For clinicians, the assiduous and sustained resistance to change common in patients with narcissistic personality disorder (NPD) has been especially noticeable and trying. The narcissistic patient's persistent denial of problems or limitations and lack of motivation for treatment until faced with a major failure have been documented by Kernberg (1985, 1992) and Millon. However, until recently the natural course of NPD has not received much attention in the clinical and empirical literature, and there is very little documented knowledge about the factors that might contribute to changes. Knowledge about the natural course of a disorder is important in evaluating the benefits of treatment. 

In a first prospective follow-up study of patients diagnosed with NPD, we investigated the occurrence of changes in pathological narcissism over time (Ronningstam and Gunderson 1995). Twenty patients with clinical NPD diagnoses were interviewed with the Diagnostic Interview for Narcissism (DIN) (Gunderson and colleagues) at baseline and three years later at follow-up, and the patients' baseline scores were compared to their follow-up scores. The DIN includes 33 characteristics for pathological narcissism, 10 of which overlap with the NPD criteria set in DSM-III-R and DSM-IV. The characteristics are grouped into five sections: grandiosity, interpersonal relations, reactiveness, affect and mood states, and social and moral adaptation. In addition to the DIN, an unstructured interview was given to explore the subjects' interval histories regarding personal, vocational and treatment events, and to identify factors that could have contributed to changes in the patients' behavior and experiences of themselves and others.

A significant decrease in the overall level of pathological narcissism occurred over the three-year period. In particular, the patients' narcissistic features had lessened in the area of their interpersonal relations and patterns of reactivity, and their unrealistic grandiose sense of themselves had substantially diminished. Of the nine NPD criteria in DSM-IV, six showed high changeability (>50 percent, defined as the rate of decrease in the DIN presence score of 2), i.e., grandiose fantasies, uniqueness, arrogant and haughty behavior, entitlement, exploitiveness and lack of empathy. Exaggeration of talents and achievements, need for admiration, and envy proved to be more stable. Sixty percent of the subjects significantly improved while 40 percent sustained a high level of pathological narcissism. This was surprising insofar as, by definition, personality disorders are expected to be stable.

Our findings suggested that what appeared to be a narcissistic personality disorder at baseline actually included two types of pathology: one being a context or state-dependent type of pathology, and the other being a more long-term and stable trait pathology. The unimproved group proved to have had a higher level of pathological narcissism in the area of interpersonal relations at baseline, especially in their capacity to become involved in committed long-term relationships. This implies that severely narcissistically disturbed interpersonal relations may be the essential feature that defines patients with narcissistic personality disorder. 

Prior research (Ronningstam and Gunderson 1990), as well as clinical and theoretical literature (Millon; Akhtar and Thomson) showed that the definition of NPD relied heavily upon characteristics of grandiosity. Our research shows that a considerable change in grandiosity occurred over the three-year period. This suggests that grandiose self-experience may be a particular mental state that is context-dependent. As such, grandiosity requires a careful assessment with specific consideration both to the patient's developmental stage-late adolescence, early adulthood, middle age-and to the mental state at the time of diagnostic evaluation.

 Another surprising result was that intervening treatment experiences (i.e., treatment length, type and intensity) were relatively equally distributed among the improved and unimproved group. In other words, treatment experiences did not differentiate between those narcissistic patients who had an enduring long-term personality disorder and those whose narcissistic pathology underwent change. What seems, however, to be causally related to the improvement in pathological narcissism were corrective life events.

Three types of such events could be identified through the unstructured interviews: those related to achievements, to interpersonal relations and to disillusionments. 

Corrective achievements, such as graduations, promotions, recognitions, acceptance to sought-after schools, programs, or positions, etc., were the most common type of life event that contributed to change in pathological narcissism. These events contributed to a more realistic and accepted sense of the self with less need for grandiose fantasies and exaggerations of talents. The following case vignette describes such development.

