (8) of items
involved, Factor 1 scores, obtained by summing the individual item scores, are reliable in samples of
prison inmates and forensic patients (see Table 2 ). Evidence presented elsewhere ( Hare, 1991 ; Harpur,
Hare, & Hakstian, 1989 ; Hart & Hare, 1989 ) indicates that Factor 1 is positively correlated with clinical
ratings of psychopathy, with prototypicality ratings of narcissistic and histrionic personality disorder, and
with self-report measures of machiavellianism and narcissism. It is also negatively correlated with
measures of empathy and anxiety.
Factor 2 reflects those aspects of psychopathy related to an impulsive, antisocial, and unstable lifestyle. It
is positively correlated with diagnoses of APD, criminal behaviors, socioeconomic background, and
self-report measures of socialization and antisocial behavior ( Hare, 1991 ; Harpur et al., 1989 ).
Validity
Evidence for the validity of the PCL and PCL—R is reviewed in detail elsewhere ( Hare, 1991 ; Hart,
Hare, & Harpur, in press ), and space limitations permit only a very brief outline of this evidence to be
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presented here. 2 When possible, we examine the comparative validity of the PCL—R and APD criteria.
Content-related evidence.
It is apparent from examination of the criteria sets (see Tables 1 and 5 ) and from our description of these
criteria that the PCL—R provides more complete coverage of the traditional construct of psychopathy
than do the APD criteria. The social deviance or antisociality facet of psychopathy is assessed reasonably
well by both the APD criteria and by Factor 2 of the PCL—R, but APD neglects the facet of psychopathy
assessed by PCL—R Factor 1.
Concurrent criterion-related evidence.
Total scores on the PCL and PCL—R are strongly related to other clinical—behavioral measures of
psychopathy: Point-biserial correlations between total scores and DSM—III or DSM—III—R diagnoses of
APD in eight samples of male offenders ( N = 1,603) and in two samples of female offenders ( N = 120)
averaged about .55 ( Hare, 1991 ); Factor 2 scores typically correlated higher with APD diagnoses than
did Factor 1 scores (about .60 vs. .40).
Total scores are also correlated with various self-report measures related to psychopathy, including the
Psychopathic Deviate and Hypomania scales of the Minnesota Multiphasic Personality Inventory, the
California Psychological Inventory Socialization scale, and the Millon Clinical Multiaxial Inventory II
Antisocial scale ( Hare, 1985b , 1991 ; Harpur et al., 1989 ). However, the magnitude of these
correlations typically is small (about .30—.35), as are the correlations between APD and self-reports (
Hare, 1985b ). In general, these self-report scales are more strongly correlated with Factor 2 than with
Factor 1.
Predictive criterion-related evidence.
Hart, Kropp, and Hare (1988) found that the PCL predicted postrelease behavior in a sample of 231
federal offenders, even after they controlled for such variables as criminal history, previous
conditional-release violations, and relevant demographic characteristics. Outcome (failure vs. success)
correlated .33 with PCL total scores, .25 with PCL diagnoses of psychopathy and .20 with diagnoses of
APD. Similar results were obtained by Serin, Peters, and Barbaree (in press) and by Serin (1990) .
Harris, Rice, and Cormier (in press) reported that the PCL—R predicted postrelease violent offending in
a sample of 169 male forensic patients. The violent recidivism rate for psychopaths (77%) was almost
four times that of nonpsychopaths (21%). The PCL—R significantly improved the prediction of outcome
over and above the use of criminal history variables and DSM—III diagnoses of APD. Violent recidivism
correlated .42 with PCL—R total scores, .56 with PCL—R diagnoses of psychopathy, and .26 with
diagnoses of APD.
In another study Rice, Harris, and Quinsey (1990) studied 54 rapists released from a maximum security
psychiatric hospital. PCL—R total scores were significantly correlated with recidivism for violent
offenses in general and with recidivism for sexual offenses in particular. A combination of PCL—R
scores and a phallometric index of arousal (based on penile plethysmography) predicted recidivism as
well as did a large battery of criminal history and demographic variables.
Ogloff, Wong, and Greenwood (1990) performed an outcome study of 80 men enrolled in a therapeutic
community program designed to treat criminals with personality disorders. The data were prospective for
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some patients and retrospective for others, and the results indicated that PCL—R psychopaths remained
in the program for a shorter period of time, put in less effort, and showed less improvement than did
other inmates.
Other construct-related evidence.
Total scores typically correlate positively with scores on various measures of impulsivity,
machiavellianism, narcissism, and sensation-seeking ( Hare, 1991 ; Harpur et al., 1989 ). Foreman (1988)
found that PCL—R total scores ( N = 79) were positively correlated ( r =.45) with staff ratings of
dominance and negatively correlated ( r = ? .46) with ratings of nurturance on the Interpersonal
Adjective Scales ( Wiggins, Trapnell, & Phillips, 1988 ).
The PCL—R shows good convergent and discriminant validity with respect to diagnoses of mental
disorder. Hart and Hare (1989) found that PCL—R total scores were positively correlated with diagnoses
of substance use disorder, histrionic personality disorder, and APD; they were also correlated with
prototypicality ratings of histrionic personality disorder, narcissistic personality disorder, and APD.
