ANRV339-CP04-09 ARI 22 February 2008 18:19

Psychopathy as a Clinical
and Empirical Construct
Annu. Rev. Clin. Psychol. 2008.4:217-246. Downloaded from www.annualreviews.org

Robert D. Hare1 and Craig S. Neumann2

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1
University of British Columbia, Vancouver, British Columbia BC V6T 1Z4;
2
University of North Texas, Denton, Texas 76203-1280;
email: rhare@interchange.ubc.ca, csn0001@unt.edu

Annu. Rev. Clin. Psychol. 2008. 4:217–46 Key Words

First published online as a Review in Advance on Cleckley, PCL-R, construct, personality, neuroscience, structure,
November 20, 2007
antisocial
The Annual Review of Clinical Psychology is online
at http://clinpsy.annualreviews.org Abstract
This article’s doi: In this review, we focus on two major influences on current concep-
10.1146/annurev.clinpsy.3.022806.091452
tualizations of psychopathy: one clinical, with its origins largely in
Copyright  c 2008 by Annual Reviews. the early case studies of Cleckley, and the other empirical, the re-
All rights reserved
sult of widespread use of the Hare Psychopathy Checklist-Revised
1548-5943/08/0427-0217$20.00 (PCL-R) for assessment purposes. Some investigators assert that the
PCL-R, ostensibly based on Cleckley’s work, has “drifted” from the
construct described in his Clinical Profile. We evaluate this profile,
note its basis in an unrepresentative sample of patients, and suggest
that its literal and uncritical acceptance by the research community
has become problematical. We also argue that the idea of construct
“drift” is irrelevant to current conceptualizations of psychopathy,
which are better informed by the extensive empirical research on
the integration of structural, genetic, developmental, personality,
and neurobiological research findings than by rigid adherence to
early clinical formulations. We offer some suggestions for future
research on psychopathy.

217
 ANRV339-CP04-09 ARI 22 February 2008 18:19

well as that of other early twentieth-century

Contents clinicians, was the search for reliable and
valid instruments to assess the disorder. The
INTRODUCTION . . . . . . . . . . . . . . . . . 218
most widely used of these instruments is the
THE PSYCHOPATHY
Hare Psychopathy Checklist-Revised (PCL-
CHECKLIST-REVISED . . . . . . . . 219
R; Hare 1991, 2003). The enormous increase
Measure as Construct? . . . . . . . . . . . . 221
in theory and research on psychopathy over
CLECKLEY REVISITED . . . . . . . . . . 221
the past two decades owes much to the de-
Construct Drift? . . . . . . . . . . . . . . . . . 222
velopment and adoption of the PCL-R as a
Evidence for Construct Drift? . . . . . 223
common metric for assessing the disorder. Its
Does It Matter? . . . . . . . . . . . . . . . . . . 224
impact has been felt by researchers who con-
Cleckley’s Patients . . . . . . . . . . . . . . . . 225
duct basic research on the etiology and na-
Annu. Rev. Clin. Psychol. 2008.4:217-246. Downloaded from www.annualreviews.org

Cleckley’s Clinical Profile:

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ture of psychopathy (e.g., Blair et al. 2005,

Empirical Analyses . . . . . . . . . . . . 225
Newman et al. 2007, Patrick 2006a), and by
Cleckley’s Clinical Profile:
those more concerned with the implications of
Rational Analyses . . . . . . . . . . . . . . 226
psychopathy for the mental health and crimi-
Cleckley and Antisocial Behavior . . 229
nal justice systems (e.g., Felthous & Saß 2007,
Clinician as Construct? . . . . . . . . . . . 230
Gacono 2000, Hervé & Yuille 2007). The
EMPIRICAL ASPECTS OF
Buros Mental Measurements Yearbooks de-
THE PSYCHOPATHY
scribed the PCL-R as the standard tool for the
CONSTRUCT . . . . . . . . . . . . . . . . . . 231
assessment of psychopathy (Acheson 2005,
Finding Structure in Psychological
Fulero 1995). It is a basis for the develop-
Phenomena . . . . . . . . . . . . . . . . . . . 231
ment and validation of most other instruments
Searching for the Structure
currently in use for the assessment of the
of Psychopathy . . . . . . . . . . . . . . . . 232
disorder.
The Superordinate Nature
In this review, we examine the associations
of Psychopathy . . . . . . . . . . . . . . . . 233
between selected clinical and empirical con-
The Dimensional Nature
ceptualizations of psychopathy, the former as
of Psychopathy . . . . . . . . . . . . . . . . 234
reflected in Cleckley’s writings, and the latter
Associations of Normal-Range
as obtained from the use of the PCL-R and
Personality with Psychopathy . . 235
related instruments. The main themes for the
Behavior Genetics of
analyses are (a) an examination of Cleckley’s
Psychopathic Traits . . . . . . . . . . . . 238
Clinical Profile and the uncritical acceptance
Longitudinal Nature of
of it as the definitive word on psychopathy;
Psychopathic Traits . . . . . . . . . . . . 238
(b) the argument that the PCL-R has “drifted”
Biological and Cognitive Features
from its roots in the writings of Cleckley
of Psychopathy . . . . . . . . . . . . . . . . 239
and other clinicians; (c) the role of antisocial
CONCLUSIONS . . . . . . . . . . . . . . . . . . . 240
behavior in the conceptualization and mea-
surement of psychopathy; (d ) the structural
properties of the psychopathy construct,
INTRODUCTION with emphasis on its measurement with the
Hervey Cleckley’s clinical descriptions, in- PCL-R; and (e) concerns that the PCL-R has
sights, and speculations, detailed in The Mask become the construct. The latter theme is
of Sanity (1941/1976), have had a strong in- discussed briefly below; the other themes are
fluence on empirical investigations of psy- addressed in separate sections throughout
chopathy, particularly in North America. An this review. We begin with a synopsis of the
important outgrowth of Cleckley’s work, as PCL-R.

218 Hare · Neumann

 ANRV339-CP04-09 ARI 22 February 2008 18:19

THE PSYCHOPATHY tic and Statistical Manual of Mental Disorders,

CHECKLIST-REVISED Third Edition (DSM-III; American Psychi-
atric Association 1980). The PCL and PCL-R
The popularity and importance of the PCL-
combined personality traits and antisocial be-
R and its derivatives for basic and applied
haviors, whereas the emphasis in APD was,
research have led to many reviews, discus-
and continues to be, antisocial behavior (see
sions, and meta-analyses, as well as unusu-
Widiger et al. 1996).
ally intensive scrutiny, both theoretical and
The PCL-R is a clinical construct rat-
empirical. This literature is too extensive to
ing scale that uses a semistructured interview,
summarize here, but many recent accounts
case history information, and specific scor-
are readily available elsewhere (e.g., Blair et al.
ing criteria to rate each of 20 items on a
2005, Book et al. 2006, Felthous & Saß 2007,
3-point scale (0, 1, 2) according to the ex-
Annu. Rev. Clin. Psychol. 2008.4:217-246. Downloaded from www.annualreviews.org

Hare 2007, Hare & Neumann 2006, Hervé

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tent to which it applies to a given individ-

& Yuille 2007, Leistico et al. 2007, Patrick
ual. As described below (Searching for the
2006a).
Structure of Psychopathy section; Figure 1),
Briefly, the PCL-R and its predecessor, the
18 of the items form four factors or di-
PCL (Hare 1980), arose because of the se-
mensions: Interpersonal (glibness/superficial
nior author’s concern in the 1970s about the
charm, grandiose sense of self worth, patho-
lack of reliable, valid, and generally accepted
logical deception, conning/manipulative); Af-
tools for the assessment of psychopathy. This
fective (lack of remorse or guilt, shallow affect,
concern was fuelled in large part by events
callous/lack of empathy, failure to accept re-
that occurred at a 1975 NATO conference
sponsibility for actions); Lifestyle (need for
(see Hare & Neumann 2006 for details) and
stimulation/proneness to boredom, parasitic
that played a role in the subsequent develop-
lifestyle, lack of realistic long-term goals,
ment of the PCL and the criteria for antisocial
impulsivity, irresponsibility); and Antisocial
personality disorder (APD) in the Diagnos-

glib/ lack remorse

superficial or guilt
.73 .80
grandiose .73 .65 shallow
self-worth affect
.70
.71 Interpersonal Affective .82
pathological callous
lying lack empathy

conning .66 .59 fail to accept

manipulative .42 .55 responsibility

.50 .51

stimulation poor behavior

seeking .65 controls
.73

impulsivity .71 .70 early behavior

problems
.60 .67
Lifestyle Antisocial
irresponsible .73
juvenile Figure 1
delinquency
.58 .54 Four-factor PCL-R
parasitic revocation of item-based model of
orientation cond. release psychopathy (N =
.60 .64 6929). Reprinted
lack of criminal with permission of
realistic goals versatility
Guilford Press.

www.annualreviews.org • Psychopathy as a Clinical and Empirical Construct 219

 ANRV339-CP04-09 ARI 22 February 2008 18:19

glib/ lack remorse

superficial or guilt
.73 .80
grandiose .65 shallow
self-worth .73 affect

pathological .71 Interpersonal Affective .82 callous

lying lack empathy

conning .66 .77 .90 .59 fail to accept

manipulative responsibility

F1
Annu. Rev. Clin. Psychol. 2008.4:217-246. Downloaded from www.annualreviews.org

.68
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stimulation F2 poor behavior

seeking .65 controls
.73

.71 .91 .81 .70 early behavior

impulsivity
problems
.60 .67
Lifestyle Antisocial
Figure 2 irresponsible juvenile
delinquency
Two-factor PCL-R .58 .54
higher-order parasitic revocation of
representation of orientation cond. release
.60 .64
the four correlated
factors model lack of criminal
realistic goals versatility
(N = 6929).

(poor behavioral controls, early behavior Walters et al. 2007a), the Psychopathy Check-
problems, juvenile delinquency, revocation list: Screening Version (PCL: SV; Hart et al.
of conditional release, criminal versatility). 1995, Walters et al. 2007b), the Psychopathy
Two other items (promiscuous sexual behav- Checklist: Youth Version (PCL: YV; Forth
ior, many short-term relationships) do not et al. 2003, Murrie et al. 2007), the Antiso-
load on any factor but contribute to the to- cial Process Screening Device (APSD; Frick
tal PCL-R score. The Interpersonal/Affective & Hare 2001, Murrie et al. 2007), or by self-
dimensions and the Lifestyle/Antisocial di- report (Marcus et al. 2004). Because there are
mensions comprise, respectively, the PCL-R no exclusion criteria for its use, it is possi-
Factors 1 and 2 (see Figure 2) described by ble to investigate PCL-R comorbidity with
Hare (2003). Total PCL-R scores can vary other disorders, but its dimensional nature
from 0 to 40 and reflect the degree to which suggests that a likely scenario is overlap of
the individual matches the prototypical psy- symptoms. There is an extensive literature at-
chopath. For research and “diagnostic” pur- testing to the reliability and validity of the
poses, a cut score of 30 typically is used for PCL-R, as well as increasing evidence that
psychopathy, perhaps implying to some that it generalizes well across a variety of pop-
the construct measured by the PCL-R is tax- ulations and contexts (e.g., Bolt et al. 2007,
onic. However, there now is good evidence Cooke et al. 2005, Hare 2003). Debates about
that the structure of psychopathy is dimen- its structural properties are examined in the
sional in nature, whether measured by the section on Searching for the Structure of
PCL-R (Edens et al. 2006, Guay et al. 2007, Psychopathy.