Case vignette #1. - Mr. A, an extremely intelligent, shy but arrogant 25-year-old man, was a college student and came for psychotherapy because he had suffered from depression for several years. Although an exceptionally competent student, he constantly felt unappreciated. He tended to devote his time in lectures to "giving the teachers and professors a hard time" by criticizing them, and asking "impossible" questions in order to prove their incompetence and make them embarrass themselves in public. He described himself as extraordinarily superior with feelings of disdain and confusion toward people he experienced as different from himself-people who he felt had lower standards and different values than he. He also described himself as intellectually unique, stressing his specific theoretical and philosophical perspectives and high academic standards. He had several close friends among his male peers, but admitted that he experienced severe problems in relating to young women, had difficulty connecting, and felt shy and insecure.Mr. A came from a very competitive and successful family background. His father was a famous lawyer in his early 60s, and Mr. A described having a complicated relationship, with mixed feelings toward the father. On the one hand he highly admired and idealized his father; on the other hand he despised the father's demands, values and expectations, and tended to take every opportunity to protest against him. While he envied his father and fantasized about becoming as successful, Mr. A also felt inferior, and believed that he would never become as successful as his father. Often he felt deeply misunderstood by his father. After successfully graduating from college, Mr. A decided to work as a pizza deliverer, a decision that he considered to be unusually risky but in line with his "unique approach" to life.

At follow-up time three years later, Mr. A reported a number of important changes and developments in his life. He had been in individual psychotherapy for 18 months and had specifically focused on depression and insecurity. A new job as a university teacher had, according to Mr. A, contributed to the most important change in his behavior and attitude toward himself and others. As a teacher, he had the opportunity to create the specific teaching atmosphere and technique he felt that his former teachers were unable to do. Through his work, he had learned to interact with people, was forced to and actually successfully managed to understand people with different ideas and values, and made efforts to develop specific teaching methods to facilitate learning and intellectual growth for his students. He described himself as more tolerant of criticism. His sense of pride was associated with a far more realistic self-appraisal and markedly diminished derogatory, arrogant behaviors. His relation with his father was still conflictual, but a more sincere desire to identify with the competent successful father had appeared. His relations to women had improved and a two-year relationship with a girlfriend also contributed to a change in Mr. A's self-esteem.

As Mr. A's experiences of realistic academic competence and independent professional responsibility increased, his need for exaggerated superior and unique self-experience and grandiose fantasies diminished as did his need to antagonize and devalue others' achievements. Animosity and arrogant, passive-aggressive oppositional behavior were replaced by active, goal-oriented professional striving, and Mr. A's underlying capacity for interpersonal relations could in that context develop. At baseline he did not present the severe manifestations of narcissistic interpersonal relations such as exploitiveness, lack of commitment, and deep envy and inability for empathy.

Corrective relationships, where the person was able to establish a long-term, close and mutual relation seemed to diminish pathological narcissism in three cases. Changes were evident in diminished need for devaluation, entitlement and exploitive behavior. Two of the subjects had actually become engaged, and one was in the process of getting married.

Case vignette # 2. - Miss B, an attractive, intelligent, self-assertive and articulate woman in her 30s, was caught stealing drugs at a drug company where she had been working as a research assistant since her graduation from college. It became evident that over the last five years she had been using increasing amounts of intravenous drugs, more recently on a daily basis.

She came from a working-class background with parents with high expectations, and she graduated from college magna cum laude. However, the parents decided not to support her continuing education in graduate school and she experienced this as a treachery.Miss B described herself as superior, especially compared to other drug abusers since she had been able to keep herself "clean" and use more sophisticated methods to gain access to drugs. Although hard to please, she usually got what she wanted. She dreamt about becoming a famous journalist, and she loved to drive her car recklessly, believing that she would not be caught. After graduation from college, three problem areas gradually emerged and became more apparent despite Miss B's intense efforts to deny their presence and consequences. A feeling of indecisiveness and lack of certainty made it difficult for her to identify her purpose and track in life. A pattern of relationships developed, especially to boyfriends, characterized by quick, intense involvement and abrupt withdrawal when the relationship stabilized and became more close. She especially feared spending sustained time with the same man and expressing and returning feelings and intimacy, and sharing personal private matters. A fear of becoming bored and failing at work also became more predominant, despite her high level of competence.

At follow-up, Miss B described several notable changes in her life. Six months of drug detoxification and drug-abuse-focused treatment and two years of psychotherapy had contributed to a remission of drug dependency and highlighted underlying problems of low self-esteem and inferiority feelings. She had been accepted to graduate school and was studying business. However, the most important and fundamental change, according to Miss B, was that she had met a man and experienced being in love for the first time in her life, and she was actually in the process of getting married.