(Positive correlations between the PCL—R and substance use have also been reported by Smith &
Newman, 1990 .) Psychopaths were less likely than other patients to receive a DSM—III Axis I diagnosis
(other than substance use disorder). PCL—R total and factor scores were either uncorrelated or
negatively correlated with prototypicality ratings of schizophrenia and personality disorders (except
histrionic, narcissistic, and antisocial, as noted earlier).
Further evidence of the discriminant validity of the PCL and PCL—R comes from studies with
standardized psychological tests. Total scores are uncorrelated or negatively correlated with self-report
measures of empathy, anxiety, depression, and general distress or neuroticism ( Hare, 1991 ; Harpur et
al., 1989 ; Hart, Forth, & Hare, 1990 ). The results of over a dozen studies indicate that there is no
association between total scores and performance on various intelligence tests ( Hare, 1991 ). Also, two
studies have reported that total scores are not associated with any impairment in performance on standard
neuropsychological tests ( Hare, 1984 ; Hart, Forth, & Hare, 1991).
The PCL and PCL—R have a strong and stable association with various indexes of criminality.
Psychopaths are charged with a greater number and variety of criminal offenses than nonpsychopaths,
regardless of race ( Kosson, Smith, & Newman, 1990 ; Wong, 1984 ) or psychiatric status ( Hare, 1991 ;
Hart & Hare, 1989 ). Psychopaths commit violent and aggressive offenses at a particularly high rate. For
example, in a sample of 244 inmates, Hare and McPherson (1984) found that PCL-defined psychopaths
were significantly more likely than other criminals to engage in physical violence and other forms of
aggressive behavior, including verbal abuse, threats, and intimidation, both in and out of prison.
Williamson, Hare, and Wong (1987) examined the nature of the violent offenses committed by
psychopaths. Official police reports were used to analyze the circumstances of the most serious of
inmates' instant offenses. Most of the murders and serious assaults committed by the nonpsychopaths
occurred during a domestic dispute or during a period of extreme emotional arousal, whereas this was
seldom true of the psychopaths. The victims of the nonpsychopaths were likely to be women and known
to them, but the victims of the psychopaths were likely to be men and unknown to them. The violence of
the psychopaths frequently had revenge or retribution as the motive or occurred during a drinking bout.
In general, it appeared that most of the psychopaths' violence was callous and cold-blooded or part of an
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aggressive, macho display, without the affective coloring that accompanied the violence of
nonpsychopaths.
Laboratory studies have generated a body of data that is theoretically meaningful with respect to
psychopathy and that provides particularly important evidence for the construct validity of the PCL and
PCL—R. For example, psychopathy is associated with abnormal processing of the affective components
of language in a variety of laboratory tasks ( Williamson, Harpur, & Hare, 1990 , in press ; see also
review by Hare, Williamson, & Harpur, 1988 ). Psychophysiological aspects of affective functioning in
psychopaths have also been examined by Patrick and his colleagues ( Patrick, Bradley, & Cuthbert, 1990
; Patrick, Cuthbert, & Lang, 1990 ). They have reported that psychopaths, defined with the PCL—R,
gave smaller autonomic responses during fearful imagery than did other offenders and failed to show
normal modulation of the blink reflex to an acoustic startle stimulus presented while slides with affective
content were viewed. A third line of research has investigated Hare's (1982) hypothesis that psychopaths
may be unusually proficient at selectively focusing attention on events that interest them. Several PCL
and PCL—R studies have produced results that are generally consistent with the hypothesis (for a
review, see Harpur & Hare, 1990 ). Finally, Newman and his colleagues have published a series of
studies of passive-avoidance learning, disinhibition, and dominant-response set in psychopaths, as
defined by the PCL or PCL—R (e.g., Kosson & Newman, 1986 ; Newman, Patterson, & Kosson, 1987 ).
Consistent with the theoretical model that underlies this research, there was general support for the
hypothesis that the disinhibited behavior of psychopaths is related to a dominant-response set for reward.
Summary
The PCL—R assesses both the affective or interpersonal and the social deviance facets of psychopathy,
whereas the DSM—III—R focuses on the latter. The incremental validity obtained by including explicit
inferences about key personality traits in the diagnosis of psychopathy is substantial, even when the
criterion involves antisocial or criminal behaviors. This is an important point, given that the items that
define APD are from much the same domain as, and therefore ought to predict, criterion variables related
to criminality, violence, and recidivism. The fact that the PCL and PCL—R generally are more strongly
related to these criterion variables than is APD attests to the value of including inferences about
personality traits in the assessment of psychopathy. Equally important here is the evidence that
laboratory tests of hypotheses about the nature of psychopathy are supported when assessment is based
on the PCL or PCL—R. Although there is no similar body of systematic laboratory research on APD,
several of the laboratory studies of psychopathy discussed above also obtained DSM—III or
DSM—III—R diagnoses of APD (C. J. Patrick, personal communication, October 23, 1990; Williamson
et al., 1990 , in press ). In each case, the effects that were significant with the PCL or PCL—R were not
significant when the presence or absence of APD was the basis for group selection.