220 Hare · Neumann

 ANRV339-CP04-09 ARI 22 February 2008 18:19

The PCL-R was designed as a research development for the field. Indeed, efforts over
scale to measure the clinical construct of the past decade have expanded the assessment
psychopathy, and it is widely used for this pur- repertoire to include a variety of behavioral
pose. However, because of its demonstrated rating scales, specialized self-report scales,
ability to predict recidivism, violence, and and omnibus personality inventories (see
treatment (e.g., Leistico et al. 2007), the PCL- Frick & Hare 2001, Lilienfeld & Fowler 2006,
R routinely is used in forensic assessments, ei- Livesley 2007, Lynam & Gudonis 2005,
ther on its own or, more appropriately, as part Lynam & Widiger 2007, Williams et al.
of a battery of variables and factors relevant to 2007). Many of these measures are concep-
forensic psychology and psychiatry (see Hare tually related to the PCL-R; others have
2007b, Hilton et al. 2007, Quinsey et al. 2006, their origins in empirical research on psy-
Webster et al. 1997). chopathology and general personality. All
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A derivative of the PCL-R, the PCL: benefit from the large body of theory and re-
SV, was constructed for use in nonforensic search that resulted from widespread adop-
contexts. It is used as a screen for psychopa- tion of the PCL-R family of instruments.
thy or as a stand-alone instrument for assess- Rather than being concerned about its popu-
ing psychopathy in civil psychiatric and com- larity, clinicians might better view the PCL-R
munity populations (Guy & Douglas 2006, as an “anchor for the burgeoning nomologi-
Hare 2007b). It is strongly related to the cal network of psychopathy” (Benning et al.
PCL-R, both conceptually and empirically 2005b, p. 271). This network not only in-
(Cooke et al. 1999, Guy & Edens 2006). The cludes diverse measurement tools but also in-
Psychopathy Checklist: Youth Version (PCL: put from behavioral genetics, developmental
YV; Forth et al. 2003) is an age-appropriate, psychopathology, personality theory, cogni-
downward extension of the PCL-R. Both tive neuroscience, and community studies.
the PCL: SV and the PCL: YV have much
the same conceptual, psychometric, struc-
tural, and predictive properties as the PCL-R CLECKLEY REVISITED
(e.g., Book et al. 2006, Neumann et al. 2006, In a recent article, Westen & Weinberger
Vitacco et al. 2005). (2004) commented, “An emerging body of re-
search suggests that clinical observations, just
like lay observations, can be quantified us-
Measure as Construct? ing standard psychometric procedures, so that
There is little doubt that the PCL-R and clinical description becomes statistical predic-
its derivatives have become the dominant in- tion” (p. 595). They went on to say, “Virtu-
struments for the assessment of psychopa- ally all current research on psychopathy. . .
thy and that their use has resulted in the presupposes the observations of a bril-
accumulation of a large body of replicable liant clinical observer [Cleckley 1941] whose
findings, both basic and applied. Although clinical immersion among psychopaths over
some might view such a situation as felic- 60 years ago still provides the foundation
itous, others (e.g., Cooke et al. 2005) have for the measure considered the gold stan-
expressed concerns that the PCL-R has be- dard in psychopathy research . . .” (p. 599).
come the construct. The first two meetings The measure to which they refer is the PCL-
(2005, 2007) of the new Society for the Scien- R. Similarly, Minzenberg and Siever (2006,
tific Study of Psychopathy made it clear that p. 251) noted, “DSM-IV criteria for APD
although the PCL-R may be the dominant consist almost exclusively of behavioral indi-
measure of psychopathy, it clearly has not im- cators, neglecting the affective-interpersonal
peded attempts by researchers to devise and features that appear to reflect much of the no-
validate other measurement tools, a healthy tion of a distinct personality type as described

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 ANRV339-CP04-09 ARI 22 February 2008 18:19

by Cleckley [1941/1976]. To address these is- sions and other signs of irrational thinking;
sues, Hare and colleagues revived the con- 3) absence of “nervousness” or psychoneu-
struct of psychopathy, operationally defined rotic manifestations; 4) unreliability; 5) un-
by the Psychopathy Checklist, presently avail- truthfulness and insincerity; 6) lack of remorse
able in a revised version.” or shame; 7) inadequately motivated antiso-
Their comments illustrate the conceptual cial behavior; 8) poor judgment and failure to
connection that exists between the work of learn by experience; 9) pathologic egocentric-
Cleckley and the development and nature of ity and incapacity for love; 10) general poverty
the PCL-R and its derivatives. It is important in major affective reactions; 11) specific loss of
to note, however, that Cleckley was not the insight; 12) unresponsiveness in general in-
only inspiration for the PCL-R and its pre- terpersonal relations; 13) fantastic behavior
decessor, the PCL (Hare 1980). Many other with drink and sometimes without; 14) suicide
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clinicians and investigators, including Arieti, rarely carried out; 15) sex life impersonal, triv-
Karpman, Gough, Quay, and William and ial, and poorly integrated; 16) failure to follow
Joan McCord, to name but a few, also made any life plan.
major contributions to a “traditional concept Based on earlier comments about the
of psychopathy” (Hare 1991). The PCL, and PCL-R made by Rogers (1995), Salekin
later the PCL-R, were designed to tap this (2002) had this to say: “[W]hile psychopa-
clinical tradition, as exemplified in, but not thy has received increasing attention from
restricted to, the writings of Cleckley. In par- both clinicians and scientists over the last two
ticular, derivation of the PCL and the PCL-R decades, it is important to note that the defini-
was not based on uncritical acceptance and tions of the disorder have drifted from earlier
mechanical application of the 16 characteris- conceptualizations provided by Cleckley and
tics (the so-called Cleckley criteria) listed in theorists before him” (p. 81). More recently,
his Clinical Profile, but rather on (a) an ap- Patrick (2006b) suggested that PCL-R scores
preciation of the rich clinical material con- “index a construct somewhat different from
tained in the body of the text, much original Cleckley,” for several reasons. First, Cleck-
and some an interpretation and integration of ley’s description of the psychopath as not par-
other clinical writings; and (b) fifteen years of ticularly hostile or aggressive is at odds with
experience and empirical research by the se- empirical data that the PCL-R is strongly re-
nior author and his colleagues, as well as the lated to “the personality traits of aggression
many scores of theoretical and empirical arti- and antagonism” and is “reliably predictive
cles on psychopathy published in the years be- of aggressive behavior and violent recidivism
fore the PCL was first described (Hare 1980) in criminal offenders” (p. 608). We see this
and before a draft version of the PCL-R was as less of a problem with the PCL-R than as
first circulated in 1985. We mention this be- indication of scientific progress. Patrick also
cause some commentators have asserted that noted that Cleckley’s Clinical Profile included
the PCL-R actually is characterized by “con- several items (1, 2, 3, and 14) indicative of
struct drift” from the entity that Cleckley had “positive adjustment,” whereas these items are
in mind when he wrote the various editions not part of the PCL-R. We address this is-
of The Mask of Sanity. We address this and sue below. Cooke et al. (2005) also have ar-
related issues in the sections that follow. gued that the PCL-R deviates from its roots
in Cleckley because it includes antisocial be-
havior in the conceptualization and measure-
Construct Drift? ment of psychopathy. The impression given
Cleckley (1976) listed the following features by these commentators is that the PCL-R has
in his Clinical Profile: 1) superficial charm strayed from the “truth,” that this represents
and good “intelligence”; 2) absence of delu- a problem for the PCL-R and the field, and

222 Hare · Neumann

 ANRV339-CP04-09 ARI 22 February 2008 18:19

that subsequent research should go “back to were highly correlated (r’s = 0.80–0.90) with
the future” (Patrick 2006b, p. 605). the PCL and the PCL-R (see Hare 2003).
The correlations among these three measures
Evidence for Construct Drift? (global ratings, 16-item scale, PCL scales)
The term “construct drift” is catchy, but what approach their reliabilities and suggest that
is the theoretical or empirical evidence that they measure much the same construct. Vir-
the idea has any validity at all? We note that tually the same pattern of correlations among
Cleckley did not compile (nor rank-order) the the PCL-R, Cleckley global ratings, and total
list of characteristics in the Clinical Profile for scores derived from the Cleckley items, was
purposes of formal assessment, but rather as a obtained in a recent study of female offenders
clinical synopsis of what he considered to be (Kennealy et al. 2007). To put these correla-
typical of his psychopathic patients. tions into context, they are in the same range
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Prior to the PCL, Hare and his colleagues as the correlations between the PCL-R and its
used Cleckley’s writings as a general frame- derivative, the PCL: SV. Item response the-
work for making global clinical (prototypical- ory (IRT) analysis indicated that the latter is
ity) ratings of psychopathy. However, in some “so strongly and linearly related to PCL-R
cases each of the 16 characteristics in the Clin- total scores that the scales can be considered
ical Profile was scored on a 3-point scale, with metrically equivalent measures of the same
0 indicating that the characteristic definitely psychological construct” (Cooke et al. 1999,
was not present or did not apply, 1 indicat- p. 11). Although IRT has not been used to
ing some uncertainty about whether or not compare the three measures described above,
it applied, and 2 indicating that it definitely it is not a big stretch to conclude from these
was present or applied. Hare (1980) reported early studies that they tap much the same
that the resulting scale had good internal con- construct and that the PCL scales are con-
sistency but that some items were difficult to ceptually consistent with Cleckley’s views on
score or were only weakly related to the other psychopathy. As Lynam & Gudonis (2005,
items. p. 382) put it, “Since Cleckley’s original writ-
In developing the PCL, care was taken to ings, other clinicians and researchers [Buss
make it conceptually consistent with much 1966, Hare 2003, Karpman 1941, McCord &
of what Cleckley had to say about psychopa- McCord 1964] have been remarkably consis-
thy. However, we also took into account the tent in their descriptions of the psychopath.”
work of other influential clinicians, as well After the introduction of the PCL, there
as the many years of experience and em- have been few studies in which individuals are
pirical research by the senior author and identified as psychopathic through use of the
other investigators, with the result that several 16-item clinical profile described by Cleckley.
items not in the Clinical Profile were added. In sharp contrast, numerous empirical studies
Nonetheless, the PCL was strongly correlated have used the PCL and the PCL-R to gen-
(r = 0.83) with the 16-item scale described erate a large body of findings that generally
above, and a series of factor analyses and is in line with the traditional conception of
canonical correlations led to the conclusion psychopathy, as exemplified by Cleckley and
that “All of the clinically important informa- other clinicians. Ironically, if there has been
tion contained in the Cleckley criteria ap- construct drift, it is the construct measured
pears to be covered by the checklist” (Hare by the PCL-R—not the one some argue was
1980, p. 118). Moreover, the global ratings of described by Cleckley—that has received the
the “Cleckley psychopath” were highly cor- vast majority of empirical support. Cleckley’s
related (independent raters) with the 16-item views were based on intensive study of several
scale (r = 0.84). In several studies by Hare hundred patients (see below), whereas sup-
and other researchers, these global ratings port for the validity of the PCL-R and the