Contrary to all previous men with whom she had been involved, she experienced that her husband-to-be accepted her, was stronger than she without defeating her, and she could feel secure and able to stay in and develop the relationship. Her self-description was no longer exaggerated and focused on her specialness; she was more realistic and pointed out changes within several areas. She used to think she did not need other people but now realized that she did and that she actually enjoyed them. In the past she felt she was different from other people and constantly misunderstood. She now realized that she had, through her tough, independent and self-sufficient demeanor, actually made people unnecessary in her life.

The most important change according to Miss B was her new capacity to tolerate and enjoy closeness and intimacy. This experience had a major impact on improving her self-esteem. Grandiose fantasies still sustained, but now related to success within the field she was studying. She still had strong feelings of envy and difficulties empathizing with other peoples' sadness, which made her helpless and disgusted.

Miss B's low self-esteem, compensatory grandiosity, recklessness and drug dependency developed out of increasing difficulties in the context of close and intimate relations. However, the absence of more severe narcissistic features (deep devaluating, condescending, ruthless, paranoid, and exploitive attitudes and behavior) in her interpersonal relations at baseline made it possible to attach, first to treaters and later to a man. The correctional achievements and being accepted to graduate school also improved her self-esteem.

Corrective disillusionment involved experiences that challenged the person's previous grandiose self-experience and actually resulted in an adjustment toward a self-concept more in accord with their actual capabilities. This could be the realization of personal, intellectual or vocational limitations, failure to achieve goals in life, or facing losses or lost opportunities in life. (However, if these disillusions are too severe and experienced without support, a development into a worsening narcissistic pathology can occur.)

Case vignette #3. - Mr. C, a man in his mid-40s, considered himself to be goal-oriented and superintelligent, with strong puritan values, quick reasoning skills and an extraordinary leadership capacity. Although happily married with two teenage sons and one younger daughter, he considered himself to be a loner, not interested in wasting time on meaningless social activities. He had a top managing position in a small Canadian company where he had worked since graduation from high school. Showing a bragging, self-praising and self-centered manner, devaluating behavioral styles of others, he did admit that he actually envied them for their social belonging.

When he reached his early 40s, two things happened in Mr. C's life. When his company suddenly and unexpectedly underwent a major expansion, he was sent to one of the most challenging business schools in the country for graduate education in order to meet the company's new needs for business expertise. At this time his sons reached adolescence and developed lifestyles, value systems and spheres of interests that disgusted and threatened Mr. C. He could not find reasonable and adequate ways to communicate with or to influence his sons. He considered himself a failure as a parent and struggled with intense aggressive impulses, urges to either detach from them totally or to punish them in various ways.

As he had been a straight-A student in college and the most intellectually accomplished person in his environment, Mr. C was at first consternated when he discovered the high level of intelligence among the students in the graduate program. It was with a combination of humbleness, envy and admiration he gradually accepted that the majority of the other students were extremely capable and that he, despite enormous efforts, only managed to maintain a B to B-plus level.

At follow-up this man, who was in the process of moving back and reinstating himself into a new position in his company, was remarkably more humble, and had less intense aggressive reactions, bragging and self-inflating behavior. He felt that he had reached the maximum of his capacity professionally and as a father, and although satisfied with his results in graduate school, he felt dethroned and incompetent in his parental role because he realized that he could not convince his sons about the importance of his own values and lifestyle. However, his intense anger was replaced with a new and more realistic ambition to become a friend and supporter of his sons.

Mr. C's experience of shortcomings and limitations in both professional and personal life was an enormous challenge for his self-esteem. However, the sustained support from his loyal wife, and his own personal flexibility and capacity to integrate initially unacceptable aspects of himself, made it possible to modify his grandiose self-experience into more realistic concepts. Although grandiosity and reactivity improved, the narcissistic interpersonal style with devaluation, envy and some arrogant behavior still remained.

