شخصیت روانی و یا شخصیت ها؟ بررسی انواع اختلالات فکری و روانی بالقوه و پیامدهای آن برای ارزیابی ریسک

Although psychopathy typically has been construed as a relatively uniform construct, seminal theories and contemporary research suggest that it may be heterogeneous. In this article, the most promising literature is distilled to distinguish among potential variants of antisocial personality disorder (APD) that can be derived from, and informed by, modern conceptions of psychopathy. This analysis suggests that there are primary and secondary variants of psychopathy, which may be distinguished based on the extent to which they are heritable and are characterized by affective deficits, impulsivity, trait anxiety, and characteristics of borderline and narcissistic personality disorders (NPD). These variants also may differ in their patterns of violence and responsivity to treatment. If variants of psychopathy can be identified reliably and supported empirically, psychopathy may be transformed from a global label to a set of more specific constructs that improve our ability to understand, manage, and treat individuals who have largely been regarded as dangerous and untreatable.

In the Diagnostic and Statistical Manual of Mental Disorders—4th Edition (DSM-IV; American Psychiatric Association, 1994), longstanding patterns of antisocial and violent behavior are captured by a single category, antisocial personality disorder (APD). However, chronic antisocial behavior likely is a function of a host of factors other than personality deviation (Blackburn, 1998a). Moreover, there is preliminary evidence that individuals classified with APD can differ substantially from one another both behaviorally and characterologically Cunningham & Reidy, 1998 and Rogers & Dion, 1991. The probable over-inclusiveness of the APD diagnosis (Lilienfeld, 1994) is reflected in the finding that this “disorder” tends to be the rule rather than the exception in correctional settings, with 50–80% of offenders typically meeting diagnostic criteria Hart & Hare, 1997 and Widiger & Corbitt, 1997. A large body of research conducted over the past two decades indicates that the construct of psychopathy captures individual differences among those with APD and that this construct bears critical implications for clinical and legal decisions about violence risk and treatment (see Edens et al., in press, Hart & Hare, 1997, Hemphill et al., 1998, Rice, 1997 and Salekin et al., 1996). Unlike the more behaviorally focused diagnosis of APD, psychopathy can be understood as a constellation of personality features that generally includes remorselessness, callousness, deceitfulness, egocentricity, failure to form close emotional bonds, low anxiety proneness, superficial charm, and externalization of blame (Lilienfeld, 1998). The most widely accepted measure of psychopathy is the Psychopathy Checklist-Revised (PCL-R; Hare, 1991), which assesses a set of interpersonal, affective, and behavioral features that are based largely on Cleckley's (1941) seminal description of psychopathy (see Rogers, 1995). In contrast to the APD criteria, only about 15–30% of correctional offenders in North America typically are classified as psychopathic, based on standard PCL-R cut-off scores (Hart & Hare, 1997). More important, the narrower class of individuals identified as psychopathic in correctional, forensic, and psychiatric samples appears to be at disproportionate risk for a variety of negative outcomes. Psychopathic traits have been associated with higher rates of community violence, violent and nonviolent criminal recidivism, institutional management difficulties, and poor treatment outcomes, and generally have proven more useful for predicting these outcomes than has APD (see reviews by Edens et al., 2002, Edens et al., in press, Edens et al., 2001, Hare et al., 2000, Hart & Hare, 1997, Hemphill et al., 1998, Rice, 1997 and Salekin et al., 1996). Although psychopathy has typically been construed as a relatively uniform construct, several scholars have postulated the existence of specific variants of psychopathy. First, the multidimensional factor structure of the PCL-R itself reflects the possibility of distinctive subgroups of criminal offenders. Although most research has focused on the predictive utility of PCL-R total scores, early factor analyses suggested that the PCL-R was composed of two correlated factors (e.g., Harpur, Hare, & Hakstian, 1989). Factor 1 emphasizes “personality” traits consistent with Cleckley's conceptualization of psychopathy (e.g., callousness and grandiosity), whereas Factor 2 emphasizes the “social deviance” and criminality (e.g., impulsivity and parasitic lifestyle) associated with recent APD