WOW! So much of this history of “how to classify human beings” is about judging people who are considered to be FAILURES at LIFE (bottom of the social pyramid) by the standards of a group of arrogant SOBs (top of the social pyramid), without regard to the ‘unlucky” circumstances of birth; the environment, economic disaster, and social oppression-manipulation committed by the “true” socio-psychopaths at the top of the social hierachy. This system is de facto RACIST and predatory; class-based and culturally anti-human in concept.
Psychopathy and the DSM
Cristina Crego and ThomasA. Widiger University of Kentucky
Psychopathy is one of the more well-established personality disorders. However,its relationship with the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) has been controversial. The purpose of this article is to trace and discuss the history of this relationship from the very ﬁrst edition of the DSM to the current ﬁfth edition. Emphasized in particular is the problematic relationship of DSM antisocial personality disorder with the diagnosis of psychopathy by Cleckley (1941,1976) and the Psychopathy Checklist- Revised (Hare,2003), as well as with the more recently developed models of psychopathy by Lilienfeld and Widows(2005), Lynametal (2011), and Patrick, Fowles and Krueger(2009).
Psychopathy is perhaps the prototypic personality disorder. The term psychopathy within Schneider’s (1923) nomenclature referred to all cases of personality disorder. The term now refers to a more speciﬁc variant: Psychopaths are social predators who charm, manipulate, and ruthlessly plow their way through life….(recognize the “true” successful predators in American life – ? Our “leaders”…) Completely lacking in conscience and feeling for others, they selﬁshly take what they want and do as they please, violating social norms and expectations without the slightest sense of guilt or regret. (Hare, 1993, p. xi)
Nevertheless, the construct of psychopathy has had a troubled, and at times controversial, relationship with the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM). The purpose of this article is to trace and discuss this history from the very ﬁrst edition of the DSM to the current ﬁfth edition.
PSYCHOPATHYAND DSM-I As suggested by Hare (1986), Patrick (2006a), and many others, the most inﬂuential description of psychopathy was provided by Cleckley (1941, 1976). Cleckley (1941) provided a diagnostic list of 21 features, eventually reduced by Cleckley (1976) to 16. Cleckley’s (1941) seminal text on psychopathy preceded the ﬁrst edition of the APA (1952) nomenclature by about 10 years. It is not clear, though, how much speciﬁc impact Cleckley’s formulation had on DSM-I, as the latter was based on a number of alternative descriptions that were present at the time (Millon,2011). However, it is evident that there was a considerable degree of overlap and congruence. DSM-I included a “sociopathic personality disturbance” (APA, 1952, p. 38), one variation of which was the “antisocial reaction.” These persons were said to be “chronically antisocial,” and to proﬁt neither from experience nor punishment. They maintained no real loyalties to any person or group and were “frequently callous and hedonistic, ”with a lack of a sense of responsibility.” As expressed in DSM-I, “the term includes cases previously classiﬁed as ‘constitutional psychopathic state’ and ‘psychopathic personality’ ” (APA, 1952, p. 38).
PSYCHOPATHYAND DSM-II The description of DSM-II’s (APA, 1968) “antisocial personality” was somewhat expanded and perhaps closer to Cleckley (1941), indicating that these persons were “grossly selﬁsh, callous, irresponsible, impulsive, and unable to feel guilt or to learn from experience and punishment” (APA, 1968, p. 43), along with being “repeatedly into conﬂict with society” (p. 43), having low frustration tolerance, and having a tendency to blame others for their problems. It is perhaps noteworthy that it was further speciﬁed that “a mere history of repeated legal or social offenses is not sufﬁcient to justify this diagnosis” (p. 43).