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 ANRV339-CP04-09 ARI 22 February 2008 18:19

construct it measures is provided by hundreds tion are much the same. Although the edi-
of studies involving many thousands of indi- tions are very similar, there also are some sub-
viduals from a variety of populations. In any stantive differences. For example, the 1941
case, we contend that arguments in favor of chapter titled “A Clinical Profile” listed 21
the drift hypothesis are not based on empirical characteristics of psychopathy, paraphrased
evidence but rather on side-by-side armchair as follows: 1) usually very attractive person
comparisons of two lists of characteristics, one superficially, more clever than average, su-
based on clinical/empirical and psychometric perior general objective intelligence; 2) free
considerations and the other on literal appli- from demonstrable symptoms of psychosis,
cations of a clinical synopsis provided more free from any marked nervousness of other
than half a century ago. symptoms of a psychoneurosis; 3) no sense
of responsibility, not concerned about irre-
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sponsible behavior; 4) total disregard for the

Does It Matter? truth; 5) does not accept blame for actions;
Before attempting to answer the question of 6) no sense of shame; 7) undependable, cheats
whether it matters, we should note that if the and lies without compunction, commits an-
term “construct drift” is meant to describe dif- tisocial acts without adequate motivation;
ferences between the Cleckley and the PCL-R 8) execrable judgment; 9) inability to learn or
conceptions of psychopathy, it clearly is mis- profit from experience; 10) egocentricity, in-
applied. A more appropriate term would be capacity for object-love; 11) general poverty
“construct shift.” If substantive differences ex- of affect, readiness of expression rather than
ist, they did not develop gradually but rather depth of feeling; 12) lacks insight, cannot see
were present at the inception of the PCL, the self as others see him; 13) no appreciation for
result of item selection procedures that were kindness or consideration shown by others;
based on experience and empirical research. 14) alcoholic indulgences; 15) when drinking
In any case, we suggest that both terms may readily places self in disgraceful or ignomin-
be irrelevant to current discussions about the ious position, bizarre behavior when drinking,
nature and measurement of psychopathy, un- seeking a state of stupefaction; 16) does not
less we uncritically view The Mask of Sanity as choose to attain permanent unconsciousness
a bible and those who deviate from its teach- by taking own life; 17) sex life shows pecu-
ings as apostates. We believe that Cleckley’s liarities, casual sex; 18) no evidence of adverse
work should be put into perspective and sub- heredity, familial inferiority; 19) often no evi-
jected to some of the intensive analyses and dence of early maladjustment; 20) inability to
critiques directed at the PCL-R. Given that follow any life plan consistently; 21) goes out
virtually no empirical data exist on which to of way to make a failure of life.
base such analyses and critiques, we are forced Some of these items were curious (e.g., 18,
to fall back on the same sort of appraisals, in- 19, 21), perhaps a reflection of the lack of in-
terpretations, and use of quotations that have formation in the 1930s about behavioral ge-
led some to the belief that any deviation from netics and developmental psychopathology, as
Cleckley is problematic. Because of space lim- well as a psychodynamic orientation to un-
itations, we confine our comments to several derstanding abnormal behavior. In any case,
of the more salient examples used by com- they were short-lived. Most of the other items
mentators to argue their position. were included and expanded upon in later edi-
When discussing Cleckley, many contem- tions of The Mask of Sanity, as illustrated in
porary researchers make simultaneous refer- the 1976 (fifth) edition. One item from 1941
ence to the 1941 and 1976 editions of The (item 2) was split into two characteristics, sev-
Mask of Sanity, apparently on the assumption eral (items 8 and 9; items 14 and 15) were
that the material and arguments in each edi- pooled into single items, and three (items 18,

224 Hare · Neumann

 ANRV339-CP04-09 ARI 22 February 2008 18:19

19, and 21) were deleted. There were nine flect a unitary construct, supporting evidence
case studies (all males) in 1941, seven of which is sparse. An early empirical analysis of these
were included in the 1976 edition, which con- items is of interest here (see Hare 1980, 2003).
tained 15 case studies (two females). Because Coefficient alpha for the total 16-item scale
these case studies and references to other pa- was 0.80. However, the item-total correlation
tients seen by Cleckley form the basis for his for “absence of ‘nervousness’ or other psy-
Clinical Profile, it is important to understand choneurotic manifestations” was only 0.05,
something about them. suggesting that it was unrelated to the con-
First, though, we suggest that The Mask of struct measured by the total scale. Two other
Sanity is so detailed and complex in its descrip- features also had a small item-total correla-
tions and speculations that a suitable quote tion: “absence of delusions and other signs
can be found to support a variety of divergent of irrational thinking” (–0.02) and “suicide
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opinions. Unfortunately, this makes it easy for rarely carried out” (0.21). For this and con-
various commentators (including the present ceptual reasons, these items were not included
authors) to “cherry pick” quotes to suit their in the PCL (see below). Interestingly, a re-
particular position. Quotes should be accom- cent attempt to develop a self-report version
panied by additional supporting arguments of the Cleckley items also resulted in exclu-
and evidence, a practice we try to adopt here. sion of the same three items. The Minnesota
Temperament Inventory (MTI) includes “16
Cleckley’s Patients psychopathy items that were designed to tap
the hallmark features of psychopathy origi-
Unfortunately, it is difficult to obtain a clear
nally outlined by Cleckley [1976]. These items
picture of the extent to which Cleckley’s pa-
were adapted into a self-report format and
tients were representative of the general pop-
consist of brief behavioral . . . and personal-
ulation or even of the other patients he had
ity referents” (Loney et al. 2007, p. 244). A
observed over the years. It is apparent that
“rationale-empirical” approach led to the re-
his “psychopathic” patients had psychologi-
moval of the anxiety item, “I am an anxious,
cal and behavioral problems severe enough to
nervous, and fearful person,” whereas factor
warrant psychiatric attention, but no informa-
analyses resulted in deletion from the scale of
tion is provided about the procedure used to
two items derived from Cleckley’s “superficial
select those described in The Mask of Sanity.
charm and good intelligence.” These were “I
In each edition, he estimated that from 12%
am very charming, and tend to make a good
to 27% of the psychiatric patients in the var-
impression on others,” and “I give the im-
ious facilities in which he worked were psy-
pression of being intelligent; show sound rea-
chopathic, depending on the degree of mal-
soning and common sense in conversation.”
adjustment needed for such a diagnosis and
The Cleckley item, “Absence of delusions and
on Cleckley’s uncertainty about whether or
other signs of irrational thinking,” was not
not those with serious alcohol abuse should
included in the analyses. The MTI subscales
be included. These estimates are much higher
used for research purposes thus are based on
than typically found in modern day psychiatric
only 13 items, seven in the Antisocial scale and
samples (e.g., Jackson et al. 2007), suggesting
six in the Detachment scale. As with the PCL
that Cleckley was somewhat overinclusive in
and the PCL-R, the Cleckley items having to
his diagnoses.
do with “absence of nervousness,” “absence
of delusions,” and “good intelligence” were
Cleckley’s Clinical Profile: omitted from the scale. The remaining items
Empirical Analyses in the Antisocial and Detachment scales look
Although some researchers appear to treat the very much like items in the PCL-R (see Loney
16 items in the Clinical Profile as if they re- et al. 2007, Table 1).

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 ANRV339-CP04-09 ARI 22 February 2008 18:19

Cleckley’s Clinical Profile: out of his Clinical Profile, features that other
Rational Analyses clinicians had described or that have emerged
from the extensive empirical research over the
The literal use of the items in Cleckley’s
past half century? Large-sample IRT analy-
Clinical Profile presents the clinician and re-
ses have provided us with information about
searcher with several unresolved problems.
the contribution of each PCL-R item to the
The items could be used as a framework
construct of psychopathy (Bolt et al. 2004),
for global impressions, but difficulties with
but similar information has not been provided
this procedure prompted development of the
for the items in Cleckley’s Clinical Profile. In
PCL. If the features in the Clinical Profile are
any case, the consequences of this omission
to be used for assessment, how does one go
of “important criteria” for diagnosis may be
about scoring them? In the early research de-
relatively minor, given that the PCL-R and
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scribed above, Hare and colleagues attempted

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the Clinical Profile (scored globally or from

to score each item on a three-point scale based
items) are strongly associated with one an-
on a careful reading of The Mask of Sanity.
other, and result in much the same individuals
The process proved to be cumbersome and
being assessed as psychopathic (Hare 2003).
unsatisfactory. Cleckley did not offer useful
More generally, there is virtually no empiri-
advice on how much maladjustment or pathol-
cal evidence that systematic use of the Clin-
ogy must be exhibited to warrant a conclusion
ical Profile over the past few decades would
that a given feature is present, beyond saying,
have generated different or more informative
“Standard textbooks did not and still do not
results or conclusions about psychopathy than
make clear to what precise degree the person
those obtained through use of the PCL-R and
must be affected to be justifiably placed in this
its derivatives.
category” (Cleckley 1976, p. 452). This raises
Cleckley (1976, p. 371) considered the fun-
the question of how many of the features in
damental factor in psychopathy to be an in-
the Clinical Profile are required to warrant a
ability to participate in, or understand, the
diagnosis of psychopathy. Cleckley apparently
emotional aspects of humanity. “Let us say
believed that psychopathy is a taxon, a “very
that, despite his otherwise perfect function-
definite clinical entity” (p. 188), but that there
ing, the major emotional accompaniments are
also are incomplete manifestations, a “milder
absent or so attenuated as to count for lit-
or more limited” (p. 189) form of the disor-
tle . . . . If we grant the existence of a far-
der. What is the threshold for number and
reaching and persistent blocking, absence,
severity of features required for inclusion in
deficit, or dissociation of this sort, we have
the putative taxon? Are all of the 16 listed fea-
all that is needed, at the present level of our
tures necessary for a diagnosis of psychopathy,
inquiry, to account for the psychopath.” We
and if not, which ones are essential, impor-
know of no theoretical or empirical attempts
tant, or useful? These issues take on added
to “account” for all, or even most, of the
importance in light of the dimensional nature
features in the Clinical Profile in terms of
of psychopathy, at least as measured by the
such an emotional defect. Indeed, it is dif-
PCL-R and related instruments.
ficult to imagine how this defect might be
Some commentators suggest that the
associated with at least two features con-
PCL-R is incomplete because it does not
tained in the Clinical Profile (good intelli-
“capture important Cleckley criteria” (Salekin
gence and absence of delusions) but omit-
2002, p. 81). But how important are the “cri-
ted from the PCL-R. At the same time, even
teria” (a term not used by Cleckley with re-
most of those who believe that the PCL-R
spect to his Clinical Profile) that the PCL-R
deviates from Cleckley agree that it does a
fails to capture? Are there important features
good job in capturing the emotional features
of psychopathy that Cleckley might have left
he considered fundamental to psychopathy

226 Hare · Neumann

 ANRV339-CP04-09 ARI 22 February 2008 18:19

(e.g., Patrick 2006b). Indeed, perhaps the first Absence of delusions and other signs of
empirical support for some of Cleckley’s spec- irrational thinking. In 1941, Cleckley con-
ulations about emotion was provided by a sidered psychopaths to be “frankly and un-
PCL study of psychopathy (Williamson et al. questionably psychotic” (p. 257). He seemed
1991). Almost all of the subsequent studies of to modify this view somewhat in later editions,
affective processing in psychopaths have been but nonetheless still considered psychopathy
based on the PCL-R, with findings that are, in as a “masked psychosis” (p. 253) and an in-
the main, consistent with Cleckley. However, dividual with the disorder as a “downright
since his time there have been enormous ad- madman” (p. 370). He also explicitly acknowl-
vances in modeling and measuring brain func- edged that psychotic symptoms did not pre-
tion; these studies go well beyond what Cleck- clude a diagnosis of psychopathy: “If the psy-
ley might have imagined during his writings chopath develops a major or minor disorder
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about psychopathy. of a type classed among ‘the psychoses,’ it can

