Personality Disorders: Theory, Research, and Treatment 2015, Vol. 6, No. 1, 64 –74

© 2014 American Psychological Association 1949-2715/15/$12.00 http://dx.doi.org/10.1037/per0000096

Comparing the Utility of DSM-5 Section II and III Antisocial Personality Disorder Diagnostic Approaches for Capturing Psychopathic Traits Lauren R. Few

Donald R. Lynam

Washington University School of Medicine

Purdue University

Jessica L. Maples, James MacKillop, and Joshua D. Miller This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

University of Georgia The current study compares the 2 diagnostic approaches (Section II vs. Section III) included in the Diagnostic and Statistical Manual for Mental Disorders-5 (DSM-5; American Psychiatric Association, 2013) for diagnosis of antisocial personality disorder (ASPD) in terms of their relations with psychopathic traits and externalizing behaviors (EBs). The Section III approach to ASPD, which is more explicitly trait-based than the Section II approach, also includes a psychopathy specifier (PS) that was created with the goal of making the diagnosis of ASPD more congruent with psychopathy. In a community sample of individuals currently receiving mental health treatment (N ⫽ 106), ratings of the 2 DSM-5 diagnostic approaches were compared in relation to measures of psychopathy, as well as indices of EBs. Both DSM-5 ASPD approaches were significantly related to the psychopathy scores, although the Section III approach accounted for almost twice the amount of variance when compared with the Section II approach. Relatively little of this predictive advantage, however, was due to the PS, as these traits manifested little evidence of incremental validity in relation to existing psychopathy measures and EBs, with the exception of a measure of fearless dominance. Overall, the DSM-5 Section III diagnostic approach for ASPD is more convergent with the construct of psychopathy, from which ASPD was originally derived. These improvements, however, are due primarily to the new trait-based focus in the Section III ASPD diagnosis rather than the assessment of personality dysfunction or the inclusion of additional “psychopathy-specific” traits. Keywords: psychopathy, antisocial personality disorder, DSM-5, assessment, diagnosis

Within these dimensional frameworks, PDs are conceptualized as maladaptive configurations of personality traits that are associated with dysfunction. The ability of dimensional trait models to represent personality pathology has been demonstrated across a variety of personality models and assessment methods. For example, research supports the use of five factor model (FFM) PD prototype matching approaches, as well as simple additive count techniques that involve the summation of relevant traits (see Miller, 2012 for a review) to generate DSM–IV PD scores. Consistent with this body of research, the DSM-5 (American Psychiatric Association, 2013) Personality & Personality Disorder Work Group proposed a diagnostic model of PDs that included an assessment of general impairment in personality functioning (i.e., Criterion A), as well as the utilization of a newly created dimensional model of pathological personality traits to be used in the assessment and diagnosis of PDs (Criterion B). Specifically, Criterion A requires “moderate or greater impairment in personality (self/interpersonal) functioning.” Following the assessment of severity of personality impairment, one considers Criterion B, which requires the presence of one or more pathological personality traits from five broad pathological trait domains (i.e., negative affectivity, detachment, antagonism, disinhibition, and psychoticism) and 25 more specific facets (e.g., callousness). Specific PD diagnoses are then given based on an individual’s match to the pattern of personality impairment and elevations on mal-

Limitations of the categorical diagnostic system for personality disorders (PDs) utilized in the Diagnostic and Statistical Manual for Mental Disorders-IV (DSM–IV; American Psychiatric Association, 2000) are well documented and include arbitrary diagnostic thresholds, excessive comorbidity, and considerable heterogeneity within diagnostic categories (e.g., see Widiger, Livesley, & Clark, 2009 for a comprehensive review). Conversely, dimensional models of personality traits appear to be successful at assessing and conceptualizing PDs and are able to account for core issues such as comorbidity and changes over time (e.g., Vachon et al., 2013; Warner et al., 2004).

This article was published Online First November 3, 2014. Lauren R. Few, Department of Psychiatry, Washington University School of Medicine; Donald R. Lynam, Department of Psychological Sciences, Purdue University; Jessica L. Maples, James MacKillop, and Joshua D. Miller, Department of Psychology, University of Georgia. Preparation of this article was supported by a National Institute on Drug Abuse (NIDA) grant: T32DA007313. Correspondence concerning this article should be addressed to Lauren R. Few, Department of Psychiatry, Washington University School of Medicine, 660 South Euclid, Campus Box 8134, St. Louis, MO 63110, or to Joshua D. Miller, Department of Psychology, University of Georgia, Athens, GA 30602–3013. E-mail: [email protected] or jdmiller@uga .edu 64

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DSM-5 ANTISOCIAL PD AND PSYCHOPATHY

adaptive traits that are specified for six PD types. This proposed diagnostic approach is now included in Section III of the DSM-5 on “emerging measures and models” so as to encourage empirical examination of its strengths, weaknesses, and clinical utility. In place of this new approach, the DSM–IV PD diagnostic approach was included in its entirety in the main body of the DSM-5 (i.e., Section II). Psychopathy, a PD that encompasses traits such as a lack of remorse, callousness, irresponsibility, shallow affect, as well as antisocial behavior (Cleckley, 1941), has not been officially recognized in the last four editions of the DSM as a stand-alone entity, despite significant empirical support. Although psychopathy is not an officially recognized PD in DSM–IV or DSM-5, antisocial personality disorder (ASPD), its closest counterpart, is included. However, distinctions exist between the two PDs. When ASPD was first introduced into the DSM–III, it was modeled after psychopathy; however, it was assumed that personality traits were too difficult to measure reliably, thus the ASPD criteria were written so as to emphasize observable manifestations of the disorder rather than relying on inferences about traits (Hare, Hart, & Harpur, 1991). As a result, psychopathy and DSMbased assessments of ASPD tend to be highly correlated but are far from fungible. Convergence between ASPD and psychopathy should be higher for Section III as the new ASPD assessment approach (a) relies more on inferred traits and less on specific behavioral manifestations of those traits and thus allows for a wider array of behavioral examples to serve as indicators, and (b) includes additional psychopathy-specific traits in the form of a new DSM-5 psychopathy specifier (DSM-5 PS). In addition to the presence of traits necessary for the diagnosis of ASPD from the domains of antagonism (deceitfulness, manipulativeness, hostility, and callousness) and disinhibition (i.e., impulsivity, risk taking, and irresponsibility), the DSM-5 PS requires the presence of three traits: low anxiousness (negative affectivity domain), low withdrawal (detachment domain), and high attention seeking (antagonism domain). The text describes the DSM-5 PS as “marked by a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviors (e.g., fraudulence)” and further states that, “high attention seeking and low withdrawal capture the social potency (assertive/dominant) component of psychopathy, whereas low anxiousness captures the stress immunity (emotional stability/ resilience) component” (p. 765). The inclusion of the DSM-5 PS is noteworthy as there is a substantial debate regarding the importance of these traits, typically referred to as fearless dominance, to the conceptualization of psychopathy (e.g., Lilienfeld et al., 2012; Lynam & Miller, 2012; Marcus, Fulton, & Edens, 2013; Miller & Lynam, 2012). Given the significance and utility of psychopathy, it is important to investigate how effectively the two DSM-5 ASPD approaches (Section II vs. Section III) capture features of this construct. To our knowledge, there are only two published study to date that have examined aspects of the newly developed Section III trait model in relation to psychopathy. Specifically, Strickland, Drislane, Lucy, Krueger, and Patrick (2013) examined the extent to which ASPD traits as specified in Section III provide coverage of psychopathy as conceptualized by the triarchic psychopathy model (i.e., psychopathy comprising meanness, boldness, and disinhibition; see Patrick, Fowles, & Krueger, 2009), and assessed by the triarchic