This first prospective study of narcissistic patients raises questions about the construct validity of NPD. It seems as if patients with identifiable pathological narcissism and NPD actually can have grandiosity with higher degree of changeability, as well as pathologically narcissistic relations that can remain stable over time. These results also raise the question whether people with NPD differ in their capacity to gain from life events or environmental influence-whether people with certain types of narcissistic psychopathology, including more narcissistic interpersonal relations, have more difficulties in accommodating to or benefiting from environmental experiences. If these results can be replicated with other samples and with an assessment instrument that identifies and differentiates covert forms of pathological narcissism (Akhtar & Thomson; Gabbard; Cooper and Ronningstam) from overt types, a redefinition of the diagnostic category of NPD would be necessary. 

 	Akhtar S, Thomson JA Jr. Overview: narcissistic personality disorder. Am J Psychiatry. 1982;139(1):12-20.


 	Cooper A, Ronningstam E. Narcissistic Personality Disorder. In: Tasman A, Riba MB, eds. American Psychiatric Press Review of Psychiatry, Vol.  11. Washington: American Psychiatric Press; 1992.


 	Gabbard GO. Two subtypes of narcissistic personality disorder. Bull Menninger Clin. 1989;53(6):527-532.


 	Gunderson JG, Ronningstam E, Bodkin A. The diagnostic interview for narcissistic patients. Arch Gen Psychiatry. 1990;47(7):676-680.


 	Kernberg O. Borderline Conditions and Pathological Narcissism. New York: Jason Aronson; 1992.


 	Kernberg O. Internal World and External Reality. New York: Jason Aronson; 1985.


 	Millon T. Disorders of Personality DSM III: AXIS II. New York: Wiley & Sons; 1981.


 	Ronningstam E, Gunderson. Identifying criteria for narcissistic personality disorder. Am J Psychiatry. 1990;1477:918-922.


 	Ronningstam E, Gunderson J, Lyons M. Changes in pathological narcissism. Am J Psychiatry. 1995;152(2):253-257.

Articles

For clinicians, the assiduous and sustained resistance to change common in patients with narcissistic personality disorder (NPD) has been especially noticeable and trying. However, until recently the natural course of NPD has not received much attention in the clinical and empirical literature, and there is very little documented knowledge about the factors that might contribute to changes.

Narcissistic Personality: A Stable Disorder or a State of Mind?

Personality disorders are characterized by the presence of inflexible and maladaptive patterns of perceiving oneself and relating to the environment that result in psychosocial impairment or subjective distress. The enduring nature of the behaviors, their impact on social functioning, the lack of clear boundaries between normality and illness, and the patient's perception of the symptoms as not being foreign make this group of conditions more difficult to conceptualize than the more typical, episodic mental disorders. 

Personality disorders are both frequent and difficult to treat. Individuals with these problems consume substantial resources and seriously burden society. A survey of the work of Australian psychiatrists showed that although patients with personality disorders amounted to only 6 percent of the people in treatment, they exhausted 13 percent of the psychiatrists' treatment time (Andrews and Hadzi-Pavlovic). 

 includes diverse conditions that originated in very different clinical, theoretical and research settings, as Rutter pointed out. Some conditions, such as the concept of borderline personality disorder, are mainly the result of psychodynamic thinking. Others, such as schizotypal personality disorder, have their origin predominantly in genetics. Irrespective of the history of each construct, most experts agree that personality disorders emanate from childhood. 

Despite this, little empirical evidence is available on the developmental pathways that underpin these disorders, with the exception of antisocial personality disorder (Robins; Zoccolillo and others). This evidentiary lack may be the consequence of ambiguities surrounding the concepts of temperament, character and personality (Rutter) or the result of child and adolescent psychiatrists being reluctant to make a diagnosis of personality disorder. The recent surge of research reports dealing with personality disorders in adolescent groups suggests that this reluctance may be waning. 

Because personality is shaped by experiences during childhood and adolescence, it is likely that mental disorders occurring during these years may have an influence on personality development. Childhood mental disorders may increase the risk of affected children developing a personality disorder when they grow up. This can happen in a variety of ways. The disorder itself, for example, depression, may directly influence personality development. Alternatively, symptoms of the condition (e.g., disruptive disorder) may elicit environmental responses (e.g., increased control or likelihood of abuse by caregivers) that in turn may alter personality development. It may be that the disorder observed in childhood is an earlier manifestation of the same underlying pathology that results in the development of personality disorder in adulthood. Consequently, the study of the continuities between child or adolescent disorders and adult personality disorders is likely to be a fertile ground that will facilitate our understanding of these conditions.