Development of the Criteria Set for Psychopathic Personality Disorder
The extensive evidence on the psychometric properties of the PCL—R clearly indicates that it is possible
to obtain reliable and valid measures of the personality traits and behaviors associated with psychopathy.
However, it is important to note that completion of the PCL—R requires a relatively long semistructured
interview and access to a considerable amount of collateral information.
There is some evidence that the PCL—R can be shortened and simplified for clinical use without an
unacceptable decrease in reliability or validity. As part of a large-scale study on the risk of violence in
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the mentally disordered, funded by the John D. and Catherine T MacArthur Foundation and directed by
John Monahan (see Monahan, 1990 ), a 12-item screening version of the PCL—R (the PCL:SV; Hare,
Cox, & Hart, 1989 ) has been tested in seven samples (three prison, two forensic psychiatric, and two
civil psychiatric). The items were designed to tap each of the PCL—R factors and are scored on the basis
of a 30- to 45-min interview and minimal collateral information. Preliminary analyses of data from 331
subjects indicate that the PCL:SV has good psychometric properties. Thus, the average intraclass
correlation coefficient (ICC) for a single rating and for the average of two ratings was about .80 and .85,
respectively. The average alpha coefficient was about .80 and the mean inter-item correlation (MIC)
about .25. The correlation between independent ratings on the PCL:SV and the PCL—R averaged about
.80.
Encouraged by these results, we used the PCL—R and the PCL:SV as the basis for development of the
10-item criteria set for psychopathic personality disorder (PPD) presented in Table 4 . These items are
substantively the same as those in the PCL:SV, and a reasonable reflection of the constructs measured by
PCL—R Factors 1 and 2. Specific, though relatively brief, instructions are used to score each PPD item
on a 3-point scale (2 = item applies, 1 = item applies somewhat, or evidence is mixed, 0 = item does not
apply). Total scores can range from 0 to 20 and represent the extent to which the person matches the
clinical prototype of the psychopath.
Despite the advantages that dimensional ratings have in clinical research and practice, DSM—IV plans to
continue using simple categorical diagnoses. On the basis of some preliminary analyses, we determined
that a diagnosis of PPD must require that 7 of the 10 criteria be satisfied (i.e., scored 2). We estimate that
it will yield a base rate for psychopathy of about 25%—30% among federal prisoners and about 15%
among forensic psychiatric inpatients; these values are similar to those obtained with the PCL—R and
PCL:SV, and less than one-half the prevalence of APD. 3
DSM—IV Field Trials
As we noted earlier, Widiger et al. (1991) describe the APD field trials in some detail. Briefly, they noted
that the four criteria sets presented in Tables 1 to 4 will be tested at five different sites. At each site
approximately 100 patients (total N = 500) will be administered structured interviews and subsequently
assessed with all four criteria sets, wherein about half of subjects will receive an independent
reassessment at a later date. This will allow a determination of the interrater reliability, internal
consistency, concurrent validity, and coverage of the various criteria sets. In addition, self-report,
demographic, and psychosocial history data will be collected to evaluate the construct validity of the
criteria sets. If no single criteria set is clearly superior to the others, the Task Force may test various
combinations of symptoms from the different criteria sets.
We concur with Widiger et al. (1991) that these field trials represent a significant advance over
committee or expert consensus approaches to decision making with respect to the content of diagnostic
criteria: "The results will not be unambiguous with respect to which criteria set is preferable, but the field
trial will provide reliability and validity data that will be informative for their evaluation, and together
with the results provided by the literature review and data reanalyses, the study will facilitate the effort to
have the decisions of the work group be empirically based" (pp. 286). Perhaps the biggest strength of the
field trials is the attempt made to sample subjects from diverse populations (e.g., prisoners, psychiatric
inpatients, substance abusers, and adopted-away offspring), so that reliability and validity data can be
compared across various settings.
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Of course, a single study–even a large, multicenter study–cannot answer all the relevant questions. An
important limitation of the field trials is that they will be unable to examine some important aspects of
validity, for example, predictive validity with respect to criminal behavior, or experimental validity with
respect to psychophysiological or cognitive variables. (As noted earlier, it is in precisely these areas that
the PCL and PCL—R approach appears superior to APD.) Full evaluation of the construct validity of the
criteria sets will be a lengthy (and, some may argue, a never-ending) process, however, and we recognize
that the publication of the DSM—IV is a practical necessity that cannot be postponed indefinitely.
Concluding Comments
Despite the successes of the DSM—III and DSM—III—R APD criteria, conceptual and empirical
arguments exist for evaluating alternative approaches to the assessment of psychopathy. The field trials
described are an important–but not final–step in this direction, and the data collected may play a crucial
role in the selection of the DSM—IV APD criteria. However, our hope is that the information presented
here will stimulate further research on the comparative validity of diagnostic criteria for psychopathy;
although too late to influence DSM—IV, this research may well play a decisive role in subsequent
versions or revisions of the DSM.
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