Comparisons between lists of items form be signified by addition of the usual term, just
the basis for most arguments that the PCL-R as if he had developed a brain tumor or peptic
has drifted from its roots. Four items in the ulcer” Cleckley (1976, pp. 248). Because the
1976 Clinical Profile that did not make it into PCL-R does not have an exclusion criterion
the PCL-R are superficial charm and good for psychosis, and because of its dimensional
“intelligence, Absence of delusions and other nature, there now is a substantial literature
signs of irrational thinking, Suicide rarely car- on the nature and implications of comorbid-
ried out, and Absence of “nervousness” or psy- ity between psychopathy and other disorders
choneurotic manifestations. Patrick (2006b, (e.g., Harris & Rice 2007, Quinsey et al. 2006,
p. 612) described these items as compris- Tengström et al. 2004, Vitacco et al. 2005).
ing a “positive adjustment” category. Appar-
ently, their omission from the PCL-R is prob- Good Intelligence. This item is listed as
lematical, for Patrick (2006b, p. 613) states, an indication of positive adjustment that is
“the effort to operationalize Cleckley’s crite- not captured by the PCL-R. We contend
ria as a unitary construct in the PCL resulted that Cleckley included “good intelligence”
in an item set that was generally more re- in his Clinical Profile because of the selec-
flective of deviance and maladjustment.” But tive nature of his patients, many of whom
why is this considered a problem? Psychi- were well educated and from middle- or
atric disorders, including personality disor- upper-class backgrounds. However, a sub-
ders, typically are defined in terms of malad- stantial literature indicates that the associa-
justment, not in terms of positive adjustment tion between the PCL-R total score and stan-
(Livesley 2007). Perhaps what is in need of ex- dard measures of intelligence is weak at best
planation and justification is not the exclusion (Hare 2003). Moreover, there is no obvious
of positive adjustment items from the PCL- theoretical reason why the disorder described
R but rather their inclusion in the Clinical by Cleckley or other clinicians should be re-
Profile. lated to intelligence; some psychopaths are
None of these positive adjustment items bright, others less so.
played a role in the empirical analyses of the
Clinical Profile described above. Further, we Suicide rarely carried out. This is a cu-
know of no clinicians or researchers who actu- rious item, for several reasons. Beside the
ally make explicit use of three of these items fact that it hardly is specific to psychopathy,
in their work, for good reason in our view. what does “rarely” mean, and compared with
We briefly consider these items, followed by what? Cleckley (1976, p. 359) noted, “It was
a somewhat longer discussion of an item (re- only after a good many years of experience
lated to anxiety) that is more controversial. with actual psychopaths that I encountered

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 ANRV339-CP04-09 ARI 22 February 2008 18:19

my first authentic instance of suicide in a pa- PCL-R. However, in the previous sentence,
tient who could be called typical.” For the Cleckley commented that psychopaths expe-
sake of argument, let’s assume that this sin- rience tension or uneasiness but that it “seems
gle suicide occurred in 1000 psychopathic pa- provoked entirely by external circumstances,
tients. This would have been an event 10 never by feelings of guilt, remorse, or intra-
times more frequent than would have been ex- personal insecurity.” This psychodynamic
pected in the general population in the 1930s perspective suggests that it is not so much a
(Monk 1987). And of course, we do not know lack of anxiety that differentiates psychopaths
how many of Cleckley’s patients later com- from others as it is the source of the anxi-
mitted suicide without his knowledge. The ety (intra- or extrapsychic). Similarly, some
senior author knows of several well-defined early influential clinicians (e.g., Arieti 1967,
psychopaths who took their own lives when it Karpman 1961) believed that psychopaths
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was clear to them that there was “no other way were capable of experiencing anxiety, but as
out” of what seemed like an intolerable situa- a “proto-emotion,” a superficial, short-lived
tion: surrounded by the police, facing a heavy reaction to immediate needs, frustrations,
prison term, incurable illness, and so forth. threats, concerns, and discomforts. Even the
We suspect that at least some cases of “sui- level of manifest anxiety in psychopaths, how-
cide by cop” involved psychopaths who were ever it is defined, is unclear in Cleckley’s
trapped and wished to go out in a “blaze of writings. For example, he says, “The true
glory” (Mohandie 2007). Finally, the results psychopaths personally observed have usually
of an extensive study on psychopathy and sui- been free, or as free as the general run of hu-
cidality (Douglas et al. 2006) concluded that manity, from real symptoms of psychoneuro-
“clinicians should not consider psychopathy a sis” (Cleckley 1976, p. 259).
buffer against suicidal behavior” (p. 97). Presumably, most of the psychiatric pa-
tients Cleckley saw were beset by a myriad
Absence of nervousness and other psy- of serious psychological problems, including
choneurotic manifestations. Evaluation of personal distress and anxiety-related symp-
this item in Patrick’s positive adjustment cat- toms. Psychopaths, by contrast, must have
egory is not straightforward, for several rea- seemed relatively free of anxiety and related
sons. First, the item typically is treated as symptomatology. Some of his psychopathic
if it were equivalent to “anxiety.” Second, patients may indeed have experienced subjec-
Cleckley was somewhat unclear and inconsis- tive distress, but it is unlikely that they would
tent concerning the definition and role of this have disclosed their symptoms unless it was to
item, and of anxiety, in his conceptualization their advantage to do so, given their penchant
of psychopathy. In the first edition of The Mask for impression management. It also can be dif-
of Sanity, the Clinical Profile devoted only ficult to make valid inferences about anxiety
half a sentence to the topic: “He is . . . usu- when a psychopathic patient is able to mimic
ally free from any marked nervousness or other emotions so well that he “appears to react with
symptoms of psychoneurosis” (Cleckley 1941, normal emotions” (Cleckley 1976, p. 239).
p. 239; emphasis in original). But so are most If Cleckley considered lack of anxiety to
normal people. Coverage in later editions in- be a defining feature of psychopathy, as some
creased to about half a page, although there commentators argue, then the disorder should
are references throughout the text to anxiety be incompatible with disorders characterized
of one form or another. Cleckley said, “Within by anxiety and other psychoneurotic symp-
himself he appears almost as incapable of anx- toms. Although he noted that differences typ-
iety as of profound remorse” (p. 340), a state- ically exist between the psychopath and the
ment oft quoted by those who believe that lack psychoneurotic, he also referred to a study
of anxiety should have been included in the in which Caldwell (1944) “reports neurotic

228 Hare · Neumann

 ANRV339-CP04-09 ARI 22 February 2008 18:19

manifestations in patients whose chief features Cleckley and Antisocial Behavior

were plainly those of the psychopath. I be-
A misconception promulgated by some ob-
lieve that the two types of reaction are not
servers is that the PCL-R’s inclusion of items
characteristically seen together but perhaps
related to antisociality is inconsistent with
there are no two pathologic syndromes in psy-
the conception of psychopathy provided by
chiatry, however distinct, that may not some-
Cleckley and other early clinicians. Cooke
times overlap” (Cleckley 1976, p. 259). And,
et al. (2005) have reformulated this miscon-
of course, the possibility of overlap is greatly
ception by wrongly stating that Hare and col-
increased when at least one of the disorders is
leagues consider criminality to be an essential
dimensional in nature, as psychopathy appears
component of psychopathy. Cooke and col-
to be.
leagues contend that factor analytic models of
Several final points can be made. First, in
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the PCL-R that include items related to anti-

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a previous section, we described research in-

social behavior are not viable, whereas a model
dicating that the “anxiety” item did not “be-
that excludes these items yields a three-factor,
long” with the other items in the Clinical Pro-
personality-based model. But their bases for
file, a finding that held when the item was
inclusion and exclusion of items are convo-
rated or when it was a self-report. Second,
luted and difficult to defend, as is the con-
a great deal of empirical literature indicates
tention that only personality traits have been
that psychopathy, measured with the PCL-
retained in the model (e.g., “parasitic lifestyle”
R or self-report, is at best only weakly re-
is considered to be a personality trait, whereas
lated to various measures of anxiety (Hare
“poor behavior controls” is not). This and
2003). In a recent study, Hale et al. (2004,
other issues having to do with the struc-
p. 705) concluded that the PCL-R was un-
tural properties of the PCL-R and related
related to contemporary measures of anxiety
instruments are discussed at length in the
and that the “finding raises questions about
section Searching for the Structure of Psy-
traditional conceptualizations of psychopathy
chopathy. Here we comment only on the
that posit an attenuated capacity for anxiety
claims that Cleckley did not include anti-
[e.g., Cleckley 1976].” Admittedly, there is an
sociality in his conception and diagnosis of
extensive research literature (to which the se-
psychopathy. We leave aside the problems
nior author has contributed) indicating that
inherent in inferring psychopathy-related
the concepts of “low fear arousal” or “fearless-
dispositions from only prosocial behavior,
ness” (e.g., Lykken 1995) may help to explain
without reference to the asocial, antisocial,
the psychopath’s apparent social poise, sensa-
and problematic behaviors that distinguish
tion seeking, and difficulty in staying out of
between psychopathic and other individuals,
trouble. We suggest that these concepts are
and that bring the former to our attention (see
subsumed under PCL-R items associated with
discussions by Hare 2003, Hare & Neumann
more general emotional experiences and pro-
2006, Neumann et al. 2005).
cesses, including lack of remorse or guilt, shal-
Inspection of the items that comprise
low affect, and callous/lack of empathy. Al-
the 1941 and 1976 Clinical Profiles in The
though Cleckley (1976, p. 319) believed that
Mask of Sanity clearly conveys the important
“fearlessness stand(s) out in contrast” to psy-
role played by antisocial behavior in Cleck-
chopathy, we agree that its role and that of
ley’s description of psychopathy. Certainly,
anxiety are in need of further empirical in-
his patients could not be considered proso-
vestigation, not only as potential defining fea-
cial, or even simply asocial, without stretch-
tures but also as variables whose interactions
ing the meanings of these terms. In 1941, al-
with psychopathy may have explanatory value
cohol abuse and the problems it caused for
in a variety of learning and motivational con-
the individual and those around him were
texts (e.g., Newman et al. 2007).