65

psychopathy measure (TriPM; Patrick, 2010). Furthermore, they examined whether additional traits not specified for the assessment of ASPD improved the coverage of the psychopathy construct. Using a sample of undergraduate students and community individuals scoring high and low on the TriPM, these authors found that DSM-5 Section III ASPD traits effectively captured the disinhibition and meanness components of psychopathy, however, additional traits (i.e., low anxiousness, low submissiveness, and high attention seeking) were necessary in order to provide coverage of the boldness component. There is an important limitation to this approach, however, as the incremental utility of the DSM-5 PS traits was not tested in the prediction of psychopathy scores in relation to all seven traits specified for the assessment of ASPD in Section III of the DSM-5. Anderson and colleagues (2014) recently examined the incremental validity of self-report DSM-5 Section III traits and the PS above and beyond Section II ASPD symptoms in community and undergraduate samples. These authors found the Section III ASPD traits generally provided some degree of incremental validity over the Section II symptoms in the prediction of psychopathy scores and that the DSM-5 PS provided incremental validity primarily in relation to psychopathy scales that assess the traits of fearless dominance. Given the relative dearth of empirical research in this area, the goal of the current study was to compare the utility of the DSM-5 Section II and III diagnostic approaches to ASPD, including the Section III PS, in relation to psychopathic traits, using ratings of the DSM-5 ASPD and PS constructs, and tested in a community sample of individuals currently receiving outpatient mental health treatment. More specifically, we examined the variance accounted for in seven psychopathy scores, generated using alternative measures of psychopathy, by the DSM-5 Section II and III approaches to ASPD, including the DSM-5 PS. Multiple measures of psychopathy were used in the current study. Although all are influenced by the seminal work of Cleckley and Hare, each was developed by different authors using different approaches and the measures diverge in the degree to which more adaptive features are included as part of the construct. For example, fearless dominance is less well represented in the Self-Report Psychopathy Scale–III (Paulhus, Neumann, & Hare, in press) than in the FFM psychopathy prototype (Miller et al., 2001) or FFM-based proxy of fearless dominance (Witt et al., 2010). We also examined the incremental validity of each DSM-5 approach over the other in the statistical prediction of the psychopathy scores. Finally, we examined the DSM-5 PS in greater detail by testing whether PS scores interact with the DSM-5 Section III ASPD trait count to account for variance in psychopathy scores and indices of functioning. With regard to the latter test, we were specifically interested in testing whether the presence of high DSM-5 PS scores strengthened DSM-5 Section III ASPD relations with psychopathy and EBs. These moderation tests are important because traits associated with fearless dominance tend to be generally unrelated to externalizing behaviors and many measures of psychopathy; however, these traits may moderate the relations between the DSM-5 ASPD traits and measures of psychopathy and EBs. In order to ensure there were no methodological advantages for the Section II or III approach, the same methodology (ratings provided by trained graduate students) was used for all independent variables (i.e., Section II and II ASPD symptoms; Section III PS

FEW, LYNAM, MAPLES, MACKILLOP, AND MILLER

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symptoms) in relation to self-report scores on the dependent variables (i.e., psychopathy and EB).

Method

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Participants and Procedures Data from 110 participants were collected; one participant was removed from the sample due to invalid responding, and three participants did not complete all the current measures, resulting in a final sample of 106 participants (71% female; Mean age ⫽ 35.9 [SD ⫽ 12.7]; 91% White; 6% Black; 3% Asian; see Few et al., 2013 and Miller, Few, Lynam, & MacKillop, 2014, for details). Inclusionary criteria were as follows: (a) currently in psychological/psychiatric treatment, (b) aged 18 – 65, (c) minimum of an eighth grade education, and (d) use of a computer 3 or more days per week (to ensure ability to complete computerized assessments). Individuals could not participate if they were experiencing psychotic symptoms or were currently receiving inpatient treatment. Advertisements were posted in local newspapers and mental health treatment facilities. The advertisement called for individuals “currently receiving mental health treatment” to contact the laboratory if interested in participating in a research study “examining relationships between personality and behavior.” Interested participants contacted the laboratory via telephone and provided verbal consent prior to being administered a screening questionnaire that assessed relevant inclusionary and exclusionary criteria. Eligible participants were then scheduled for a 3-hr in-person assessment session. Upon arrival to the lab, the study consent form was verbally reviewed with the participant. Following informed consent, one of four trained doctoral students in clinical psychology conducted a videotaped interview using a semistructured PD diagnostic assessment and then completed ratings of pathological personality traits and impairment. Observer ratings of pathological personality traits and impairment were completed by one of the remaining three trained graduate student raters using the videotaped interview. Following the interview, participants completed several self-report assessments, were debriefed, and compensated $30.

Measures Structured Clinical Interview for DSM–IV Personality Disorders (SCID-II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997). The SCID-II is a semistructured interview that assesses the 10 DSM–IV/DSM-5 PDs. Each PD criterion is scored using a 0 (absent), 1 (subclinical), or 2 (present) rating. In the current study, we used DSM-5 Section II ASPD dimensional scores only (i.e., summation of 0, 1, and 2s for ASPD criteria; M ⫽ 3.41; SD ⫽ 3.67; ␣ ⫽ .83). Intraclass correlations were computed using ratings provided by the interviewer and one observer using the videotaped interview (n ⫽ 103) to assess the interrater reliability of the ASPD ratings, which was high (.86). All analyses reported here used the interviewers’ ratings. Administration training consisted of reading and discussing the SCID-II manual, watching a videotaped SCID-II interview, rating the videotaped

participant independently, and discussion of each symptom rating and any discrepancies. Level of Personality Functioning Scale (LPFS; American Psychiatric Association, 2013). The LPFS scale is used to characterize severity of personality impairment on four dimensions (self-identity: M ⫽ 1.66, SD ⫽ .98; self-direction: M ⫽ 1.48, SD ⫽ .93; interpersonal: empathy, M ⫽ 1.25, SD ⫽ 1.03; intimacy, M ⫽ 1.76, SD ⫽ 1.09), each of which is rated on a scale of 0 (healthy functioning) to 4 (extreme impairment). Ratings on these four dimensions were completed by the trained graduate student interviewer following administration of the SCID-II. Rater training consisted of watching a videotaped SCID-II interview, rating the four dimensions independently, and discussion of each rating and discrepancies. All analyses with the LPFS were conducted using the interviewers’ ratings. Interrater reliability, computed using the ratings from the interviewer and one observer (n ⫽ 103), for the four domains ranged from .44 (self-direction) to .49 (empathy). DSM-5 pathological trait measures. DSM-5 Clinicians’ Personality Trait Rating Form (PTRF; American Psychiatric Association, 2011). This rating form uses a single-item to assess each of the 25 proposed traits subsumed by five trait domains: negative affectivity, detachment, antagonism, disinhibition, and psychoticism. Trained graduate students provided a 0 (very little or not at all descriptive) to 3 (extremely descriptive) rating based on their perceived presence of a given trait. Rater training consisted of watching a videotaped SCID-II interview, rating the 25 traits independently, and discussion of each trait rating and discrepancies. Interrater reliability, computed using the ratings from the interviewer and one observer (n ⫽ 103), for the DSM-5 Section III ASPD (␣ ⫽ .89) and PS traits (␣ ⫽ .53) ranged from .40 (anxiousness) to .83 (impulsivity) with a median of .63. Self-Report Psychopathy Scale-III (SRP-III; Paulhus, Neumann, & Hare, in press). The SRP-III is a 64-item self-report measure answered on a 1 (disagree strongly) to 5 (agree strongly) that provides scores for four subscales: interpersonal manipulation (SRP-IPM; M ⫽ 35.68, SD ⫽ 9.7); callous affect (SRP-CA; M ⫽ 34.45, SD ⫽ 7.8); erratic life style (SRP-ELS; M ⫽ 44.28, SD ⫽ 9.7); and antisocial behavior (SRP-ASB; M ⫽ 29.64, SD ⫽ 8.8). Coefficient alphas ranged from .75 (SRP-ASB) to .86 (SRP-IPM). Revised NEO Personality Inventory (NEO PI-R; Costa & McCrae, 1992). The NEO PI-R is a 240-item measure of the FFM of personality answered on a 0 (strongly disagree) to 4 (strongly agree) that assesses the five major domains (i.e., neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness) and 30 more specific facets. Coefficient alphas for the facets ranged from .58 (tendermindedness) to .90 (trust) with a median of .81. The NEO PI-R data were used to score the FFM psychopathy count (Miller, Bagby, Pilkonis, Reynolds, & Lynam, 2005; Miller et al., 2001), as well as two additional components of psychopathy originally assessed using the Psychopathic Personality Inventory (Lilienfeld & Andrews, 1996) and subsequently conceptualized using FFM traits (Witt et al., 2010): fearless dominance (FFM FD) and self-centered impulsivity (FFM SCI). The FFM psychopathy count (FFM Psych; M ⫽ 266.68, SD ⫽ 36.5; ␣ ⫽ .56) was scored by summing the scores on the following facets (r ⫽ facet reversed before being summed): anxiety-r, depression-r, self-conscious-r, impulsiveness, vulnerability-r, warmth-r, assertiveness, excitement-seeking, openness to feelings-r, openness to actions, trust-r, straightforwardness-r, altruism-r, compliance-r,