Seeking to clarify some of these issues, my colleagues and I followed up a group of adolescents who had been referred for assessment to an adolescent unit in Sydney, Australia (Rey and others). Follow-up consisted of a lengthy interview during which a variety of diagnostic instruments and questionnaires was administered. These included the Personality Disorders Examination (Loranger). At the time of initial assessment, the average age was 14 years, while at follow-up it was 20 years. Of the 205 subjects who were located, 145 were fully interviewed. About half of these (44 percent) were female. 

During the ensuing six years, four of the subjects had died. One female, initially diagnosed as having attention-deficit disorder with hyperactivity, died of a heroin overdose following a period of severe disturbance during which she probably met criteria for conduct disorder. Two males suffered from conduct disorder. One committed suicide; the other died of multiple organ failure caused by hepatitis one day after being released from prison. One male had an adjustment disorder with disturbance of conduct. Reports from relatives at the time of follow-up suggest he was well-adjusted. He died in a car accident. There were 114 (56 percent) individuals with a disruptive disorder diagnosis among the 205 subjects located. Although numbers are too small to draw conclusions, these findings suggest that mortality (3.5 percent) among adolescents with these conditions is likely to be high.

 The main findings from the examination of the relationships between adolescent diagnosis, developmental variables and adult personality disorder were:

Personality disorders were frequent (28 percent), particularly among those with disruptive diagnoses (40 percent). Further, of those young adults with a personality disorder, one-third had more than one personality disorder diagnosis.

Females were more likely than males to have a Cluster C personality disorder. However, males were not more likely to have a Cluster B disorder once the effect of adolescent diagnosis was taken into account.

Adolescents with disruptive disorders were more likely to have a Cluster B personality disorder than those with an emotional disorder but not less likely to have a Cluster C disorder.

Significant associations existed between conduct disorder and antisocial personality disorder and between attention-deficit/hyperactivity disorder .i.attention-deficit/ hyperactivity disorder;(ADHD) and borderline personality disorder.

Quality of the family environment before the age of 12 years was the most robust developmental predictor of personality disorder in young adults. Externalizing symptoms between the ages of 4 and 7 years was also predictive of Cluster B personality disorders (unpublished data).

While the continuity between conduct disorder and antisocial personality is well documented, the association between ADHD in adolescents and borderline personality disorder in young adults was unexpected. It contrasts with the reported lack of continuity between childhood and adult borderline disorders (Lofgren and others).

The impulsive, erratic, intense temperament of ADHD children, their low self-esteem, interpersonal problems and moodiness are characteristics shared with borderline personality disorder and give face validity to this link. However, the association between ADHD and borderline personality disorder can have several explanations. 

There might be a continuity between the two conditions; ADHD in children may elicit a response in their caregivers that in turn results in an increased risk for borderline personality disorder; both disorders may have some other common etiologic factor; or this association may be an artifact of poor diagnostic operationalization of the constructs.

If ADHD is confirmed as one of the pathways leading to borderline personality disorder, particularly in females, a reappraisal of the nature of this disorder might be required. In the meantime, clinicians need to keep in mind the possibility of this negative outcome when treating ADHD patients, particularly if they are female. 

Females with ADHD are an under-researched group that may have severe and complex psychopathology and requires more attention. Conversely, practitioners might find it useful to inquire into the presence of ADHD symptoms during childhood when assessing patients with borderline personality disorder.

When psychosocial functioning in this group of young adults was examined (unpublished data), my colleagues and I found that having a personality disorderand not adolescent diagnosiswas the best predictor of poor functioning at follow-up. The adult functioning of referred adolescents who had emotional or disruptive disorders was comparable in adulthood when the effect of having a personality disorder was controlled. Developing a personality disorder seems to be the critical factor which results in poor functioning. This is consistent with findings already reported (Casey and Tyrer, Shea and others; Klein and Mannuzza; Johnson and others; Quinton and others). However, developmental variables, with the exception of quality of the family environment, did not contribute to the predictability of poor functioning over and above the effect of having a personality disorder.

Subjects with personality disorders were in trouble with the law, unemployed, cohabiting with a sexual partner, had no friends, did not go out socially, had problems in their relationships with other people and felt that their life situation was bad more often than their counterparts without a personality disorder. Antisocial personalities were typified by difficulties with the law, poor work record and early cohabitation. This is consistent with other reports (Robins and others). Other personality disorders were characterized mainly by social isolation and problems in interpersonal relationships. 