PSYCHOPATHYAND DSM-III A signiﬁcant shift occurred with DSM-III (APA, 1980). Prior to DSM-III, mental disorder diagnosis was notoriously unreliable, as it was based on clinicians providing an impressionistic matching of what they knew about a patient (on the basis of unstructured assessments) to a narrative paragraph description of a prototypic case. No speciﬁc or explicit guidelines were provided as to which features were necessary or even how many to consider (Spitzer, Williams, & Skodol, 1980). Spitzer and Fleiss (1974) reviewed nine major studies of inter-rater diagnostic reliability. Kappa values for the diagnosis of a personality disorder ranged from a low of .11 to .56, with a mean of only .29. DSM-II (APA, 1968) was blamed for much of this poor reliability, along with idiosyncratic clinical interviewing (Spitzer, Endicott, & E. Robins, 1975). Feighner et al. (1972) developed speciﬁc and explicit criterion sets for 14 mental disorders. As expressed recently by Kendler, Muñoz, and Murphy (2010), “the renewed interest in diagnostic reliability in the early 1970s—substantially inﬂuenced by the Feighner criteria—proved to be a critical corrective and was instrumental in the renaissance of psychiatric research witnessed in the subsequent decades” (p. 141). Antisocial personality disorder (ASPD) was the only personality disorder to be included within the inﬂuential Feighner et al. list. Antisocial’s inclusion in Feighner et al. (1972) was due largely to L. Robins’s (1966) systematic study of 524 persons who had been seen 30 years previously at a child guidance clinic for juvenile delinquents. Robins was studying what she described as a “sociopathic” personality disorder that she aligned closely with Cleckley’s (1941) concept of psychopathy. “It is hoped that Cleckley is correct that despite the difﬁculties in terminology and deﬁnition, there is broad agreement on which kinds of patients are psychopaths, or as we have designated them, ‘subjects diagnosed sociopathic personality’ ” (L. Robins, 1966, p. 79). Despite her intention or hope of being closely aligned with Cleckley (1941), there are notable differences in her 19-item list. On the positive side, Robins did not include some of the unusual or questionable items of Cleckley (Hare & Neumann, 2008), such as no evidence of adverse heredity and going out of the way to make a failure of life. (? !) Robins also included a number of key Cleckley traits, such as no guilt, pathological lying, and the use of aliases. However, missing from Robins’s list were no sense of shame, not accepting blame, inability to learn from experience, egocentricity, inadequate depth of feeling, and lacking in insight. In addition, the Robins list contained quite a bit of what was perhaps nonspeciﬁc dysfunction, such as somatic complaints, suicide attempts (or actual suicide), drug usage, and alcohol use problems (albeit some of this was also in the description by Cleckley, 1941). It is also important to note that most of Robins’s items were accompanied by quite speciﬁc requirements for their assessment. For example, poor marital history required “two or more divorces, marriage to wife with severe behavior problems (? !), repeated separations”; repeated arrests required “three or more non-trafﬁc arrests”; and impulsive behavior required “frequent moving from one city to another, more than one elopement, sudden army enlistments, [or] unprovoked desertion of home” (L.Robins,1966,p.342). The only exception was perhaps lack of guilt, which was inferred on the basis of the “interviewer’s impression from the way in which patient reports his history” (L. Robins, 1966, p. 343), and, not coincidentally, Robins suggested that lack of guilt was among the least valid criteria due in large part to poor reliability of its assessment. The 19-item list from Robins (1966) was substantially reduced by Feighner et al. (1972) to nine items. Relatively weak items were dropped (e.g., heavy drinking, excessive drug usage, somatic symptoms, and suicide). However, notably absent as well was lack of guilt. Pathological lying and aliases were collapsed into one item. Each of the items was again accompanied by relatively speciﬁc criteria for their assessment. The Feighner et al. (1972) criteria were subsequently revised for inclusion within the Research Diagnostic Criteria of Spitzer, Endicott, and E. Robins (1978), and then revised again for DSM-III (APA, 1980). Dr. Robins was a member of the DSM-III personality disorders work group. The nine items in DSM-III were conduct disorder (required), along with poor work history, irresponsible parent, unlawful behavior, relationship inﬁdelity or instability, aggressiveness, ﬁnancial irresponsibility, no regard for the truth, and recklessness (APA, 1980). It is again worth noting that each criterion had relatively speciﬁc requirements. For example, recklessness required the presence of “driving while intoxicated or recurrent speeding” (APA, 1980, p. 321), and relationship inﬁdelity required “two or more divorces and/or separations (whether legally married or not), desertion of spouse, promiscuity (ten or more sexual partners within one year)” (APA, 1980, p. 321). The major innovation of DSM-III was the inclusion of the speciﬁc and explicit criterion sets (Spitzer et al., 1980). DSMIII ASPD became the “poster child” within the personality disorders section for the success of this innovation. All of the personality disorders, including those with highly inferential diagnostic criteria, could be assessed reliably when aided by the presence of a semi structured interview (Widiger & Frances, 1987). However, in the absence of a structured interview, the clinical assessment of personality disorders continued to be unreliable, with one exception: ASPD (Mellsop, Varghese, Joshua, & Hicks, 1982; Spitzer, Forman, & Nee, 1979). Concurrently with the development of DSM-III, however, was the development of the Psychopathy Checklist (PCL) by Hare (1980), “the conceptual framework for the ratings being typiﬁed best by Cleckley’s (1976) The Mask of Sanity” (p. 111).“We wished to retain the essence of psychopathy embodied in Cleckley’s work” (Hare, 1986, p. 15). Hare worked from the 16-item list of Cleckley, administering them to 143 prison inmates. Hare (1980) acknowledged, consistent with the view of L. Robins (1966), that “some of these criteria seem rather vague and require a considerable degree of subjective interpretation and difﬁcult clinical inference” (p. 112). Hare (1980) constructed a 22-item checklist on the basis of the16-item Cleckley (1976) list. Hare’s (1986) 22-item PCL was aligned much more closely with Cleckley’s list than the DSM-III.
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