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DSM-5 ANTISOCIAL PD AND PSYCHOPATHY

modesty-r, tendermindedness-r, competence, dutifulness-r, selfdiscipline-r, deliberation-r. FFM FD (M ⫽ 30.10, SD ⫽ 11.25; ␣ ⫽ .87) was scored using 17 NEO items comprising low neuroticism (depression and self-consciousness), high extraversion (gregariousness, assertiveness, activity, and excitement seeking), and low agreeableness (modesty). FFM SCI (M ⫽ 28.88, SD ⫽ 7.77; ␣ ⫽ .72) was scored using 17 NEO items comprising high neuroticism (angry hostility, impulsiveness), low agreeableness (straightforwardness, altruism, compliance), and low conscientiousness (competence, dutifulness, achievement striving, selfdiscipline, deliberation). Crime and Analogous Behavior Scale (CAB; see Miller & Lynam, 2003). The CAB is a self-report inventory that assesses a variety of externalizing behaviors, including substance use and antisocial behavior. A lifetime drug use variety score was created by giving participants a 1 for every different drug endorsed (eight items; e.g., cocaine; ␣ ⫽ .80; M ⫽ 2.82, SD ⫽ 2.20). A lifetime antisocial behavior variety score was created by giving participants a 1 for every different act endorsed (10 items; e.g., stealing; ␣ ⫽ .76; M ⫽ 2.25, SD ⫽ 2.14). Alcohol Use Disorders Identification Test (AUDIT; Saunders, Aasland, Babor, de la Fuente, & Grant, 1993). The AUDIT is a 10-item self-report measure of problematic alcohol consumption. In the current study, 95 participants completed the AUDIT and only the total score was examined (␣ ⫽ .90); scores ranged from 0 –36, with a mean of 8.29 (SD ⫽ 8.26).

Results Bivariate Correlations Among Study Variables We first examined the correlations among the psychopathy scores, which ranged from ⫺.19 (FFM FD with FFM SCI) to .63 (SRP-IPM with SRP-CA) with a median correlation of .44 (see Table 1). The psychopathy scales were also generally positively correlated with the DSM-5 Section II ASPD symptom count (mean r ⫽ .44), with the exception of the FFM FD score. From a DSM-5 Section III approach, the psychopathy scores generally manifested small positive correlations with the four ratings of impairment (mean rs ranged from .09 [identity impairment] to .24 [empathy impairment]), although these were uniformly negative for FFM FD. Similarly, the seven psychopathy scores were generally positively correlated with the DSM-5 Section III ASPD traits (mean rs .29 [DSM-5 hostility] to .39 [DSM-5 callousness]), although FFM FD was unrelated to all DSM-5 ASPD traits. The psychopathy scores were unrelated to two of the traits comprising the DSM-5 PS (i.e., DSM-5 anxiousness [mean r ⫽ ⫺.05] and withdrawal [mean r ⫽ ⫺.03]) and positively related to one (i.e., DSM-5 attention seeking; [mean r ⫽ .19]). Again, these relations were different when examining FFM FD, which manifested substantial correlations with the DSM-5 PS traits (mean r ⫽ .48). Finally, the psychopathy scores manifested small to moderate mean positive correlations with the self-reported EBs (mean rs ranged from .24 [alcohol misuse] to .32 [antisocial behavior]), with the exception that FFM FD scores were unrelated to all three EBs.

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Using the DSM-5 Section II and III ASPD Approaches in the Prediction of Psychopathy To examine the multistage approach used in the DSM-5 Section III model we conducted hierarchical regression analyses in which the psychopathy scores were regressed on the four DSM-5 Section III impairment ratings at Step 1, the seven DSM-5 Section III ASPD traits at Step 2 (i.e., manipulativeness, deceitfulness, callousness, hostility, irresponsibility, impulsivity, risk taking), and the three DSM-5 Section PS traits at Step 3 (anxiousness, withdrawal, attention seeking; see Table 2 which presents the coefficients for all predictors from the last step in the model). At Step 1, the impairment variables accounted for significant proportions of the variance in all cases, with R2 values ranging between 11% (SRP-ELS; SRP-ASB) and 28% (FFM FD) with an average of 16%. At Step 2, the seven ASPD traits accounted for statistically significant increments in the variance accounted for in all psychopathy scores with change in R2 values ranging from 17% (SRP-IPM) to 40% (SRP-ELS) with an average of 24%. At Step 3, the three DSM-5 PS traits provided a statistically significant increment in the variance accounted in two cases (i.e., SRP-CA and FFM FD). Across the seven psychopathy scores, the DSM-5 PS traits accounted for an additional 1% (SRP-ELS) to 21% (FFM FD) of the variance, with an average of 6%. Combined, these components of the DSM-5 Section III ASPD diagnostic approach accounted for between 32% (SRP-IPM) and 63% (FFM FD) of variance with a mean of 46%. Overall, the diagnostic approach used in Section III of the DSM-5 to assess ASPD accounted for substantially more variance in psychopathy scores than the DSM-5 Section II approach (i.e., 46% compared with 22% on average, which can be obtained by squaring the zero-order correlations presented in Table 1). The most consistent unique contributor to the prediction of the psychopathy scores was the DSM-5 Section III trait of callousness. The traits included in the DSM-5 PS contributed little additional variance in the SRP-III subscales and in the one case in which one of the traits (i.e., withdrawal) was significantly related to psychopathy (SRP-CA), the relation was in the opposite direction of how the PS is hypothesized to work (i.e., high withdrawal was associated with SRP-CA rather than low withdrawal). Two of the three DSM-5 PS traits did, however, account for additional variance in FFM FD scores in the expected direction (low withdrawal and high attention seeking).