These results suggest that individuals suffering from disruptive disorders in adolescence have a particularly negative personality outcome in adulthood. Not only conduct disorder but all disruptive disorders are associated with a wide range of personality psychopathology. This finding emphasizes the importance of these childhood conditions in relation to a variety of mental health problems in adulthood besides antisocial behavior. It would also appear from these results that to diminish the risk of personality disorder and poor psychosocial functioning in adult life it will be necessary to devise interventions that will improve the quality of the family environment, and will reduce disruptive behavior symptoms during childhood and disruptive disorders during adolescence.

Dr. Rey is director of Rivendell Child, Adolescent and Family Psychiatric Services and clinical professor, department of psychological medicine, University of Sydney.

Personality disorders are characterized by the presence of inflexible and maladaptive patterns of perceiving oneself and relating to the environment that result in psychosocial impairment or subjective distress. The enduring nature of the behaviors, their impact on social functioning, the lack of clear boundaries between normality and illness, and the patient's perception of the symptoms as not being foreign make this group of conditions more difficult to conceptualize than the more typical, episodic mental disorders.

Antecedents of Personality Disorders in Young Adults

A Secret Service agent recently asked if I was familiar with a 1992 FBI report that almost half of the killers of law enforcement officers met the criteria for 

. I replied that I had not seen the report but that the finding did not seem surprising or noteworthy to me. My comment was based on the assumption that the report had used 

 as a synonym for antisocial personality disorder (ASPD), a category listed in the fourth edition of the 

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)

 and applicable to the majority of criminals.

However, the agent explained that the description of the killers in question indicated to him that they matched the profile of the psychopath defined by the Psychopathy Checklist-Revised (Hare 1991). When I later saw a copy of the FBI report, I realized that he was correct in his assessment and that the report's findings were indeed noteworthy and chilling, particularly for law enforcement officers.

The killers' characteristics referred to as antisocial personality in the FBI report were as follows: sense of entitlement, unremorseful, apathetic to others, unconscionable, blameful of others, manipulative and conning, affectively cold, disparate understanding of behavior and socially acceptable behavior, disregardful of social obligations, nonconforming to social norms, irresponsible. These killers were not simply persistently antisocial individuals who met 

criteria for ASPD; they were psychopaths- remorseless predators who use charm, intimidation and, if necessary, impulsive and cold-blooded violence to attain their ends.

The distinction between psychopathy and ASPD is of considerable significance to the mental health and criminal justice systems. Unfortunately, it is a distinction that is often blurred, not only in the minds of many clinicians but in the latest edition of 

Traditionally, affective and interpersonal traits such as egocentricity, deceit, shallow affect, manipulativeness, selfishness, and lack of empathy, guilt or remorse, have played a central role in the conceptualization and diagnosis of psychopathy (Cleckley; Hare 1993; in press); Widiger and Corbitt). In 1980 this tradition was broken with the publication of 

 Psychopathy-renamed antisocial personality disorder- was now defined by persistent violations of social norms, including lying, stealing, truancy, inconsistent work behavior and traffic arrests.

Among the reasons given for this dramatic shift away from the use of clinical inferences were 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. The result was a diagnostic category with good reliability but dubious validity, a category that lacked congruence with other, well-established conceptions of psychopathy. This "construct drift" was not intentional but rather the unforeseen result of reliance on a fixed set of behavioral indicators that simply did not provide adequate coverage of the construct they were designed to measure.

 were widely discussed in the clinical and research literature (Widiger and Corbitt). Much of the debate concerned the absence of personality traits in the diagnosis of ASPD, an omission that allowed antisocial individuals with completely different personalities, attitudes and motivations to share the same diagnosis. At the same time, there was mounting evidence that the criteria for ASPD defined a disorder that was more artifactual than "real" (Livesley and Schroeder).

in 1980, I presented some preliminary findings on efforts to provide researchers with an operational definition of psychopathy in offender populations (Hare 1980). During the next decade those early efforts evolved into the Hare Psychopathy Checklist-Revised (PCL-R) (Hare 1991), a 20-item construct rating scale that uses a semi-structured interview, case-history information and specific diagnostic criteria for each item to provide a reliable and valid estimate of the degree to which an offender or forensic psychiatric patient matches the traditional (prototypical) conception of the psychopath (Fulero; Stone). Each item is scored on a 3-point scale (0, 1, 2) according to the extent to which it applies to the individual. The total score can range from 0 to 40, with between 15 percent and 20 percent of offenders receiving a score of at least 30, the cutoff for a research diagnosis of psychopathy. To put this into context, the mean scores for offenders in general and for noncriminals typically are around 22 and 5, respectively.

