Reflections on the Controversy

terrified woman with arms over eyes and DSM-5 text

The initial contentions between Cleckley and Hare’s construct of psychopathy, and the DSM’s construct of antisocial personality disorder seemed mostly about the former construct assessing traits, while the latter stressed behavior. And over which was more or less useful in prison and convict populations; and whether one was sacrificing validity for reliability, or the other way around.

In terms of the last mentioned, the members of the DSM3-R’s personality disorder work group seemed to appreciate the criticism that ASPD criteria might have been lacking in the validity vs. reliability debate. And therefore, new to the DSM criterion set was lacks remorse—which had been culled from Cleckley and Hare. Similarly, the addition of the Alternative Model in DSM-5, a model that was to be more “trait-specified,” seems to have arisen from having the PCL as its foil and competitor.

By the time DSM-4 appeared in 1994, the PCL also had a new version, PCL-R (Hare, 1991). In the latter, Hare had deleted a behavior—drug and alcohol abuse—from his former checklist, while also broadening irresponsibility beyond the behavior of parenting. The above changes in the PCL-R were part of an emerging new shape in Hare’s conception of psychopathy; one starting to form around 2 separate, broad factors.

The first was a “selfish, callous, and remorseless use of others.” This wing of the PCL-R was favored in the psychopathy literature, and was said by Hare to involve the traits “fundamental to the construct of psychopathy.” While the second of Hare’s factorial “wings”—somewhat its junior partner—was a “chronically unstable lifestyle.” That is, traits that correspond to social deviancy.

These different wings help us to see a significant difference between Hare’s construct and the ASPD of the DSM. For by now, ASPD had evolved into a construct built around social deviancy. Of this, Hare said: “Research that uses a DSM diagnosis of ASPD taps the social deviance component of psychopathy but misses much of the personality component, whereas each component is measured by the PCL-R.”

Meanwhile, studies at the time that directly compared ASPD to the PCL-R within prison and forensic settings consistently reported Hare’s model to be more discerning. And it was also obtaining incremental validity over the ASPD in predicting criminal recidivism. Therefore, it became the intention of the authors of the DSM-4 to shift the diagnosis more toward the PCL-R. Considered for edition 4 was thus an abbreviated version of Hare’s PCLR consisting of 10 of Hare’s items. Though the consideration got scrapped, when field tests revealed that for purely clinical—vs. prison settings, the PCL-R lost some of its edge.

And though by now ASPD had a rich empirical history of its own, by the time the DSM-5 was in the works, there had been considerably more research taking place concerning psychopathy than ASPD. It thus again appeared the intention of the personality disorder group of the DSM to shift the diagnosis of ASPD toward the perspective of Cleckley and Hare. This was explicitly evident in the proposal to change the name from “anti-social” to “antisocial/psychopathic.” But for other reasons, that proposal also got scrapped, and replaced by a hybrid proposal in which no reference was made of PCL-R or Cleckley.*

For those who aren’t psychological professionals, I extend my apologies for spending the last pages taking you through these weeds. But part of what should be inescapable is the extent to which the personality disorder work group of the DSM, consistently, and practically since the inception of the Manual, had attempted to use the traits provided by two individuals—Cleckley and Hare—to augment the perceived lacks of their own group-derived construct, ASPD. (And that this had largely been done in the shadows, un-noticed by the vast majority of psychological professionals).

My takeaways from the above history of these contending constructs are numerous, and have had greater cultural implications than merely the rivalry between two schools of thought on the part of shrinks. And that’s what I’d like to talk about next.

*Author’s Note: My reflections about the historical controversy between psychopathy and the DSM’s construct of antisocial personality disorder are enormously in debt to an online article I chanced upon entitled “Psychopathy and the DSM.” It was authored by Christina Crego and Thomas A. Widiger. Its 10 pages took me a night and a day, taking notes on the way, to plow through it, so dense was the terrain before I could see the forest for the trees. But it was worth the effort and more than I’d expected; both historical document, and a knowing form of psychological reportage.

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