Incremental Validity of the Two DSM-5 ASPD Approaches in the Prediction of Psychopathy Next, we tested whether the DSM-5 Section III ASPD diagnostic approach, including the traits contributing to the DSM-5 PS, accounted for additional variance in the seven psychopathy scores, above and beyond the DSM-5 Section II ASPD scores (see Table 3, which presents the coefficients for all predictors from the last step in the model). To do this, a series of hierarchical multiple regression analyses were conducted in which the DSM-5 Section II ASPD scores were entered at Step 1, the four impairment ratings were entered at Step 2, the seven ASPD traits were entered at Step

2

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9

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11

12

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15

16

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19

20

21

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24

25

26 27

Note. SRP ⫽ Self-Report Psychopathy Scale-Version III; IPM ⫽ interpersonal manipulation; CA ⫽ callous affect; ELS ⫽ erratic life style; ASB ⫽ antisocial behavior; FFM Psych ⫽ five factor model psychopathy count; FFM FD ⫽ five factor model fearless dominance; FFM SCI ⫽ five factor model self-centered impulsivity; DSM-5 Section II ASPD ⫽ dimensional scores for DSM-5 Section II antisocial personality disorder; ASPD count ⫽ dimensional scores generated via summation of seven antisocial personality disorder traits specified in Section III; Psych count ⫽ dimensional scores generated via summation of three DSM-5 PS traits specified in Section III (anxiousness and withdrawal were reverse scored). Correlations ⱖ .20 are significant at p ⱕ .05.

Psychopathy 1. SRP-IPM — 2. SRP-CA .63 — 3. SRP-ELS .44 .33 — 4. SRP-ASB .55 .39 .48 — 5. FFM Psych .53 .47 .44 .38 — 6. FFM FD .03 ⫺.15 .06 .04 .46 — 7. FFM SCI .57 .42 .60 .37 .47 ⫺.19 — DSM-5 Section II 8. ASPD .45 .33 .62 .68 .39 .01 .49 — DSM-5 Section III Impairment 9. Identity .23 .19 .29 .22 ⫺.17 ⫺.47 .33 .35 — 10. Self-direction .24 .20 .29 .31 .00 ⫺.39 .28 .46 .73 — 11. Empathy .35 .37 .28 .27 .24 ⫺.16 .33 .48 .53 .66 — 12. Intimacy .33 .31 .24 .30 .05 ⫺.38 .39 .44 .70 .70 .76 — ASPD traits 13. Manipulativeness .36 .20 .40 .43 .36 .14 .40 .71 .22 .41 .46 .35 — 14. Deceitfulness .37 .24 .38 .49 .28 ⫺.03 .42 .67 .33 .41 .44 .37 .80 — 15. Callousness .46 .51 .41 .38 .51 .10 .32 .59 .19 .33 .60 .35 .53 .47 — 16. Hostility .37 .21 .40 .30 .26 .00 .45 .59 .52 .50 .59 .55 .52 .54 .46 — 17. Irresponsibility .37 .22 .45 .55 .34 ⫺.05 .43 .71 .31 .51 .43 .43 .55 .56 .30 .44 — 18. Impulsivity .37 .20 .64 .54 .29 .02 .48 .76 .39 .43 .37 .37 .59 .52 .36 .51 .65 — 19. Risk taking .37 .25 .66 .56 .28 .00 .44 .82 .39 .43 .46 .40 .62 .53 .47 .50 .62 .82 — 20. ASPD count .48 .32 .63 .60 .41 .03 .54 .90 .44 .55 .60 .52 .82 .79 .62 .73 .77 .85 .86 — Psychopathy specifier 21. Anxiousness .15 .19 ⫺.05 .01 ⫺.26 ⫺.46 .13 ⫺.03 .53 .43 .21 .36 ⫺.06 ⫺.02 .08 .16 .01 .03 ⫺.01 .04 — 22. Withdrawal .15 .36 ⫺.01 .07 ⫺.14 ⫺.66 .16 .02 .41 .35 .33 .52 ⫺.13 ⫺.06 .16 .09 .04 ⫺.08 .02 .00 .42 — 23. Attention seeking .13 .02 .32 .13 .28 .26 .17 .37 .30 .24 .30 .22 .45 .46 .22 .45 .31 .45 .35 .49 ⫺.09 ⫺.29 — 24. Psych count ⫺.08 ⫺.25 .17 .02 .32 .65 ⫺.05 .18 ⫺.29 ⫺.25 ⫺.11 ⫺.31 .30 .25 ⫺.01 .10 .12 .24 .16 .21 ⫺.69 ⫺.81 .65 — Outcomes 25. Alcohol misuse .31 .24 .34 .35 .15 .01 .27 .53 .22 .24 .17 .09 .47 .52 .34 .25 .44 .50 .46 .54 .10 ⫺.05 .17 .17 — 26. Drug use .26 .07 .49 .47 .11 ⫺.05 .31 .46 .26 .31 .20 .25 .40 .37 .22 .24 .35 .49 .57 .50 .03 .10 .10 .10 .32 — 27. ASB .30 .18 .37 .71 .25 .03 .26 .64 .25 .30 .24 .30 .45 .49 .37 .32 .43 .45 .52 .55 ⫺.03 .09 .11 .11 .26 .44 —

1

Table 1 Correlations Among Study Variables

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68 FEW, LYNAM, MAPLES, MACKILLOP, AND MILLER

DSM-5 ANTISOCIAL PD AND PSYCHOPATHY

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Table 2 Predictive Validity of Section III DSM-5 ASPD Approach in Relation to Psychopathy SRP-IPM 2

Step 1: R Impairment Step 2: R2 ASPD traits Step 3: R2⌬ Psych. specifier

ⴱⴱ

.13 .17ⴱⴱ .02

SRP-CA

SRP-ELS

ⴱⴱ

SRP-ASB

ⴱ

.14 .18ⴱⴱ .06ⴱ

ⴱ

.11 .40ⴱⴱ .01

.11 .35ⴱⴱ .02

FFM Psych ⴱⴱ

.18 .26ⴱⴱ .04

FFM FD ⴱⴱ

.28 .14ⴱⴱ .21ⴱⴱ

FFM SCI .16ⴱⴱ .19ⴱⴱ .03

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␤ Coefficients from Step 3 DSM-5 ASPD Section III Impairment Identity Self-direction Empathy Intimacy ASPD traits Manipulativeness Deceitfulness Callousness Hostility Irresponsibility Impulsivity Risk Taking Psychopathy specifier Anxiousness Withdrawal Attention seeking

.05 ⫺.26 ⫺.03 .12

⫺.02 ⫺.18 .05 .03

.09 .05 ⫺.23 ⫺.01

⫺.07 .03 ⫺.24 .18

⫺.26 ⫺.11 ⫺.01 .01

⫺.20 ⫺.19 .01 .03

.14 ⫺.29 ⫺.05 .13

.02 .09 .32ⴱ .10 .22 .15 ⫺.05

⫺.10 .11 .46ⴱⴱ ⫺.09 .12 .10 ⫺.02

⫺.17 .01 .27 .08 .05 .25 .40ⴱⴱ

⫺.19 .32ⴱ .23ⴱ ⫺.06 .24ⴱ .21 .23

.00 ⫺.12 .51ⴱⴱ .10 .31ⴱⴱ .11 ⫺.15

.16 ⫺.33ⴱⴱ .24ⴱ .15 .06 ⫺.10 .02

.09 .11 .07 .19 .17 .30 ⫺.07

.13 .04 ⫺.10

.11 .29ⴱ .00

⫺.11 .03 .07

⫺.01 ⫺.01 ⫺.16

⫺.13 .01 .19

⫺.10 ⫺.49ⴱⴱ .19ⴱ

.05 .10 ⫺.14

Note. IPM ⫽ interpersonal manipulation; CA ⫽ callous affect; ELS ⫽ erratic life style; ASB ⫽ antisocial behavior; FFM Psych ⫽ five factor model psychopathy count; FFM FD ⫽ five factor model fearless dominance; FFM SCI ⫽ five factor model self-centered impulsivity. Coefficients presented are from Step 3 when all variables are in the model. Information on variance accounted for is derived from the various steps (i.e., Step 1: DSM-5 ASPD symptoms; Step 1: four impairment ratings entered; Step 2: seven DSM-5 Section III ASPD traits entered; Step 3: three DSM-5 Section III psychopathy specifier traits entered). ⴱ p ⱕ .05. ⴱⴱ p ⱕ .01.