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 ANRV339-CP04-09 ARI 22 February 2008 18:19

emphasized. Later editions also described at with a problem that is more serious than
length the socially disruptive behaviors exhib- heavy reliance on a single measure of psy-
ited by psychopaths under the effects of al- chopathy. The senior author admits to having
cohol. More directly, Cleckley (1976) stated contributed to the problem by “promoting”
that he was “in complete accord” with the de- Cleckley’s work over the past four decades,
scription of the psychopath as “simply a basi- and that he now might be considered a “back-
cally asocial or antisocial individual” (p. 370). slider.” However, in his defense he might ar-
“Not only is the psychopath undependable, gue that the construct drift for which he is
but also in more active ways he cheats, deserts, charged is presumptive evidence that his orig-
annoys, brawls, fails, and lies without any ap- inal intention to rely more-or-less entirely on
parent compunction. He will commit theft, Cleckley soon was compromised by research
forgery, adultery, fraud, and other deeds for experience, as reflected in the content of the
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astonishingly small stakes, and under much PCL. In any case, we contend that it makes lit-
greater risks of being discovered than will the tle sense to base theory and research primarily
ordinary scoundrel” (p. 343). Some commen- on conceptions of psychopathy that are frozen
tators (e.g., Cooke & Michie 2001) have ar- in time, a time (the 1930s) when psychody-
gued that such behaviors (reflected in the item namic models were prevalent, experimental
“inadequately motivated antisocial behavior”) psychopathology and psychometric the-
are not specific to psychopathy and therefore ory were in their infancy, and behav-
should not play a role in assessment of the dis- ioral genetics, developmental psychopathol-
order. Of course, none of the other 15 features ogy, and cognitive neuroscience had yet to
in the Clinical Profile is specific to psychopa- arrive on the scene. This is not meant to di-
thy but, nonetheless, they do not recommend minish in any way the brilliant writings of a
that these features be excluded from either the renaissance man whose clinical insights and
description or the assessment of the disorder. dramatic case studies have had a profound in-
Finally, we note that other researchers fluence on generations of clinicians and re-
do not accept the argument that Cleckley searchers. We can continue to benefit from
excluded antisocial behavior from his de- the testable insights and speculations con-
scriptions and diagnosis of psychopathy. As tained in The Mask of Sanity. But Cleckley
Patrick (2006b, p. 608) wrote, “There is no cannot be the first and last word on psychopa-
question that Cleckley considered persistent thy and its measurement, a point he himself
antisocial deviance to be characteristic of psy- made in extensive correspondence over the
chopaths. Without exception, all the individ- years with Hare. “Going back to the future”
uals represented in his case histories engage in this case would really be going back to the
in repeated violations of the law—including past.
truancy, vandalism, theft, fraud, forgery, fire- As put by Livesley (2007, p. 216), “[The
setting, drunkenness and disorderly conduct, PCL-R] is based on a ‘top-down’ definition
assault, reckless driving, drug offenses, pros- of psychopathy based on Cleckley’s [1976]
titution, and escape.” observations of relatively few individuals.
The important question is whether PCL-
R psychopathy converges with ‘bottom-up’
Clinician as Construct? models identified from empirical analyses
Unlike the case with other influential fig- of the structure of personality characteris-
ures, including Freud, critical examination of tics in different samples.” The following sec-
Cleckley’s work is virtually nonexistent. To tions indicate that convergence does occur,
a large extent, the clinician has become the not only with research in psychopathology
construct for many investigators and com- and personality theory but also with find-
mentators. In our view, this presents the field ings from such relevant fields as behavioral

230 Hare · Neumann

 ANRV339-CP04-09 ARI 22 February 2008 18:19

genetics, developmental psychopathology, Moreover, identification of the basic struc-

and neurobiology. ture of physical, biological, and psychological
phenomena frequently precedes theory devel-
opment (Stelmack 1997). Paradoxically, ad-
EMPIRICAL ASPECTS OF THE herence to Cleckley’s (1941/1976) theoretical
PSYCHOPATHY CONSTRUCT perspective often determines whether investi-
The concept of psychopathic personality has gators value the findings of structural research
a long history that began well before Cleck- on psychopathy, despite the fact that Cleckley
ley and is closely tied to early conceptions relied solely upon case study methodology.
of personality (e.g., Hervé 2007). As dis- One of the major challenges in trying
cussed in detail by Berrios (1996), “Impul- to elucidate the structure of psychopathy
sion and impulsive insanity provided the ker- is that, as a latent construct, it is not di-
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nel around which the notion of psychopathic rectly observable. Indeed, most everything
personality was eventually to become orga- in psychological science refers to latent con-
nized” (p. 428). Even Cleckley (1941) noted structs (Bollen 2002), as do most concepts
the essential fact that the “psychopath shows in science (Cartwright 1983; Devitt 1991, as
a striking inability to follow any sort of life cited in Borsboom et al. 2003). Fortunately,
plan consistently” (p. 255). As it turns out, the groundbreaking work of Spearman in
many of the findings presented below are con- 1904 on factor analytic models opened a new
sistent with the early conceptual beginning paradigm that provided investigators a means
of psychopathic personality. On the other for mathematically representing latent vari-
hand, some investigators do not consider psy- ables (Borsboom et al. 2003). With the devel-
chopathy to be fundamentally linked to un- opment of confirmatory factor analysis (e.g.,
dercontrolled pathology and instead view an Bentler 1980, Joreskog 1971, Sorbom 1974)
affective deficit as the core of the disorder. and other latent variable approaches (e.g.,
Nevertheless, a growing body of literature in- Thissen & Steinberg 1984), it became possi-
dicates that the affective features of psychopa- ble to move beyond exploratory analyses and
thy are intimately tied—i.e., psychometrically, instead to precisely hypothesize model spec-
genetically, and longitudinally—to the under- ifications (e.g., variable-to-factor and factor-
controlled and fundamentally antisocial fea- to-factor relations) that could then be tested
tures of psychopathy. Thus, there appears to statistically. It is important to emphasize that
be no basis for holding one component of psy- good statistical fit of a latent variable model
chopathy as more essential than other compo- does not prove the existence of causal la-
nents (Neumann et al. 2005). tent variables (Bentler 1980). However, such
models do involve testable hypotheses (e.g.,
five factors account for the natural language
Finding Structure in Psychological terms referencing normal personality) and,
Phenomena therefore, good model fit can be “adduced”
A very old Aristotelian idea is that “form fol- as evidence in support of such hypotheses
lows function” (e.g., knifes were designed to (Borsboom et al. 2003). In addition, a key as-
cut, eyes designed to see). If something is pect of latent variable models is that “latent
known about a phenomenon’s structural form, variables provide a degree of abstraction that
then it is possible to glean an understanding permits us to describe relations among a class
of how it functions. In modern science, expli- of events or variables that share something in
cation of a phenomenon in terms of its struc- common, rather than making highly concrete
ture remains a critical area of investigation, statements restricted to the relation between
whether it involves identification of the struc- more specific, seemingly idiosyncratic vari-
ture of atoms, DNA, or human personality. ables. In other words, latent variables permit

www.annualreviews.org • Psychopathy as a Clinical and Empirical Construct 231

 ANRV339-CP04-09 ARI 22 February 2008 18:19

us to generalize relationships” (Bollen 2002, such a diverse set of samples suggests

p. 606). Thus, if a latent variable model re- that the measure is highly compatible
ceives additional support from independent with both traditional-clinical and modern-
replications based on diverse samples of in- empirical conceptualizations of psychopathy.
dividuals assessed via different methods, the The results show that the PCL-based psy-
model’s verisimilitude increases as a viable chopathic personality dimensions reflect a
representation of a theoretical construct. broadly antisocial and undercontrolled per-
sonality disposition, involving deceptiveness,
pathological lying, and absence of remorse
Searching for the Structure and guilt, as well as irresponsible, impulsive,
of Psychopathy and versatile antisocial tendencies.
A number of recent studies, based on latent Based on other recent research, several
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variable analyses of the PCL instruments, pro- self-report measures also appear to have la-
vide considerable support for a four-factor tent dimensions that resemble the four PCL
model of psychopathy across diverse and pri- dimensions. Using large samples of young
marily very large samples of male and female adults to conduct a two-stage study for ex-
offenders (Hare & Neumann 2006, Neumann traction and then cross-validation of a new
et al. 2007), forensic and civil psychiatric pa- structural model for the Self-Report Psy-
tients (Hill et al. 2004, Jackson et al. 2007, chopathy Scale III (SRP-III), Williams et al.
Neumann et al. 2007, Vitacco et al. 2005), and (2007) identified four factors that closely ap-
youth offenders ( Jones et al. 2006, Neumann proximated the four PCL dimensions. Each
et al. 2006, Salekin et al. 2006, Vitacco et al. SRP-III factor displayed substantive links to
2006), as well as individuals from the gen- critical external correlates, in line with pre-
eral community (Hare & Neumann 2006; vious PCL validation studies. Similarly, the
Neumann & Hare 2007). Figure 1 illustrates self-report Youth Psychopathic Traits Inven-
the form and content of the model, as well tory (YPI; Andershed et al. 2002) was de-
as standardized item-discrimination parame- signed to reflect the interpersonal, affective,
ters, based on a mega-sample of 6929 male and impulsive lifestyle dimensions of psy-
and female adult offenders and male forensic chopathy in youth. However, based on a
psychiatric patients. large population-based sample of twins, the
In this model, the four strongly correlated three YPI factors were modeled in conjunc-
psychopathy dimensions represent interper- tion with a fourth facet reflecting antisocial
sonal (e.g., pathological lying, conning), af- tendencies (Larsson et al. 2007). Although
fective (e.g., shallow affect, remorseless), im- not designed specifically for assessment of
pulsive lifestyle (e.g., irresponsible, stimulus psychopathy, the Multidimensional Person-
seeking, impulsivity), and diverse external- ality Questionnaire (MPQ; Tellegen 2003)
izing, antisocial tendencies (e.g., poor be- is a normal-range personality measure that
havioral controls, versatile antisociality). The has been suggested to contain underlying di-
model has also shown structural invariance mensions that reflect interpersonal-affective
across North American and United Kingdom (called Fearless-Dominance) and impulsive-
samples of adolescent offenders (Neumann antisocial (called Impulsive-Antisociality) fea-
et al. 2006) and adult male African Ameri- tures (Blonigen et al. 2005). Thus, rather than
can and Caucasian civil psychiatric patients reflecting four dimensions, the MPQ model
( Jackson et al. 2007; see also Bolt et al. 2004, combines the interpersonal and affective di-
2007). Although the PCL-R and its deriva- mensions into a single factor and the lifestyle
tives cannot be equated with the construct of and antisocial factor into its own factor, rem-
psychopathy (Neumann et al. 2005), the ro- iniscent of the traditional PCL-R Factor 1
bustness of the four-factor model across and 2 dimensions. The MTI (Loney et al.

232 Hare · Neumann

 ANRV339-CP04-09 ARI 22 February 2008 18:19

2007, Taylor et al. 2003) does not contain mensions of the psychopathy construct, some
four dimensions, but it has two factors (De- investigators continue to find the traditional
tachment and Antisocial) that are strongly two-factor model (Hare et al. 1990, Harpur
correlated, similar to the antisocial and af- et al. 1989) useful in helping them to organize
fective PCL factors. Similarly, the APSD, a and understand the correlates of psychopa-
20-item teacher/parent rating scale, measures thy. Interestingly, inspection of the pattern
three dimensions of behavior thought to be of factor correlations in Figure 1 indicates
precursors to psychopathic traits: Callous/ that the four-factor model can easily be con-
Unemotional, Narcissism, and Impulsivity. verted to two-factor form (see Figure 2).
Each of these latent dimensions is signifi- While this model shows the same degree of
cantly linked to PCL: YV/PCL: SV dimen- good fit as that of the four-factor model, it
sions reflecting interpersonal-affective and may not be advantageous to use the tradi-
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impulsive-antisocial tendencies (Vitacco et al. tional two-factor model in some instances.

