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Psychopathy and Antisocial Personality Disorder: A Case of Diagnostic Confusion: Page 2 of 2

Psychopathy and Antisocial Personality Disorder: A Case of Diagnostic Confusion: Page 2 of 2

The differences between psychopathy and ASPD are further highlighted by recent laboratory research involving the processing and use of linguistic and emotional information. Psychopaths differ dramatically from nonpsychopaths in their performance of a variety of cognitive and affective tasks. Compared with normal individuals, for example, psychopaths are less able to process or use the deep semantic meanings of language and to appreciate the emotional significance of events or experiences (Larbig and others; Patrick; Williamson and others).

It is worth noting that it is the interpersonal and affective components of psychopathy (as measured by PCL-R, Factor 1) that are most discriminating in these experiments. In sharp contrast, those with a diagnosis of ASPD (in which interpersonal and affective traits play little role) differ little from those without ASPD in their processing of linguistic and emotional material.

DSM-IV

Widespread dissatisfaction with the conceptualization and criteria for ASPD led the American Psychiatric Association to initiate a field trial in preparation for DSM-IV. A stated goal of the trial (Widiger and others) was to improve coverage of the traditional symptoms of psychopathy. Included with the DSM-III-R criteria for ASPD was a 10-item version of the PCL-R, referred to in the trial as the psychopathic personality disorder criteria. Many researchers and clinicians hoped that the field trial would bring the diagnosis of ASPD back on track, but it did so in only a limited sense (Hare and Hart 1995).

The field trial clearly indicated that most of the personality traits that reflect the traditional symptoms of psychopathy were just as reliable as those of the more behaviorally specific DSM-III-R items (Widiger and colleagues). Thus, the original premise for excluding personality from the diagnosis of psychopathy/ASPD (in DSM-III) turned out to be untenable. There was now a firm empirical basis for increasing the content-related validity of ASPD in DSM-IV, without a reduction in reliability. Yet this did not happen, partly because, it was argued, the average clinician would not use the carefully structured approach to the assessment of personality traits used in the field trial.

It may come as a surprise to most clinicians that the criteria adopted for DSM-IV were not actually evaluated in the field trial. What was evaluated was the 10-item set of adult symptoms (Criterion C) for ASPD listed in DSM-III-R. The seven-item set listed in DSM-IV was derived from the 10-item set; this derivation was logical rather than empirical. Further, the field trial did not include evaluations of Criterion B (conduct disorder before age 15), a criterion listed in DSM-IV as a necessary condition for a diagnosis of ASPD.

Things become even more problematic when we consider that the DSM-IV text description of ASPD (which it says is also known as psychopathy) contains many references to traditional features of psychopathy. But in many respects the text account is incongruent with the formal diagnostic criteria. Further, the "Associated Features" section of the text contains this statement, and I paraphrase: Lack of empathy, inflated and arrogant self-appraisal, and glib, superficial charm are features of ASPD that may be particularly useful in prison or forensic settings wherein criminal, delinquent and aggressive acts will be less specific to the disorder.

The words used to describe these and related affective and interpersonal features are those typically associated with psychopathy and were based heavily on the 10-item psychopathic personality disorder set derived from the PCL-R. It is difficult not to conclude that DSM-IV contains two sets of diagnostic criteria for ASPD, one consisting of antisocial and criminal behaviors, and the other consisting of these behaviors plus clinical inferences about personality. The clinician is not provided with guidelines on how to make these inferences.

Some Problems

An unfortunate consequence of the ambiguity inherent in DSM-IV is likely to be a court case in which one clinician says the defendant meets the DSM-IV definition of ASPD, another clinician says he does not, and both are right! The first clinician uses only the formal diagnostic criteria whereas the second clinician agrees that the defendant meets the formal criteria but argues that he or she does not have the personality traits described in the "Associated Features" section of the DSM-IV text.

The failure to differentiate between psychopathy and ASPD can have serious consequences for clinicians and for society. For example, most jurisdictions consider psychopathy to be an aggravating rather than a mitigating factor in determining criminal responsibility. In some states an offender convicted of first-degree murder and diagnosed as a psychopath is likely to receive the death penalty on the grounds that psychopaths are cold-blooded, remorseless, untreatable and almost certain to reoffend. But many of the killers on death row were, and continue to be, mistakenly referred to as psychopaths on the basis of DSM-III, DSM-III-R or DSM-IV criteria for ASPD (Meloy). We dont know how many of these inhabitants of death row actually exhibit the personality structure of the psychopath, or how many merely meet the criteria for ASPD, a disorder that applies to the majority of criminals and that has only tenuous implications for treatability and the likelihood of violent reoffending. If a diagnosis of psychopathy has consequences for the death penalty- or for any other severe disposition, such as an indeterminate sentence or a civil commitment- clinicians making the diagnosis should make certain they do not confuse ASPD with psychopathy.

Had DSM-IV accepted the results of its own trial, ASPD and psychopathy might now be more or less synonymous constructs. Instead, the failure to explicitly bring personality back into the diagnosis of ASPD means that the disorder is ambiguous and continues to lack congruence with traditional conceptions of psychopathy.

Perhaps this situation- an unfortunate and unnecessary one in my view- will be rectified in DSM-V. Meanwhile, it is worth noting that interpersonal and affective traits are more discriminating of the construct of psychopathy than are the socially deviant behaviors reflected in the DSM-IV criteria for ASPD (Cooke). Diagnostic confusion about the two disorders has the potential for harming psychiatric patients and society as well.

Camouflage Society

In my book, Without Conscience, I argued that we live in a "camouflage society," a society in which some psychopathic traits- egocentricity, lack of concern for others, superficiality, style over substance, being "cool," manipulativeness, and so forth- increasingly are tolerated and even valued. With respect to the topic of this article, it is easy to see how both psychopaths and those with ASPD could blend in readily with groups holding antisocial or criminal values. It is more difficult to envisage how those with ASPD could hide out among more prosocial segments of society. Yet psychopaths have little difficulty infiltrating the domains of business, politics, law enforcement, government, academia and other social structures (Babiak). It is the egocentric, cold-blooded and remorseless psychopaths who blend into all aspects of society and have such devastating impacts on people around them who send chills down the spines of law enforcement officers.

More on Personality Disorders

 

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References

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