3, and the three traits included in the DSM-5 PS were entered at Step 4. At Step 2, the impairment ratings explained, on average, an additional 10% of the variance; the increment was statistically significant only for FFM Psych and FFM FD psychopathy scores. At Step 3, the Section III ASPD traits explained, on average, an additional 9% of the variance in the psychopathy scores; the increment was statistically significant for SRP-CA, SRP-ELS, FFM Psych, and FFM FD scores. At Step 4, the DSM-5 PS traits explained, on average, an additional 5% of the variance in psychopathy scores; these increments were significant for SRP-CA and FFM FD psychopathy scores. In terms of individual predictors, callousness was again the most consistent unique predictor of the psychopathy scores (significant in five of seven analyses). Only one of the DSM-5 PS traits, withdrawal, was a significant unique predictor of any of the SRP-III scales; this occurred for SRP-CA such that withdrawal was positively related to callous affect. FFM FD psychopathy scores were significantly predicted, in the expected directions, by withdrawal (negatively) and attention seeking (positively). We also tested whether the DSM-5 Section II ASPD scores demonstrated incremental validity above and beyond the Section III components by changing the order in which the variables were entered into the same series of regression analyses. The DSM-5 Section II ASPD scores explained no additional variance for six of the seven psychopathy scores; Section II ASPD did account for significant additional 5% of the variance in the prediction of SRP-ASB scale (i.e., mean change in R-squared ⫽ .01).

DSM-5 PS as a Potential Moderator of the Relations Between the DSM-5 Section III ASPD Traits and Measures of Psychopathy and Externalizing Behaviors We next tested whether the DSM-5 PS traits interacted with the DSM-5 Section III ASPD traits to account for additional variance in the seven psychopathy scores and three EBs. In these analyses, separate counts of the seven DSM-5 ASPD traits and the three DSM-5 PS traits were created. The ASPD and psychopathy specifier trait counts were then mean-centered and multiplied to create a product term to carry information on their interaction. At Step 1, the mean centered ASPD and psychopathy specifier counts were entered, followed by their product term at Step 2; the coefficients from the final step are provided in Table 4. The DSM-5 Section III ASPD trait count was significantly related to six of the seven psychopathy scores (all except FFM FD) and all three EBs, with coefficients ranging from .43 (SRP-CA; FFM Psych) to .66 (SRPASB). The DSM-5 PS count was significantly positively related to psychopathy scores in two instances (FFM Psych and FFM FD), significantly negatively related in three instances (SRPIPM, SRP-CA, FFM SCI), and nonsignificantly related to SRPELS, SRP-ASB, and all three EBs. Together the two main effects accounted for, on average, 31% of the variance in the self-report psychopathy scores and EBs. At Step 2, the interaction between the ASPD and psychopathy specifier trait counts accounted for, on average, an additional 2% of the variance in the psychopathy scores and EBs. The product term was statis-

FEW, LYNAM, MAPLES, MACKILLOP, AND MILLER

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Table 3 Incremental Validity of Section III DSM-5 ASPD Over Section II ASPD in Relation to Psychopathy SRP-IPM

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Step Step Step Step

1: 2: 3: 4:

2

.20 .04 .07 .02

R Section II ASPD R2⌬ Impairment R2⌬ ASPD Traits R2⌬ Psych. Specifier

Section II DSM-5 ASPD Section III DSM-5 ASPD impairment Identity Self-direction Empathy Intimacy Section III DSM-5 ASPD traits Manipulativeness Deceitfulness Callousness Hostility Irresponsibility Impulsivity Risk taking Section III DSM-5 psychopathy specifier Anxiousness Withdrawal Attention seeking

ⴱⴱ

.04

SRP-CA

SRP-ELS

ⴱⴱ

SRP-ASB

ⴱⴱ

.11 .07 .14ⴱ .06ⴱ

ⴱⴱ

.38 .02 .11ⴱⴱ .01

ⴱⴱ

.46 .01 .05 .01

␤ Coefficients from Step 4 .13 .11

FFM Psych .15 .16ⴱⴱ .13ⴱⴱ .04

.56ⴱⴱ

FFM FD

FFM SCI .24ⴱⴱ .05 .06 .03

.00 .32ⴱⴱ .10ⴱ .21ⴱⴱ

⫺.04

⫺.12

.02

.05 ⫺.26 ⫺.02 .11

⫺.02 ⫺.19 .08 .02

.09 .04 ⫺.20 ⫺.03

⫺.06 .01 ⫺.13 .12

⫺.27 ⫺.11 ⫺.02 .02

⫺.20 ⫺.18 ⫺.01 .04

.14 ⫺.29 ⫺.05 .13

.02 .09 .31ⴱ .09 .21 .14 ⫺.06

⫺.11 .10 .43ⴱⴱ ⫺.10 .09 .08 ⫺.07

⫺.18 ⫺.01 .24ⴱ .06 .03 .24 .36ⴱ

⫺.24 .27ⴱ .08 ⫺.13 .11 .15 .02

.00 ⫺.12 .52ⴱⴱ .11 .32ⴱ .11 ⫺.13

.17 ⫺.32ⴱⴱ .27ⴱ .16 .09 ⫺.09 .07

.09 .11 .06 .18 .17 .30 ⫺.08

.14 .04 ⫺.10

.12 .29ⴱ .00

⫺.11 .03 .07

.03 ⫺.01 ⫺.14

⫺.14 .01 .18

⫺.11 ⫺.49ⴱⴱ .18ⴱ

.05 .10 ⫺.13

Note. IPM ⫽ interpersonal manipulation; CA ⫽ callous affect; ELS ⫽ erratic life style; ASB ⫽ antisocial behavior; FFM Psych ⫽ five factor model psychopathy count; FFM FD ⫽ five factor model fearless dominance; FFM SCI ⫽ five factor model self-centered impulsivity. Coefficients presented are from Step 4 when all variables were entered simultaneously. Information on variance accounted for is derived from the various steps (i.e., Step 1: DSM-5 ASPD symptoms; Step 2: four impairment ratings entered; Step 3: seven DSM-5 Section III ASPD traits entered; Step 4: three DSM-5 Section III psychopathy specifier traits entered). ⴱ p ⱕ .05. ⴱⴱ p ⱕ .01.

tically significant in the prediction of FFM Psych and FFM FD scores. Both cases ran contrary to expectations with DSM-5 Section III ASPD trait bearing stronger positive relations to the outcome at low rather than high levels of the DSM-5 psychopathy specifier (Bs for product term ⫽ ⫺.89 and ⫺.20, p ⱕ .01 for FFM Psych and FFM FD, respectively). Figure 1 provides a graphic representation of the interactions. For FFM Psych, the DSM-5 Section III ASPD trait count was significantly related to

FFM Psych at lower levels (i.e., 1 SD below the mean) of the DSM-5 psychopathy specifier (B ⫽ 4.99, p ⱕ .01) but not at higher levels (i.e., 1 SD above the mean; B ⫽ 1.25, ns). For FFM FD, the DSM-5 Section III ASPD trait count was nonsignificantly related at lower levels (i.e., 1 SD below the mean) of the DSM-5 psychopathy specifier (B ⫽ .27, ns) but was significantly negatively related at higher levels (i.e., 1 SD above the mean; B ⫽ ⫺.57, p ⱕ 01).