2003). Finally, psychopathic personality has For example, several studies have found that
also been understood with respect to the five- the four psychopathy dimensions have diverse
factor model (FFM) of personality and has associations with various external correlates
been described by Lynam & Widiger (2007, (e.g., Dolan & Anderson 2003, Salekin et al.
p. 171) in terms that reflect the interper- 2004, Vitacco et al. 2005). Also, Bishopp &
sonal (e.g., “cunning and manipulative”), af- Hare (2007), using a multidimensional scal-
fective (e.g., “callous and ruthless”), impulsive ing approach, have provided some evidence
lifestyle (e.g., “pan-impulsive”), and antiso- that at least four domains may be neces-
cial (e.g., “greedy and exploitive, oppositional sary to comprehensively map the psychopathy
and combative”) PCL-R dimensions. In sum, construct.
there is currently good evidence for at least
four psychopathy dimensions across a diverse
set of measures and wide array of samples. The Superordinate Nature
We do not discuss here the structure of of Psychopathy
the Psychopathic Personality Inventory (PPI; In addition to viewing the psychopathy con-
Lilienfeld & Andrews 1996) beyond noting struct in terms of lower-order domains, it
that its factor structure is complex and in- is also possible to view it in more abstract
consistent with the two-factor model orig- and general terms. For instance, using large
inally proposed (Lynam & Widiger 2007; samples of male (N = 4865) and female
C.S. Neumann, M. Malterer, & J.P. Newman, (N = 1099) offenders and forensic psychiatric
manuscript submitted) and that the PPI to- patients (N = 965), all assessed with the
tal score is significantly correlated with both PCL-R, Neumann et al. (2007) found that all
Factor 1 (r = 0.54) and Factor 2 (r = 0.42) of four psychopathy factors were explained by
the PCL-R (Poythress et al. 1998). We also do a single superordinate factor. In each sam-
not discuss the Cooke & Michie (2001) hier- ple separately, and when the samples were
archical “three”-factor model, given that this combined, the superordinate factor accounted
model has severe statistical problems—i.e., it for the majority of variance in each of the
actually contains ten factors and results in four first-order factors with but one excep-
impossible parameters (negative variances)— tion: The superordinate factor accounted for
as well as conceptual problems. For detailed 43% of the variance in the interpersonal fac-
critiques of this model, see Neumann et al. tor for the psychiatric sample. Similarly, in
(2005), Vitacco et al. (2005), Neumann (2007) a large (N = 738) cross-national study of
and Neumann & Hare (2007). adolescent offenders, Neumann et al. (2006)
Although the majority of studies cited found that a superordinate PCL: YV factor
above provide evidence of four possible di- accounted for the majority of the variance in

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 ANRV339-CP04-09 ARI 22 February 2008 18:19

the interpersonal (60%), affective (82%), im- discuss a wealth of studies employing different
pulsive lifestyle (81%), and antisocial (60%) methodologies and samples that support the
factors. These results provide support for us- contention that general antisocial tendencies
ing total scores from the PCL instruments to represent an empirically demonstrable feature
study groups of individuals and indicate that of the psychopathy construct, in conjunction
the superordinate factor captures something with features reflecting disturbances in inter-
essential that runs across the separate lower- personal, affective, and impulsive behavioral
order factors—i.e., the broad dissocial nature functioning.
of psychopathic traits. Although there may be The superordinate PCL-R/YV findings
heuristic value in considering the constituent are consistent with more general research on
dimensions in isolation of one another (e.g., personality disorder (PD). Specifically, two
for investigating their external correlates), we large-scale empirical studies (Livesley et al.
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believe that psychopathy can best be under- 1998, Ullrich & Marneros 2007) and a com-
stood in terms of the interrelations of these prehensive review of personality disorder re-
dimensions, akin to a general factor in per- search (Trull & Durrett 2005) all suggest that
sonality theory. Similarly, the practice of par- a unidimensional factor reflecting dissocial-
tialling independent variables from one an- ity/psychopathy emerges when symptoms of
other, though informative, runs the danger all PDs are factor analyzed. The Livesley
of losing sight of the original construct un- et al. (1998) study is noteworthy in that use
der investigation or of changing the nomo- of a dimensional PD symptom measure re-
logical network (see Lynam et al. 2007). As sulted in the same factor solution across large
put by Livesley et al. (1998, p. 944), “Since twin, clinical, and general population samples.
the components of personality are parts of an The dissocial or psychopathy factor was com-
integrated system, disturbance in one system posed of the following PD items: callousness,
is likely to affect the whole system.” In this conduct problems, narcissism, rejection, and
sense, antisocial tendencies are fundamentally stimulus seeking. In the Ullrich & Marneros
tied to other psychopathy dimensions since (2007) study, dimensionalized International
all four PCL-R factors stem from a cohesive Classification of Diseases-Tenth Edition
higher-order factor. An early illustration of (ICD-10) PD symptoms resulted in a fac-
this point, based on the original PCL two- tor made up of the dissocial, paranoid, histri-
factor model, was provided by Harpur & Hare onic, and impulsive PD traits and was the only
(1991), who found that inclusion of the inter- ICD-10 PD factor (out of three) that was
action of the two factors (F1 × F2) signif- strongly correlated (r = 0.77) with the PCL:
icantly improved the prediction of violence. SV.
Zeier & Newman (2007) similarly found that
it was the interaction of PCL: SV Factors
1 and 2, rather than their unique variances, The Dimensional Nature
that predicted anomalies in the performance of Psychopathy
of a selective attention task. Finally, a recent The psychopath is often portrayed in the me-
child twin study (Baker et al. 2007) found that dia as vile, inhuman, and qualitatively differ-
a single unidimensional factor explained the ent from other individuals. However, research
majority of the variance in the covariation of described above suggests that psychopathic
childhood psychopathy traits, aggression, and personality traits in adults and adolescents are
delinquency. best viewed as existing on a continuum. The
As indicated above, Cleckley (1941/1976) results of these studies are consistent with a
too believed that antisocial tendencies, very large literature indicating that person-
broadly conceived, were essential to under- ality disorders in general are dimensional in
standing the psychopath as a whole. Below we nature (Clark 2007).

234 Hare · Neumann

 ANRV339-CP04-09 ARI 22 February 2008 18:19

In line with the taxometric studies men- advocate, owes much of its existence to pre-
tioned above, there is evidence for a con- vious factor analyses of the NEO Personal-
cordant latent structure of psychopathic ity Inventory-Revised (NEO PI-R; Costa &
traits across adults and adolescents (Hare & McCrae 1992). In his review of the person-
Neumann 2006, Neumann et al. 2006). Simi- ality structure of the FFM, Digman (1990,
larly, antisocial and other externalizing behav- p. 418) stated, “views regarding the structure
iors also appear to be dimensional in nature of the concepts of personality . . . were based
(Markon & Krueger 2005). Thus, it may be on the . . . hope that the method of factor anal-
more efficient to study individuals in terms of ysis would bring a clarity to the domain of per-
level of psychopathic traits rather than pars- sonality, a hope voiced years ago by Eriksen
ing individuals into psychopath and nonpsy- [1957] and Jensen [1958].” Digman proposed
chopath groups. that the FFM of personality has given us a
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Community studies on psychopathy are in- “useful set of very broad dimensions that char-
creasing (Lilienfeld & Fowler, 2006), given acterize individual differences . . .” and that
the strength of the dimensional perspective. these dimensions provide a “good answer to
However, few studies have been conducted the question of personality structure” (p. 436).
with large, randomly ascertained samples that Digman’s (1997) FFM meta-analytic study
allow investigators to more confidently gen- suggests that the five-factor domains may not
eralize their findings as well as to understand represent the most basic structure of normal-
the distribution and function of psychopathic range personality, given that the covariance
traits in the general population. In one com- among the FFM domains can be accounted
munity study (Hare & Neumann 2006), we for in terms of two higher-order personal-
found strong support for the four-factor la- ity domains referred to as Alpha (agreeable-
tent variable model of psychopathy, despite ness, conscientiousness, low neuroticism) and
relatively low levels of these traits in the sam- Beta (extraversion, openness). Interestingly,
ple. We also found that the psychopathy traits the factor analytic work on normal-range per-
were significantly linked to a range of exter- sonality seems remarkably similar to the find-
nal correlates, particularly violent behavior ings discussed above with respect to the di-
(Neumann & Hare, manuscr. submitted). De mensions of psychopathy (i.e., they can be
Oliveira-Souza et al. (2007) found relatively modeled in terms of four lower-order domains
high PCL: SV scores in a sample of patients or two higher-order domains).
referred or brought to a Brazilian psychiatric
facility for evaluation and consultation be-
cause of a chronic pattern of social and behav- Associations of Normal-Range
ioral problems. The correlates of the PCL: SV Personality with Psychopathy
were consistent with the research literature on Research on normal-range personality traits is
psychopathy in criminal and forensic psychi- also informative for understanding psychopa-
atric populations. thy. Lynam (2002) and Widiger & Lynam
Taken together, the vast array of factor an- (1998) have mapped out in detail the associ-
alytic and other statistical findings previously ation between each of the PCL-R items and
discussed all help to flesh out the dimensions the domains and facets of the FFM (Costa &
of the psychopathy construct. Thus, we dis- McCrae 1992); they view psychopathic per-
agree with Lynam & Widiger’s (2007) sug- sonality as a maladaptive variant of common
gestion that factor analysis of particular scales personality traits (many of which are anti-
might not be optimal for uncovering core social in nature). Widiger (1998) noted that
components of the psychopathy construct. In- PCL-R and FFM conceptualizations of psy-
deed, the FFM of personality (McCrae & chopathy are complementary and that while
Costa 1990), which Lynam & Widiger (2007) the FFM enriches “the understanding of the

www.annualreviews.org • Psychopathy as a Clinical and Empirical Construct 235

 ANRV339-CP04-09 ARI 22 February 2008 18:19

syndrome of prototypic psychopathy by plac- (DeYoung et al. 2001, Musek 2007). Thus,
ing it within the broader context of normal whether the FFM domains represent distinct
personality . . . the PCL-R in turn provides a elements of personality that can explain psy-
vivid description of an especially problematic chopathic personality remains an open area
and even volatile constellation of personality of investigation. Nevertheless, despite such
traits” (Widiger 1998, pp. 64–65). Similarly, questions and considerations, we support the
Widiger et al. (2002, pp. 448–449) described line of FFM-psychopathy research being pur-
psychopathy as a particularly “virulent con- sued by a number of investigators and be-
stellation of (FFM) traits.” This latter quote lieve such endeavors not only complement
suggests that it is the combination and pro- research on the PCL instruments, but also
file of various personality traits that creates represent important avenues of investigation.
the psychopathic personality, consistent with Moreover, using self-report instruments such
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the superordinate modeling results discussed as the FFM in conjunction with the interview-
above. based PCL instruments might provide excel-
Are normal range (i.e., nonpathological) lent opportunities to conduct hetero-method
personality traits more basic than patholog- studies, which may provide additional cover-
ical dispositions of psychopathic individuals? age of the psychopathy construct as well as
Lynam & Widiger (2007) have outlined how the opportunity to model method effects (e.g.,
the FFM can be used to study the elements multitrait, multimethod confirmatory factor
of psychopathy. Their proposal is based on analysis).
the assumption that the 30 facets of the FFM Assuming that normal-range personality
are “relatively more distinct” than the PCL- traits are not synonymous with, or more ele-
R items (p. 165). For instance, based on their mental than, psychopathy traits, an important
previous translational research (e.g., Widiger avenue for future research concerns the na-
& Lynam 1998), Lynam & Widiger (2007) ture of the association between nonpathologi-
suggested that the PCL-R items might be seen cal and pathological personality trait domains.
as blends of several FFM facet domains, and There is no doubt that normal-range per-
therefore the former may be less elemental sonality traits are correlated with psychopa-
than the latter. However, large sample fac- thy traits. For instance, aggregate data can
tor analysis of the lower-order NEO facets be obtained using the results reported in
that make up the five higher-order FFM do- Table 1 in Lynam & Widiger (2007, p. 168),
mains reveals that a number of facets show which displays the correlations between the
substantial factor cross-loadings among dif- FFM facets and the PPI and Hare Self-Report
ferent FFM domains (cf. Aluja et al. 2005). Psychopathy Scale (HSRP; Hare 1991) based
That certain PCL-R items can be translated on a combined sample of 560 young adults.
to fit under several FFM facets may stem The average (absolute) correlation is approxi-
from the fact that the FFM facets themselves mately r = 0.22 between the FFM facets and
demonstrate empirical overlap across FFM the two self-report psychopathy scales. If one
domains. Thus, one might question whether uses only the highly prototypic FFM facets,
the FFM facet domains are indeed more dis- then the aggregate correlation (derived from
tinct, or elemental, than the PCL-R items Table 1 in Lynam & Widiger 2007) between
(and by extension, PCL factors). In addition, the FFM facets and the PPI or HSRP scales is
Digman’s (1997) meta-analytic factor analytic r = 0.27. Interestingly, similar results are ob-
results clearly demonstrate higher-order al- tained with offender populations, based on a
pha and beta factors that explain the signifi- hetero-method approach. For example, mod-
cant covariation among the lower-order FFM est MPQ/PCL-R correlations have been re-
domains. Similar results have been reported ported for a sample of 218 male offend-
in other large-sample factor analytic research ers (Benning et al. 2005a). Similar modest