diagnostic criteria (Lilienfeld, 1998). More recent research (Cooke & Michie, 2001) suggests that the PCL-R may be underpinned by three, rather than two, factors. This model subdivides the “personality” domain of the PCL-R into separate facets that represent an arrogant and deceitful interpersonal style and the deficient affective experience thought to be characteristic of psychopathy. The model also eliminates several items from the “social deviance” domain that are more closely tied to criminal behavior (e.g., juvenile delinquency and criminal versatility) to create an impulsive and irresponsible behavioral style facet. Some authors have argued that different score configurations across the PCL-R's two or three factors (e.g., Hervé et al., 2000 and Mealey, 1995b) may be characteristic of specific variants of psychopathy. Other reasons for hypothesizing the existence of variants range from inconsistencies in research examining the etiology of this disorder (see below, What variants of psychopathy might exist?), to phenotypic dissimilarities in the putative personality traits of individuals considered “psychopathic” (e.g., Hare, 1998a and Kosson et al., 1990), to observed differences in the outcomes associated with this diagnosis (e.g., Hare, Clark, Grann, & Thornton, 2000). A substantial proportion of criminal “psychopaths,” for example, are not convicted of subsequent crimes upon release Hemphill et al., 1998 and Salekin et al., 1996. This finding suggests that there may be compelling practical reasons for disaggregating psychopathy into more homogeneous subgroups. If variants of psychopathy can be identified reliably and supported empirically, they may improve our ability to understand, treat, and manage a class of individuals who have largely been regarded as dangerous, “incurable cases” (see Cleckley, 1982, Karpman, 1946 and Kernberg, 1998). Psychopathy is currently a global label that provides little “point of reference for clinical intervention” (Blackburn, 1988, p. 511; see also Gunn, 1998 and Lösel, 1998). In fact, Gacono, Nieberding, Owen, Rubel, and Bodholdt (1997, p. 119) recently asserted that there was “nothing the behavioral sciences can offer for treating those with psychopathy,” that is, those who exceed the PCL-R diagnostic threshold score of 30 (but see Salekin, 2001 and Skeem et al., in press for a different perspective). To the extent that psychopathy is etiologically heterogeneous, the outlook for treating and managing some variants need not be so pessimistic. As described later, several authors have argued that psychopaths differ in their symptomatology, characteristic patterns of violence, and amenability to treatment. For example, different psychopathic variants may be more or less amenable to conventional psychotherapies, based on differences in etiology and affective capacities. Similarly, there may be differences in characteristic types of aggression among psychopathic variants, with some disproportionately involved in instrumental aggression and others more impulsive, angry, and reactively violent (see Hart & Dempster, 1997 and Hart & Dempster, 1997). Clearly, if variants were characterized by different risk factors for, and pathways to, antisocial and violent behavior, this finding would have key implications for violence risk assessment, management, and treatment. Before assessment and treatment can be tailored to individuals as a function of differential psychopathic/antisocial features, however, their feature constellations must be identified. In this article, we use the modern construct of psychopathy to disaggregate and clarify the heterogeneity of APD. Our purpose is to distinguish among potential variants of APD that can be derived from, and informed by, seminal theories and contemporary research on psychopathy. We do not distinguish variants characterized solely by chronic antisocial behavior. Instead, we focus on variants that also manifest the interpersonal and affective personality traits of psychopathy, in keeping with Cleckley's (1941) approach. Our goal is to distill the most promising theories and research on potential etiological and symptomatic variants of psychopathy to focus future investigations and advance our understanding of the broad psychopathy construct. We begin by examining the debate concerning how psychopathy and its variants should be classified. We review the early clinical literature on, and seminal theories of, “secondary” psychopathy. After summarizing existing typological research, we discuss specific variants that may exist and the dimensions that may discriminate among them. We conclude by discussing the possible implications of these variants for violence risk assessment, management, and treatment.