Table 4 Does the DSM-5 Psychopathy Specifier Moderate the Relations Between the DSM-5 Section III ASPD Trait Count and Measures of Psychopathy and Externalizing Behaviors? SRP-IPM

SRP-CA

SRP-ELS

SRP-ASB

FFM psychopathy

FFM FD

FFM SCI

Alcohol misuse

Drug use

ASB

2

Step 1: R ASPD and psychopathy specifier counts Step 2: R2⌬ Interaction

ASPD TC Psych TC ASPD TC ⫻ Psych

.27ⴱⴱ .00

.21ⴱⴱ .02

.54ⴱⴱ ⫺.19ⴱ ⫺.04

.43ⴱⴱ ⫺.31ⴱⴱ ⫺.16

.40ⴱⴱ .01

.37ⴱⴱ .02

.22ⴱⴱ .07ⴱⴱ

.43ⴱⴱ .04ⴱⴱ

.33ⴱⴱ .00

.30ⴱⴱ .00

.26ⴱⴱ .00

.32ⴱⴱ .01

␤ Coefficients from Step 2 .65ⴱⴱ .66ⴱⴱ .43ⴱⴱ .06 ⫺.09 .29ⴱⴱ ⫺.11 ⫺.12 ⫺.25ⴱⴱ

⫺.06 .71ⴱⴱ ⫺.20ⴱⴱ

.59ⴱⴱ ⫺.17ⴱ ⫺.03

.56ⴱⴱ ⫺.09 .03

.54ⴱⴱ ⫺.12 ⫺.06

.60ⴱⴱ ⫺.08 ⫺.12

Note. IPM ⫽ interpersonal manipulation; CA ⫽ callous affect; ELS ⫽ erratic life style; FFM FD ⫽ five factor model fearless dominance; FFM SCI ⫽ five factor model self-centered impulsivity; ASB ⫽ antisocial behavior; ASPD TC ⫽ DSM-5 Section III trait count for antisocial PD; Psych TC ⫽ DSM-5 Section III psychopathy specifier trait count; ASPD ⫻ Psych ⫽ interaction term for ASPD and psychopathy trait counts. Coefficients presented are from Step 2 when all variables were entered simultaneously. ⴱ p ⱕ .05. ⴱⴱ p ⱕ .01.

DSM-5 ANTISOCIAL PD AND PSYCHOPATHY

280 260

FFM FD

FFM Psychopathy

300

240 220 200 Low ASPD Low PS

High ASPD Medium PS

High PS

71

45 40 35 30 25 20 15 10 5 0 Low ASPD Low PS

High ASPD Medium PS

High PS

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Figure 1. Interactions between rater-based ASPD and the psychopathy specifier in predicting FFM psychopathy and FFM FD.

Discussion The goal of the current study was to compare the DSM-5 Section II and III diagnostic models for ASPD with regard to their ability to assess content considered central to psychopathy. This is an important question in that psychopathy is a well-validated and extensively researched PD accompanied by considerable inter- and intrapersonal costs. Indeed, it is the construct from which the DSM ASPD was initially created. ASPD and psychopathy have drifted apart operationally over time, with assessments of psychopathy relying more on open, inferred trait concepts and the DSM focusing more on closed-concepts (e.g., specific behaviors). Even with this operational drift, multiple studies have demonstrated that DSM–IV ASPD (which is now the official diagnostic model in DSM-5) manifests substantial correlations with psychopathy, particularly the components of psychopathy that are related to disinhibition and antisocial behavior (e.g., Hare, 2003). The inclusion of a new diagnostic model in Section III of the DSM-5, which includes a specific psychopathy specifier and a more trait-based approach that is similar to the approach used to assess psychopathy (e.g., Hare, 2003) may bring psychopathy and ASPD closer together. This would allow the larger and more robust psychopathy literature to be brought to bear on the study of ASPD, allowing information on the etiology, correlates, consequences, and treatment of psychopathy to inform work on ASPD. Although the nominal content of the ASPD diagnosis is similar across Sections II and III of DSM-5, the approach to assessment differs substantially. That is, both sections include similar criteria for ASPD: deceitfulness, impulsivity, irritability, reckless disregard for safety, irresponsibility, and lack of remorse. The primary difference between the two approaches, beyond the role of personality impairment that is highlighted in Criterion A of Section III, is that DSM-5 Section II ASPD approach includes a criterion of failing to conform to social norms by repeatedly committing criminal and antisocial actions; Section III includes no similar criterion. The new Section III approach to ASPD relies more heavily on open constructs, however, and less on explicit behavioral markers. For example, the deceitfulness criterion in Section II reads: “Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure” (p. 659). This is a closed concept that references a specific set of acts that constitute the presence of the symptom/trait. In contrast, Section III describes deceitfulness as “dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events” and manipulativeness as “use of subterfuge to influence or

control others; use of seduction, charm, glibness, or ingratiation to achieve one‘s ends” (p. 780). These concepts are more open, allowing multiple, unspecified behaviors to serve as indicators, and requiring more inference on the part of rater. The Section III approach to ASPD, thus, is more in line with current approaches and conceptions of psychopathy than the Section II approach.

Comparing the Section II and Section III ASPD Approaches in Relation to Psychopathy In general, the DSM-5 Section III approach to ASPD was substantially more successful at explaining variance in the psychopathy scores (mean R-squared ⫽ 46%) compared with the DSM-5 Section II ASPD scores (mean R-squared ⫽ 22%). The only exception was for the Antisocial Behavior Scale of the SRP-III, which asks about specific antisocial acts; given the closed nature of these questions and the fact that Section II includes a criterion assessing antisocial behavior, this finding is not surprising. The Section III approach is complicated by the fact that it contains three separate pieces—the measurement of personality dysfunction, traits related to ASPD, and traits thought to be specific to fearless dominance related aspects of psychopathy. As a result, we also sought to parse the variance according to these three components. Although the impairment ratings made significant contributions at the first step of the model (mean R-squared ⫽ 16%), the trait ratings made even larger contributions at the second step (mean R-squared change ⫽ 24%), despite being disadvantaged by entering after the impairment ratings. At the third step, the DSM-5 PS traits accounted for a relatively small amount of additional variance (mean R-squared change ⫽ 6%), primarily in relation to a measure of fearless dominance.1 In one of the two cases where the contribution was statistically significant, the sign of the coefficient for the trait was in the direction opposite to that specified in DSM-5, such that withdrawal was significantly positively related to SRP-III callous affect. This is not surprising, however, as withdrawal is included in the PS to capture a largely unrelated component of psychopathy from callousness—fearless dominance. In addition, the positive 1 When entered alone in the prediction of the seven psychopathy scores, the three traits that comprise the psychopathy specifier accounted for, on average, 15% of the variance. Notably, for SRP-CA, the variance accounted for (15%) was due to a positive (rather than negative as articulated in the DSM-5) relation with withdrawal. With regard to the three externalizing behaviors, the three psychopathy specifier traits alone accounted for, on average, 4% of the variance, which was nonsignificant in all cases.

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correlation between withdrawal (i.e., introversion) and callous affect is consistent with previous trait-based examinations of this construct (e.g., Gaughan et al., 2009), which suggests that these individuals are both emotionally and socially detached from others.

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Incremental Validity of the Section III ASPD Approach in Relation to Psychopathy Consistent with the previous findings, the DSM-5 Section III ASPD diagnostic approach accounted for significant variance in the psychopathy scores above and beyond that explained by the DSM-5 Section II approach (mean change in R-squared ⫽ 24%); the converse was not true (mean change in R-squared ⫽ 1%). When the variance was partitioned into the three components of the Section III approach, results were similar to those found earlier. Impairment ratings made small, mostly nonsignificant, contributions when entered at the second step (mean R-squared change ⫽ 10%) and most of the variance that was predicted was due to FFM FD being significantly negatively related to personality impairment. Entered at Step 3, DSM-5 ASPD traits accounted for an additional 9% of the variance, on average, with significant increments accounted for in relation to SRP-CA, SRP-ELS, FFM Psych, and FFM FD. When entered last, the DSM-5 PS accounted for, on average, an additional 5% of the variance in psychopathy scores—most notably in relation to a different measure of the same construct, fearless dominance.