236 Hare · Neumann

 ANRV339-CP04-09 ARI 22 February 2008 18:19

associations were found between the MPQ ality traits (Livesley et al. 1998)? If so, per-
and the PCL-R facets in a sample of 157 male haps pathological traits are simply maladap-
offenders (P. Wupperman, C.S. Neumann, & tive expressions of normal-range personality
J.P. Newman, unpublished data). traits. However, an alternative empirical re-
Generally similar findings of modest cor- lation might be that normal-range traits are
relations have been reported in a meta- reciprocally related to pathological personal-
analysis by Lynam & Derefinko (2006). They ity traits. If this assumption is correct, then
used both mono-method and hetero-method normal range traits may contribute to the de-
studies of either adult or youth samples to velopment of personality disorder traits, but
gauge the strength of the association between additional factors, such as pathological in-
normal-range personality and psychopathy. teractions with parents or peers (e.g., Frick
They reported that the majority of normal- et al. 2003, Pardini et al. 2007), may be
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range personality dimensions was modestly, necessary for the development of personal-
at best, related to psychopathy traits. Interest- ity disorder traits, including those that define
ingly, neuroticism was found to be positively psychopathy.
associated with psychopathy, contrary to the- The discussions so far of lower-order and
ory. Most importantly, the normal range di- higher-order normal-range personality and
mension of agreeableness tended to display a psychopathy domains suggest that there may
moderately strong (negative) association with not be an optimal level of analysis for math-
psychopathy. Lynam & Derefinko (2006) sug- ematically representing psychopathy-related
gested that low agreeableness reflects individ- traits. For instance, higher-order levels may
uals who are suspicious, deceptive, exploitive, be linked to broad general genetic factors,
aggressive, arrogant, and tough-minded. Per- and lower-order levels linked to more spe-
haps the relation between low agreeableness cific, residual genetic factors (Livesley 2005,
and psychopathy reflects overlap in antiso- Livesley et al. 1998). However, as Little et al.
cial tendencies. Taken together, the results (2002) have discussed, it is often necessary
of these studies suggest that the empirical to represent mathematically broad constructs
link between normal-range personality traits like personality in terms of many indicators.
and psychopathic personality traits is mod- As mentioned above, Baker et al. (2007) re-
est at the measurement level, though the ported that a broad set of items reflecting
association may be stronger at the latent antisocial behavior, aggression, delinquency,
level. and psychopathic traits all formed a single
We agree with Livesley’s (2007) sugges- cohesive factor, which had significant genetic
tion that a strength of dimensional models effects across child, caregiver, and teacher
of personality disorder is that they are based ratings. The strength of measures such as
on clinical descriptions of personality disor- the PCL instruments (Hare & Neumann
ders, and also that it is difficult to explain 2006), the YPI (Andershed et al. 2002), the
how “extreme positions on dimensions such APSD (Vitacco et al. 2003), and the SRP-
as agreeableness, sociability, or conscientious- III (Williams et al. 2007) is that the item-
ness are necessarily pathological” (p. 203). to-factor relations have been clearly worked
At the same time, there appears to be a fair out and each of these measures can be pre-
degree of convergence between models of cisely represented in terms of lower-order
normal-range traits and PD traits (Widiger as well as cohesive higher-order latent vari-
& Simonsen 2005). Thus, continued research able models. Once the latent structure of
on the integration of pathological and non- a measure is known, it is then possible to
pathological trait domains is necessary. For in- determine if the same structure can be re-
stance, do the same genetic factors pertain to vealed with biometric data (e.g., Livesley et al.
both normal-range and pathological person- 1998).

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 ANRV339-CP04-09 ARI 22 February 2008 18:19

Behavior Genetics Taken together, the behavior genetic re-

of Psychopathic Traits search on psychopathy fits with the structural
research discussed previously. The results re-
There is increasing evidence that broad ge-
ported by Livesley et al. (1998) may be the
netic factors may account for a substantial por-
most informative, given that the same latent
tion of the variance and covariance of diverse
psychopathy factor resulted when using ei-
sets of psychopathy traits. For instance, inves-
ther phenotypic or genotypic PD symptom
tigators have reported bivariate analyses that
data. Thus, consistent with the observations of
suggest that there are genetic influences on
Eley (1997), the behavioral genetic evidence
the covariance of psychopathy scales reflect-
suggests, “genetic factors might be acting as
ing emotional detachment and antisocial ten-
general influences” (i.e., general genes) in
dencies (Taylor et al. 2003, Viding et al. 2005).
the manifestation of covarying psychopathic
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Relatedly, both MPQ dimensions (fearless-

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traits, with environmental factors influenc-

dominance and impulsive-antisociality) show
ing the form of specific psychopathic traits
genetic covariation with externalizing psy-
(pp. 90–91). At the same time, as discussed by
chopathology in men (Blonigen et al. 2005).
Livesley (2005), lower-order specific residual
In a large sample of 9- to 10-year-old twins,
genetic effects may also be important for un-
Baker et al. (2007) found that a common anti-
derstanding personality disorders such as psy-
social behavior factor (composed of child psy-
chopathy. For example, Larsson et al. (2007)
chopathy traits, aggression, and delinquency)
found this type of residual genetic effect for
across informants was strongly heritable. Re-
the grandiose/manipulative scale of the YPI
cently, Viding et al. (2007) found a com-
in girls.
mon genetic component to the covariation
between callous-unemotional traits and an-
tisocial tendencies in children. Finally, based
Longitudinal Nature
on a large adolescent twin sample, Larsson
of Psychopathic Traits
et al. (2007) reported that the same general Several recent longitudinal studies have pro-
four factors present in the four-factor model vided good evidence that psychopathic traits
of psychopathy (e.g., Hare & Neumann 2006, are at least moderately stable across develop-
Neumann et al. 2006, Vitacco et al. 2005) all ment. For instance, Frick et al. (2003) found
loaded onto a single genetic factor. The vari- that the APSD trait dimensions were stable
ance in the male psychopathic traits in each over a four-year period in a sample of non-
factor accounted for by the common genetic referred children in the third, fourth, sixth,
factor was 25% for grandiose/manipulative, and seventh grades at first assessment. In this
20% for callous/unemotional, 42% for im- study, baseline antisocial behavior, socioeco-
pulsive/irresponsible, 19% for antisocial be- nomic status (SES), and quality of parenting
havior (ages 13 to 14), and 30% for antisocial were significant predictors of stability. Using
behavior (ages 16 to 17). For females, the vari- a large sample of inner-city boys assessed an-
ance accounted for by the common genetic nually from ages 8 to 16 and items from a child
factor was 37% for grandiose/manipulative, behavior checklist to model interpersonal-
22% for callous/unemotional, 45% for im- callousness, Obradovic et al. (2007) found ev-
pulsive/irresponsible, 21% for antisocial be- idence of significant stability across a nine-
havior (ages 13 to 14), and 41% for antiso- year period, as well as longitudinal invariance.
cial behavior (ages 16 to 17). Notably, in both The latter finding is important because it sug-
sexes the impulsive/irresponsible and antiso- gests that the same construct was being mod-
cial facets showed some of the strongest ge- eled across time. In related research, Burke
netic components, consistent with the very et al. (2007) reported that the same behav-
early conceptions of psychopathy. ior checklist-based interpersonal-callousness

238 Hare · Neumann

 ANRV339-CP04-09 ARI 22 February 2008 18:19

measure significantly predicted PCL-R scores ever, an equally robust literature aims at un-
at age 19 in a clinic-referred sample of boys derstanding the basic nature of the disor-
assessed at ages 7 to 12. der. We discussed some of this literature
Loney et al. (2007) used a large sample of in preceding sections on behavioral genet-
twins and found that the MTI detachment and ics, developmental psychopathology, and gen-
antisocial tendencies showed good stability. eral personality theory. Here we refer to
Lynam et al. (2007) also found moderate sta- empirical research into the biological and
bility from ages 13 to 24, respectively, using cognitive mechanisms of psychopathy, begin-
the Child Psychopathy Scale (Lynam 1997) ning more than half a century ago with the-
and the PCL: SV. This latter study is notable ories and methodologies derived from the
for its use of a hetero-method approach. Also, then new field of psychophysiology (e.g.,
Lynam et al. (2007) found that in addition to Hare 1968, Lykken 1957) and continuing
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Child Psychopathy Scale scores, family struc- today with the active collaboration of sci-
ture and SES also predicted PCL: SV scores, entists in a variety of disciplines, includ-
consistent with the Frick et al. (2003) findings. ing biochemistry, neuroanatomy, and cog-
Blonigen et al. (2005) reported greater genetic nitive/affective neuroscience (e.g., see Blair
than environmental contributions to the sta- et al. 2005, Hare 2003, Kiehl 2006, Newman
bility of the MPQ factors from late adoles- et al. 2007, Patrick 2006a, Raine & Yang
cence to young adulthood, but that nonshared 2006). Space limitations do not allow for a
environmental factors contributed more to review of this literature, but a few notable
their change over time. Importantly, across trends can be mentioned. Particularly exciting
many of these studies there appear to be is the recent surge in neuroimaging research
fundamental longitudinal relations between on the structural and functional correlates of
the antisocial-tendencies component of psy- psychopathy. Most of this research uses the
chopathy and other psychopathic traits, in PCL-R or one of its derivatives, with results
line with the behavior genetic and structural that generally are consistent with the view
research findings discussed above. Similarly, that psychopathy is characterized by anoma-
Larsson et al. (2007) found that prior (ages lies in cognitive and affective processes. Per-
13 to 14) antisocial tendencies were signif- haps the most interesting findings are that
icantly positively associated with later (ages some clinical and behavioral features of psy-
16 to 17) interpersonal, affective, and impul- chopathy, such as impulsivity, poor response
sive lifestyle psychopathic traits via cross-twin inhibition, and difficulty in processing emo-
cross-trait biometric data. In sum, across a tional material, are mirrored in brain function
diverse set of psychopathy or psychopathy- and perhaps in brain structure. In most stud-
related instruments and samples, there is good ies, it is the total PCL-R or PCL: SV score
evidence for the stability of psychopathic traits that is important, but in some tasks the psy-
from childhood and adolescence into adult- chopathy dimensions are differentially—and
hood. At the same time, family factors, SES, meaningfully—related to brain function (e.g.,
and unique environmental factors also play Blair et al. 2005, Kiehl 2006). Although early
important roles in the stability and change of investigations implicated relatively localized
psychopathic traits over time. brain regions (e.g., amygdala, hippocampus,
frontal cortex) in psychopathy, more recent
theory and research takes the view that psy-
Biological and Cognitive Features chopathy can better be understood in terms
of Psychopathy of complex interactions among various re-
Much of the research literature on psy- gions and functions (e.g., Kiehl 2006), per-
chopathy has to do with its clinical and haps as part of more general models related to,
forensic implications and applications. How- for example, externalizing psychopathology