A 12-item version of the PCL-R was developed for use in the MacArthur Foundation study on the prediction of violence in the mentally disordered (Hart and others 1994). Published in 1995 as the Hare Psychopathy Checklist: Screening Version (PCL:SV) by Hart and colleagues, it is highly correlated with the PCL-R and is used both to screen for psychopathy in forensic populations and as a stand-alone instrument for the assessment of psychopathy in noncriminal populations. The PCL:SV formed the basis for the psychopathic personality disorder items used in the DSM-IV field trial for ASPD.

The items fall into two clusters: One cluster, referred to as Factor 1, reflects core interpersonal and affective characteristics; the other cluster, Factor 2, consists of items that reflect a socially deviant and nomadic lifestyle. The similarity between these factors and the behaviors and characteristics described above in the FBI report are obvious.

 (with the exception of those who somehow manage to plow their way through life without coming into formal or prolonged contact with the criminal justice system) meet the criteria for ASPD, 

but most individuals with ASPD are not psychopaths

. Further, ASPD is very common in criminal populations, and those with the disorder are heterogeneous with respect to personality, attitudes and motivations for engaging in criminal behavior.

As a result, a diagnosis of ASPD has limited utility for making differential predictions of institutional adjustment, response to treatment, and behavior following release from prison. In contrast, a high PCL-R score depends as much on inferred personality traits as on antisocial behaviors, andwhen used alone or in conjunction with other variableshas considerable predictive validity with respect to treatment outcome, institutional adjustment, recidivism and violence (Hare 1991; Harris and others; Hart and Hare, in press).

For example, several studies have found that psychopathic offenders or forensic psychiatric patients (as defined by the PCL-R) are as much as three or four times more likely to violently reoffend following release from custody than are nonpsychopathic offenders or patients. ASPD, on the other hand, has relatively little predictive power, at least with forensic populations (Hart and Hare, in press).

It might be argued that a diagnosis of ASPD is useful in civil psychiatric settings, particularly as a general risk factor for substance abuse (Leal and others). Even here, however, psychopathy may be more important than ASPD in understanding substance abuse (Alterman and colleagues; Cacciola and others).

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.

Widespread dissatisfaction with the conceptualization and criteria for ASPD led the American Psychiatric Association to initiate a field trial in preparation for 

. A stated goal of the trial (Widiger and others) was to improve coverage of the traditional symptoms of psychopathy. Included with the 

criteria for ASPD was a 10-item version of the PCL-R, referred to in the trial as the 

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 

 items (Widiger and colleagues). Thus, the original premise for excluding personality from the diagnosis of psychopathy/ASPD (in 

) turned out to be untenable. There was now a firm empirical basis for increasing the content-related validity of ASPD in 

, 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 

 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 

 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 

as a necessary condition for a diagnosis of ASPD.

Things become even more problematic when we consider that the 

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.

An unfortunate consequence of the ambiguity inherent in 

 is likely to be a court case in which one clinician says the defendant meets the 

 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 

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 

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.

 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 

. 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 

criteria for ASPD (Cooke). Diagnostic confusion about the two disorders has the potential for harming psychiatric patients and society as well.

, 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.

Neurobiology of Impulsive-Aggressive Personality-Disordered Patients

Understanding the Usefulness of Psychosocial Interventions for Personality Disorders

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Psychopathy (renamed antisocial personality disorder) is marked by persistent violations of social norms, including lying, stealing, truancy, inconsistent work behavior and traffic arrests.

Psychiatric Times Vol 13 No 2

Narcissistic Personality: A Stable Disorder or a State of Mind?

Antecedents of Personality Disorders in Young Adults

Psychopathy and Antisocial Personality Disorder: A Case of Diagnostic Confusion