Utility of the DSM-5 Section III Psychopathy Specifier The inclusion in the DSM-5 of the psychopathy specifier was somewhat surprising as there is little research examining its validity when measured in this way with measures of the DSM-5 trait model (see Crego & Widiger, 2014, for a discussion) and much debate surrounding the relevance of these constructs (i.e., fearless dominance, boldness) to psychopathy (Lilienfeld et al., 2012; Lynam & Miller, 2012; Marcus et al., 2013; Miller & Lynam, 2012). Kendler, Kupfer, Narrow, Phillips, and Fawcett (2009) published guidelines for making changes to DSM-5 and suggested that changes should be paired with substantial validation data (i.e., antecedent, concurrent, and predictive validators) and “a broad consensus of expert clinical opinion would generally be expected for all proposed changes or additions” (p. 5). One might argue that, in the case of the traits included in the DSM-5 PS, these inclusion criteria were not met, even for inclusion in the new and relatively untested Section III portion of the DSM-5. Nonetheless, the DSM-5 PS is now part of the official nomenclature and evaluation of its performance is critical. In the current study the DSM-5 PS traits accounted for little variance in the statistical prediction of psychopathy scores, with the exception of FFM FD (regardless of whether DSM-5 Section II ASPD was included in the model or not); this is consistent with previous work showing that DSM-5 PS appears to be a reasonably effective proxy measure for the controversial construct of fearless dominance (e.g., Anderson et al., 2014; cf., Crego & Widiger, 2014). The limited relations between the DSM-5 PS traits and the current outcomes (i.e., psychopathy scores, externalizing behaviors) was not limited to the multivariate analyses, however. The

bivariate correlations between the three DSM-5 PS traits and the criterion variables also demonstrate that these traits are not significantly related to most measures of psychopathy, with the exception of fearless dominance (see also Anderson et al., 2014) or externalizing behaviors. These findings are consistent with previous meta-analytic reviews of the nomological networks associated with fearless dominance (i.e., Marcus et al., 2013; Miller & Lynam, 2012) that demonstrate that this construct, which is the basis for the DSM-5 PS, manifests limited convergent correlations with other psychopathy indices and null to small correlations with criteria variables considered central to psychopathy (e.g., antisocial behavior). One would typically expect that constructs included in a diagnostic manual of mental disorders such as the DSM-5 would manifest relations with core problematic outcomes that are most salient for a given construct; we would argue that externalizing behaviors are exactly the type of outcomes that will be of most relevance when measuring constructs such as ASPD and psychopathy. It will be vital for future research on the DSM-5 PS to test whether its inclusion adds incremental utility in explaining behaviors most relevant to these disorders such as antisocial behavior, substance use, treatment noncompliance, and recidivism. To provide a comprehensive test of the DSM-5 PS, we also tested whether PS scores interacted with the ASPD traits in the prediction of psychopathy scores or externalizing behaviors. It is possible that the DSM-5 PS traits matter only in the context of high scores on the ASPD traits. In the current data, however, there was little evidence that the DSM-5 PS interacted with the ASPD traits to account for variance in psychopathy scores or externalizing behaviors. The effect sizes for these 10 interaction terms were small (mean change in R-squared ⫽ 1.7%) and only two were statistically significant (prediction of the FFM psychopathy count and fearless dominance). Explication of these interactions (see Figure 1) suggests that the presence of elevated scores on the DSM-5 PS in concert with high scores on the ASPD traits did not result in significantly higher scores on either the FFM psychopathy count or fearless dominance, even though the PS traits represent constructs correlated with these FFM indices. Overall, the traits comprising the DSM-5 PS manifested (a) mostly null to small correlations with measures of externalizing behavior and psychopathic traits other than fearless dominance; (b) limited unique relations with measures of psychopathy, when examined in concert with the ratings of DSM-5 Section III impairment and ASPD traits; (c) limited evidence of incremental validity in relation to psychopathic traits above and beyond the DSM-5 Section II ASPD symptoms and the DSM-5 Section III impairment and ASPD ratings; and (d) limited evidence that these traits act as moderators of the relations between the Section III ASPD traits and measures of psychopathy and externalizing behaviors.

Strengths, Limitations, and Conclusions The current study is one of the first studies to examine simultaneously the relations between DSM-5 Section II and III ASPD diagnostic approaches in relation to psychopathy, measured by independent psychopathy inventories (one of which is relatively unrelated to fearless dominance/boldness; one of which is strongly linked to fearless dominance/boldness), and the per-

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DSM-5 ANTISOCIAL PD AND PSYCHOPATHY

formance of the DSM-5 Section III PS in relation to measures of psychopathy and externalizing behavior. A strength of the current study is that clinical ratings were used for all aspects of the DSM Section II and III diagnostic approaches to ASPD, as this approach will likely be the gold standard in research, clinical, and forensic settings.2 By using ratings for all three key sets of variables—DSM-5 Section II and III ASPD, and PS—there were no methodological confounds that would have unfairly advantaged one approach over another. Despite these strengths, there are several notable limitations of the current study including the use of a relatively small, primarily female, and homogenous sample of individuals receiving psychological or psychiatric treatment. Further research is needed to test these issues in larger, more diverse samples. In addition, the outcome variables available in this study were limited and it is possible that the DSM-5 PS might provide clinically useful data in relation to other constructs (e.g., treatment responsiveness, likelihood of recidivism) that were not examined here. Also, because ratings of the DSM-5 traits were used here, rather than self-report scores (although see Footnote 2), some of the DSM-5 impairment ratings and traits had limited interrater reliability, including some of those used in the DSM-5 PS, which could have affected the performance of the DSM-5 traits. The DSM-5 PS count also manifested limited internal consistency, which may also have affected its predictive utility.3 Finally, the utility of the DSM-5 PS may have been limited in the current study by issues of range restriction such that the current sample comprised community participants currently receiving mental health treatment who may not have a wide array of scores on traits related to fearless dominance. Again, it will be important for the field to test the current issues using an array of samples, methodologies, and outcome variables in the hopes that a substantial empirical literature will accrue that can be used to inform decisions made on the next iteration of the DSM (e.g., 5.1, 6.0). In conclusion and most importantly, although both DSM-5 Section II and III ASPD diagnostic approaches are able to capture variance in psychopathy, the latter accounts for substantially more variance in psychopathy scores and demonstrates significant incremental validity beyond the official Section II approach. The majority of this variance is accounted for by the traits delineated for the assessment of ASPD, with relatively less incremental utility for the four impairment domains or the three traits included as part of the psychopathy specifier. Moving forward, we believe it will be important to test whether the DSM-5 PS provides clinically useful information above and beyond the impairment ratings and ASPD traits that justifies its inclusion in the official psychiatric nosology.

2 The findings for the psychopathy specifier were nearly identical when the Section III DSM ASPD and psychopathy specifier traits were assessed via self-report ratings on the Personality Inventory for DSM-5 (PID-5; Krueger, Derringer, Markon, Watson, & Skodol, 2012). The self-reported psychopathy specifier traits accounted for, on average, an additional 7% of the variance in the psychopathy scores after accounting for the impairment ratings and the seven ASPD traits (and an additional 7% of the variance when the Section II DSM-5 ASPD scores are included in the model). This incremental variance was significant for SRP-CA, FFM-Psych, and FFM FD. When interactions among the self-reported ASPD and psychopathy specifier trait counts were examined in relation to the psychopathy scores and externalizing behaviors, none were significant (mean change in R-squared ⫽ .001).

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3 When measured using the self-report PID-5 scales, the DSM-5 PS still manifested limited internal consistency (␣ ⫽ .48; mean interitem correlation ⫽ .20) suggesting that these three scale are not strongly related, primarily because attention seeking manifests limited correlations with the other two DSM-5 traits when assessed via both interview-based ratings and self-reports.