www.annualreviews.org • Psychopathy as a Clinical and Empirical Construct 239

 ANRV339-CP04-09 ARI 22 February 2008 18:19

(e.g., Markon & Krueger 2005), affective pro- widespread adoption of the PCL-R and its
cessing (Kiehl 2006), and moral behavior (e.g., derivatives as a common working model of
Moll et al. 2005, Raine & Yang 2006). A no- psychopathy. Nonetheless, some commenta-
table trend is the interest shown by neuro- tors are concerned that the PCL-R has be-
scientists in using psychopathy as a vehicle come so popular that many researchers and
for evaluating their own models of behav- clinicians ostensibly confuse the measure with
ior, personality, and brain function. The result the construct. Others are concerned that the
may ultimately be an integration of psychopa- PCL-R has deviated from its “roots” in a par-
thy theory and research with more general ticular clinical case method; they seem less
psychobiological, behavioral genetic, devel- concerned that they might be confusing the
opmental, and personality models. clinician with the construct. We find it incon-
gruous that empirical research findings should
Annu. Rev. Clin. Psychol. 2008.4:217-246. Downloaded from www.annualreviews.org
Access provided by Oklahoma State University on 01/22/15. For personal use only.

be judged by how well they fit with clinical

CONCLUSIONS observations described more than half a cen-
Prior to the development of the PCL-R, re- tury ago. We have addressed these issues, as
search on psychopathy was quite chaotic, with well as arguments about the role of antisocial-
different investigators using definitions and ity in the conceptualization and measurement
measures of the disorder that often were un- of psychopathy. We also noted that the re-
related to one another and of uncertain re- search on psychopathy is beginning to benefit
liability and validity. We now have an im- from the use of multitrait, multimethod ap-
pressive body of replicable and meaningful proaches to research, and from its integration
empirical findings, due in large part to the with other disciplines.

DISCLOSURE STATEMENT
R.D. Hare receives royalties from the sale of the PCL-R and its family of instruments.

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Annual Review of
Clinical Psychology

Contents Volume 4, 2008

Ecological Momentary Assessment

Saul Shiffman, Arthur A. Stone, and Michael R. Hufford p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p1
Annu. Rev. Clin. Psychol. 2008.4:217-246. Downloaded from www.annualreviews.org
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Modern Approaches to Conceptualizing and Measuring Human

Life Stress
Scott M. Monroe p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 33
Pharmacotherapy of Mood Disorders
Michael E. Thase and Timothey Denko p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 53
The Empirical Status of Psychodynamic Therapies
Mary Beth Connolly Gibbons, Paul Crits-Christoph, and Bridget Hearon p p p p p p p p p p p p p 93
Cost-Effective Early Childhood Development Programs from
Preschool to Third Grade
Arthur J. Reynolds and Judy A. Temple p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p109
Neuropsychological Rehabilitation
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Pediatric Bipolar Disorder
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Stress and the Hypothalamic Pituitary Adrenal Axis in the
Developmental Course of Schizophrenia
Elaine Walker, Vijay Mittal, and Kevin Tessner p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p189
Psychopathy as a Clinical and Empirical Construct
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The Behavioral Genetics of Personality Disorder
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Disorders of Childhood and Adolescence: Gender and
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Carolyn Zahn-Waxler, Elizabeth A. Shirtcliff, and Kristine Marceau p p p p p p p p p p p p p p p p275

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Should Binge Eating Disorder be Included in the DSM-V? A Critical

Review of the State of the Evidence
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Behavioral Disinhibition and the Development of Early-Onset
Addiction: Common and Specific Influences
William G. Iacono, Stephen M. Malone, and Matt McGue p p p p p p p p p p p p p p p p p p p p p p p p p p p325
Psychosocial and Biobehavioral Factors and Their Interplay
in Coronary Heart Disease
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Stigma as Related to Mental Disorders
Stephen P. Hinshaw and Andrea Stier p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p367
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Indexes

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viii Contents
 Annual Reviews
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New From Annual Reviews:

Annual Review of Organizational Psychology and Organizational Behavior
Volume 1 • March 2014 • Online & In Print • http://orgpsych.annualreviews.org
Editor: Frederick P. Morgeson, The Eli Broad College of Business, Michigan State University
The Annual Review of Organizational Psychology and Organizational Behavior is devoted to publishing reviews of
the industrial and organizational psychology, human resource management, and organizational behavior literature.
Annu. Rev. Clin. Psychol. 2008.4:217-246. Downloaded from www.annualreviews.org
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Topics for review include motivation, selection, teams, training and development, leadership, job performance,
strategic HR, cross-cultural issues, work attitudes, entrepreneurship, affect and emotion, organizational change
and development, gender and diversity, statistics and research methodologies, and other emerging topics.
Complimentary online access to the first volume will be available until March 2015.
Table of Contents:
• An Ounce of Prevention Is Worth a Pound of Cure: Improving • Perspectives on Power in Organizations, Cameron Anderson,
Research Quality Before Data Collection, Herman Aguinis, Sebastien Brion
Robert J. Vandenberg • Psychological Safety: The History, Renaissance, and Future
• Burnout and Work Engagement: The JD-R Approach, of an Interpersonal Construct, Amy C. Edmondson, Zhike Lei
Arnold B. Bakker, Evangelia Demerouti, • Research on Workplace Creativity: A Review and Redirection,
Ana Isabel Sanz-Vergel Jing Zhou, Inga J. Hoever
• Compassion at Work, Jane E. Dutton, Kristina M. Workman, • Talent Management: Conceptual Approaches and Practical
Ashley E. Hardin Challenges, Peter Cappelli, JR Keller
• Constructively Managing Conflict in Organizations, • The Contemporary Career: A Work–Home Perspective,
Dean Tjosvold, Alfred S.H. Wong, Nancy Yi Feng Chen Jeffrey H. Greenhaus, Ellen Ernst Kossek
• Coworkers Behaving Badly: The Impact of Coworker Deviant • The Fascinating Psychological Microfoundations of Strategy
Behavior upon Individual Employees, Sandra L. Robinson, and Competitive Advantage, Robert E. Ployhart,
Wei Wang, Christian Kiewitz Donald Hale, Jr.
• Delineating and Reviewing the Role of Newcomer Capital in • The Psychology of Entrepreneurship, Michael Frese,
Organizational Socialization, Talya N. Bauer, Berrin Erdogan Michael M. Gielnik
• Emotional Intelligence in Organizations, Stéphane Côté • The Story of Why We Stay: A Review of Job Embeddedness,
• Employee Voice and Silence, Elizabeth W. Morrison Thomas William Lee, Tyler C. Burch, Terence R. Mitchell
• Intercultural Competence, Kwok Leung, Soon Ang, • What Was, What Is, and What May Be in OP/OB,
Mei Ling Tan Lyman W. Porter, Benjamin Schneider
• Learning in the Twenty-First-Century Workplace, • Where Global and Virtual Meet: The Value of Examining
Raymond A. Noe, Alena D.M. Clarke, Howard J. Klein the Intersection of These Elements in Twenty-First-Century
• Pay Dispersion, Jason D. Shaw Teams, Cristina B. Gibson, Laura Huang, Bradley L. Kirkman,
• Personality and Cognitive Ability as Predictors of Effective Debra L. Shapiro
Performance at Work, Neal Schmitt • Work–Family Boundary Dynamics, Tammy D. Allen,
Eunae Cho, Laurenz L. Meier

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 Annual Reviews
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New From Annual Reviews:

Annual Review of Statistics and Its Application
Volume 1 • Online January 2014 • http://statistics.annualreviews.org

Editor: Stephen E. Fienberg, Carnegie Mellon University

Associate Editors: Nancy Reid, University of Toronto
Stephen M. Stigler, University of Chicago
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The Annual Review of Statistics and Its Application aims to inform statisticians and quantitative methodologists, as
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well as all scientists and users of statistics about major methodological advances and the computational tools that
allow for their implementation. It will include developments in the field of statistics, including theoretical statistical
underpinnings of new methodology, as well as developments in specific application domains such as biostatistics
and bioinformatics, economics, machine learning, psychology, sociology, and aspects of the physical sciences.

Complimentary online access to the first volume will be available until January 2015.
table of contents:

• What Is Statistics? Stephen E. Fienberg • High-Dimensional Statistics with a View Toward Applications
• A Systematic Statistical Approach to Evaluating Evidence in Biology, Peter Bühlmann, Markus Kalisch, Lukas Meier
from Observational Studies, David Madigan, Paul E. Stang, • Next-Generation Statistical Genetics: Modeling, Penalization,
Jesse A. Berlin, Martijn Schuemie, J. Marc Overhage, and Optimization in High-Dimensional Data, Kenneth Lange,
Marc A. Suchard, Bill Dumouchel, Abraham G. Hartzema, Jeanette C. Papp, Janet S. Sinsheimer, Eric M. Sobel
Patrick B. Ryan • Breaking Bad: Two Decades of Life-Course Data Analysis
• The Role of Statistics in the Discovery of a Higgs Boson, in Criminology, Developmental Psychology, and Beyond,
David A. van Dyk Elena A. Erosheva, Ross L. Matsueda, Donatello Telesca
• Brain Imaging Analysis, F. DuBois Bowman • Event History Analysis, Niels Keiding
• Statistics and Climate, Peter Guttorp • Statistical Evaluation of Forensic DNA Profile Evidence,
• Climate Simulators and Climate Projections, Christopher D. Steele, David J. Balding
Jonathan Rougier, Michael Goldstein • Using League Table Rankings in Public Policy Formation:
• Probabilistic Forecasting, Tilmann Gneiting, Statistical Issues, Harvey Goldstein
Matthias Katzfuss • Statistical Ecology, Ruth King
• Bayesian Computational Tools, Christian P. Robert • Estimating the Number of Species in Microbial Diversity
• Bayesian Computation Via Markov Chain Monte Carlo, Studies, John Bunge, Amy Willis, Fiona Walsh
Radu V. Craiu, Jeffrey S. Rosenthal • Dynamic Treatment Regimes, Bibhas Chakraborty,
• Build, Compute, Critique, Repeat: Data Analysis with Latent Susan A. Murphy
Variable Models, David M. Blei • Statistics and Related Topics in Single-Molecule Biophysics,
• Structured Regularizers for High-Dimensional Problems: Hong Qian, S.C. Kou
Statistical and Computational Issues, Martin J. Wainwright • Statistics and Quantitative Risk Management for Banking
and Insurance, Paul Embrechts, Marius Hofert

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Tel: 800.523.8635 (us/can) | Tel: 650.493.4400 | Fax: 650.424.0910 | Email: service@annualreviews.org