Friday, April 23, 2010

Diagnosis sociopath: DSM/Hare

The scientific push to explain how actions were determined externally is attributable to the large behaviorist movement that occurred in the United States during the mid-20th century. This focus on deviant behavior was criticized by some because all classes of criminals (e.g., thieves, sex offenders) were pushed into the same category (i.e., Sociopathic Personality Disorder). In effect, the focus shifted from the abnormal internal processes of the psychopath to include generic and overly inclusive deviant behaviors of many types of (offending) individuals. Another distinction for this diagnosis was the existence of antisocial and dyssocial sociopaths. The dyssocial sociopath was identified as a professional criminal who could be extremely loyal to his comrades (e.g., members of organized crime).

The dyssocial sociopath distinction was eliminated with the publication of the DSM-II (APA, 1968). Smith (1978) contended that the extreme loyalty to family and friends made this classification represent no other pathology except illegal behaviors. The personality characteristics of the psychopath were not conveyed in the dyssocial sociopath. The antisocial classification that remained still focused on the psychopath’s personality traits. For example, the DSM-II described this type of individual as callous, impulsive, selfish, and unable to learn from experience. However, some critics maintained that the DSM-II did not provide specific diagnostic criteria for the disorder (Hare, 1996).

The issue of explicit diagnostic criteria was solved with the publication of the DSM-III (1980) and the DSM-III-R (1987). Following both manuals, the diagnosis for psychopathy was called Antisocial Personality Disorder (ASPD); however, it no longer focused on personality traits. The criteria were changed by emphasizing behaviors. The DSM-III Task Force felt that the clinical inferences necessary to determine the personality characteristics of a psychopath lowered the reliability of the diagnosis. Therefore, a diagnostic shift to behavioral characteristics commonly associated with the disorder was considered more reliable for identification purposes than were the personality factors explaining why the behaviors occurred (Hare, 1996). However, the new criteria were so broad they included almost every known criminal offense (Stevens, 1993).

At least one member of the DSM-III Task Force was not convinced that this new diagnosis appropriately represented the psychopathy construct it was designed to identify and measure. Millon (1981) wrote of his dissatisfaction with the Task Force’s diagnosis of ASPD, alleging that “the write-up fails to deal with personality characteristics at all, but rather lists a series of antisocial behaviors that stem from such characteristics”(p. 182). In addition, he explained that too great an emphasis was placed on delinquent and criminal behaviors for the diagnosis. Millon also cited instances where some individuals with similar psychopathic personalities will express these characteristics in socially appropriate ways. In other words, he argued that the ASPD diagnosis was overly inclusive. Following Millon’s (1981) criticisms, not everyone who engages in criminal behavior experiences an absence of anxiety, guilt, or has shallow emotions. Furthermore, some psychopaths do not fit under the ASPD diagnosis, given the heavy emphasis on illicit conduct in adolescence and adulthood. Indeed, consistent with Millon’s observations, some researchers conclude that the newest nomenclature for psychopathy (i.e., ASPD) sacrifices validity for the sake of reliability (Hare, 1998). Hart and Hare (1997) contended that “there is little systematic experimental evidence to support the validity of the DSM criteria” (p. 25).

DSM-IV (1994)
The objections leveled against the DSM determination of ASPD resulted in slight changes in the DSM-IV diagnosis. According to the DSM-IV (APA, 1994), ASPD “has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder” (p. 645). Hare (1998) suggested that although this inclusion makes it easier for forensic psychologists or psychiatrists to discuss psychopathy in their evaluations or court testimony, greater confusion exists regarding the association between ASPD and psychopathy. Indeed, although the DSM-IV diagnosis retains the emphasis on antisocial behavior, many individuals diagnosed may not be psychopathic.

This particular objection prompted Hare (1980) to develop his Psychopathy Checklist (PCL), followed by a more revised version; namely, the PCL-R. Both the PCL and the PCL-R attempt to operationalize the concept of psychopathy based on the primary features of Cleckley’s (1941) original criteria. The PCL-R is a more quantifiable and semistructured interview with good reliability, validity, and norms).

Factor 1 represents interactional/emotional style and has been described as aggressive narcissism . Items that load on Factor 1 are more indicative of personality traits, including, among others, (1) glibness and superficial charm, (2) grandiose sense of self-worth, (4) pathological lying, (5) conning/manipulative, (6) lack of remorse, (7) shallow affect, (8) callous lack of empathy, and (16) failure to accept responsibility for one’s own actions.

Factor 2 items address behaviors or behavioral styles common to psychopaths, including, among others, (3) proneness to boredom, (9) parasitic lifestyle, (10) poor behavioral controls, (12) early behavioral problems, (13) lack of realistic long-term goals, (14) impulsivity, (15) irresponsibility, (18) juvenile delinquency, (19) revocation of conditional release. Whereas Factor 1 items remain relatively stable over time, Factor 2 items can diminish with age. Additionally, in Hare (1996), only Factor 2 items have any correlation with the DSM-IV’s ASPD diagnosis.


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