References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., revised). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. American Psychiatric Association. (June, 2011). DSM-5 clinicians’ personality trait rating form. Retrieved from http://www.dsm5.org/ ProposedRevisions/Pages/PersonalityandPersonalityDisorders.aspx Anderson, J. L., Sellbom, M., Wygant, D. B., Salekin, R. T., & Krueger, R. F. (2014). Examining the associations between DSM-5 Section III antisocial personality disorder traits and psychopathy in community and university samples. Journal of Personality Disorders, 28, 675– 697. http://dx.doi.org/10.1521/pedi_2014_28_134 Cleckley, H. (1941). The mask of sanity. St. Louis, MO: Mosby. Costa, P. T., & McCrae, R. R. (1992). Revised NEO Personality Inventory (NEO-PI-R) and NEO Five-Factor Inventory (NEO-FFI) professional manual. Odessa, FL: PAR. Crego, C., & Widiger, T. A. (2014). Psychopathy, DSM-5, and a Caution. Personality Disorders. Advance online publication. http://dx.doi.org/ 10.1037/per0000078 Few, L. R., Miller, J. D., Rothbaum, A. O., Meller, S., Maples, J., Terry, D. P., . . . MacKillop, J. (2013). Examination of the Section III DSM-5 diagnostic system for personality disorders in an outpatient clinical sample. Journal of Abnormal Psychology, 122(4), 1057–1069. http://dx .doi.org/10.1037/a0034878 First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. S. (1997). Structured clinical interview for DSM–IV Axis II disorders (SCID-II). Washington, DC: American Psychiatric Press. Gaughan, E. T., Miller, J. D., Pryor, L. R., & Lynam, D. R. (2009). Comparing two alternative measures of general personality in the assessment of psychopathy: A test of the NEO PI-R and the MPQ. Journal of Personality, 77, 965–996. http://dx.doi.org/10.1111/j.1467-6494.2009 .00571.x Hare, R. D. (2003). The Hare psychopathy checklist–Revised (2nd ed.). Toronto, Canada: Multi-Health Systems. Hare, R. D., Hart, S. D., & Harpur, T. J. (1991). Psychopathy and the DSM–IV criteria for antisocial personality disorder. Journal of Abnormal Psychology, 100, 391–398. http://dx.doi.org/10.1037/0021-843X.100.3 .391 Kendler, K. S., Kupfer, D., Narrow, W., Phillips, K., & Fawcett, J. (2009). Guidelines for making changes to DSM-V (revised 10/21/09). Retrieved from http://www.dsm5.org/ProgressReports/Pages/Default.aspx Krueger, R. F., Derringer, J., Markon, K. E., Watson, D., & Skodol, A. E. (2012). Initial construction of a maladaptive personality trait model and inventory for DSM-5. Psychological Medicine, 42, 1879 –1890. http:// dx.doi.org/10.1017/S0033291711002674 Lilienfeld, S. O., & Andrews, B. P. (1996). Development and preliminary validation of a self-report measure of psychopathic personality traits in noncriminal population. Journal of Personality Assessment, 66, 488 – 524. Lilienfeld, S. O., Patrick, C. J., Benning, S. D., Berg, J., Sellbom, M., & Edens, J. F. (2012). The role of fearless dominance in psychopathy: Confusions, controversies, and clarifications. Personality Disorders, 3, 327–340. http://dx.doi.org/10.1037/a0026987 Lynam, D. R., & Miller, J. D. (2012). Fearless dominance and psychopathy: A response to Lilienfeld et al. Personality Disorders, 3, 341–353. http://dx.doi.org/10.1037/a0028296

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Marcus, D. K., Fulton, J. J., & Edens, J. F. (2013). The two-factor model of psychopathic personality: Evidence from the psychopathic personality inventory. Personality Disorders, 4, 67–76. http://dx.doi.org/10.1037/ a0025282 Miller, J. D. (2012). Five-Factor Model personality disorder prototypes: A review of their development, validity, and comparison to alternative approaches. Journal of Personality, 80, 1565–1591. http://dx.doi.org/ 10.1111/j.1467-6494.2012.00773.x Miller, J. D., Bagby, R. M., Pilkonis, P. A., Reynolds, S. K., & Lynam, D. R. (2005). A simplified technique for scoring DSM–IV personality disorders with the Five-Factor Model. Assessment, 12, 404 – 415. http:// dx.doi.org/10.1177/1073191105280987 Miller, J. D., Few, L. R., Lynam, D. R., & MacKillop, J. (2014). Pathological personality traits can capture DSM–IV personality disorder types. Personality Disorders. Advance online publication. http://dx.doi.org/ 10.1037/per0000064 Miller, J. D., & Lynam, D. R. (2003). Psychopathy and the Five-factor model of personality: A replication and extension. Journal of Personality Assessment, 81, 168 –178. http://dx.doi.org/10.1207/ S15327752JPA8102_08 Miller, J. D., & Lynam, D. R. (2012). An examination of the Psychopathic Personality Inventory’s nomological network: A meta-analytic review. Personality Disorders, 3, 305–326. http://dx.doi.org/10.1037/a0024567 Miller, J. D., Lynam, D. R., Widiger, T. A., & Leukefeld, C. (2001). Personality disorders as extreme variants of common personality dimensions: Can the Five-Factor Model adequately represent psychopathy? Journal of Personality, 69, 253–276. http://dx.doi.org/10.1111/14676494.00144 Patrick, C. J. (2010). Triarchic psychopathy measure (TriPM). PhenX toolkit online assessment catalog. Retrieved from https://www .phenxtoolkit.org/index.php?pageLink_browse.protocoldetails&id_ 121601

Patrick, C. J., Fowles, D. C., & Krueger, R. F. (2009). Triarchic conceptualization of psychopathy: Developmental origins of disinhibition, boldness, and meanness. Development and Psychopathology, 21, 913– 938. http://dx.doi.org/10.1017/S0954579409000492 Paulhus, D. L., Neumann, C. S., & Hare, R. D. (in press). Manual for the Self-Report Psychopathy Scale. Toronto, Canada: Multi-Health Systems. Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., & Grant, M. (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption. II. Addiction, 88, 791– 804. http:// dx.doi.org/10.1111/j.1360-0443.1993.tb02093.x Strickland, C. M., Drislane, L. E., Lucy, M., Krueger, R. F., & Patrick, C. J. (2013). Characterizing psychopathy using DSM-5 personality traits. Assessment, 20, 327–338. http://dx.doi.org/10.1177/1073191113486691 Vachon, D. D., Lynam, D. R., Widiger, T. A., Miller, J. D., McCrae, R. R., & Costa, P. T. (2013). Basic traits predict the prevalence of personality disorder across the life span: The example of psychopathy. Psychological Science, 24, 698–705. http://dx.doi.org/10.1177/0956797612460249 Warner, M. B., Morey, L. C., Finch, J. F., Gunderson, J. G., Skodol, A. E., Sanislow, C. A., . . . Grilo, C. M. (2004). The longitudinal relationship of personality traits and disorders. Journal of Abnormal Psychology, 113, 217–227. http://dx.doi.org/10.1037/0021-843X.113.2.217 Widiger, T. A., Livesley, W. J., & Clark, L. A. (2009). An integrative dimensional classification of personality disorder. Psychological Assessment, 21, 243–255. http://dx.doi.org/10.1037/a0016606 Witt, E. A., Hopwood, C. J., Morey, L. C., Markowitz, J. C., McGlashan, T. H., Grilo, C. M., . . . Donnellan, M. B. (2010). Psychometric characteristics and clinical correlates of NEO-PI-R fearless dominance and impulsive antisociality in the Collaborative Longitudinal Personality Disorders Study. Psychological Assessment, 22, 559 –568. http://dx.doi .org/10.1037/a0019617