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Antisocial Personality Disorder and Psychopathy:

Historical Changes and Lack of Consensus

Jessica Tarr

Bay Path University

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Jessica Tarr

02/05/2023

Psychopathology

Antisocial Personality Disorder: Historical Changes and Lack of Consensus

Those of whom are not familiar with diagnostic classifications within the Diagnostic and

Statistical Manual of Mental Disorders [DSM] might be surprised to learn that the term

“psychopathy” has no longer been used to make diagnosis within the official diagnostic criteria

and codes within Section II of the manual. The term “psychopath” has widely been used in

media, and even recently, there have been increased interest within the public population to

absorb themselves with information on infamous figures (e.g., Ted Bundy) via the help of

releases by streaming services. For instance, according to Smith (2022), the Netflix show titled

‘Monster: The Jeffrey Dahmer Story’ occupied the top spot on the Netflix TV Charts in the

month of October, 2022. Even fictional characters, such as James Bond and Sherlock Holmes,

have been described as having prototypic psychopathic characteristics (Lilienfeld et al., 2015, as

cited in Crego & Widiger, 2022). As a term used by average laypersons with no associations to

the psychological field, why has psychopathy dwindled to mere mentions in the current DSM-5-

TR? (American Psychiatrist Association [APA], 2022) That is the topic in question within the

current paper. The answer can largely be contributed to continuous criterion changes and name

changes in the DSM editions over the many decades (Gurley, 2009; Crego & Widiger, 2015). In

an effort to include alterative diagnostic models of personality disorders, the DSM-5 (APA,
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2013) and DSM-5-TR (APA, 2022) added an alternative model for personality disorders

(AMPD) within Section III of the manual. Not only has this exposed the disagreements that have

occurred within the field in regard to how to best diagnose personality disorders, but the AMPD

for antisocial personality disorder (ASPD) has included psychopathic features. Thus, the second

question to the paper is whether Section III tests better than Section II within research in relation

to psychopathy variants and its diagnosis of ASPD.

Many individuals have continued to use the term ‘psychopathy,’ ‘sociopathy,’ and

‘antisocial personality disorder’ interchangeably. Much of the overlap and confusion might be

seen as a result of continuous change within criteria and terminology within the DSM editions

over the last seven decades (Gurley, 2009). Indeed, once upon a time (i.e., ~20 years before the

release of the DSM-I) psychopathy referred to all cases of personality disorders (Schneider,

1923, as cited in Crego & Widiger, 2015). Cleckley (1941) was the most influential in his

definition of psychopathy, and the DSM-I (APA, 1952) had significant overlap with his

formulation within their ”sociopathic personality disturbance, antisocial reaction” diagnosis

variation (APA, 1952, p. 38). Within the first edition, it explicitly stated that the term would be a

replacement for the previous terms of ‘psychopathic personality’ and ‘constitutional

psychopathic state.’ It also described such individuals to be frequently callous, hedonistic, and

chronically antisocial. The DSM-II (APA, 1968) changed this term to “antisocial personality,”

with even more of Cleckley’s (1941) formulation, which included the features of selfishness,

impulsivity, irresponsibility, inability to feel guilt or to learn from experience, and having

conflict with society. A more significant change occurred within the DSM-III (APA, 1980),

when the term changed to “antisocial personality disorder” (ASPD) and diagnostic guidelines
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were officially provided for the first time due to the lack of reliability with previous editions for

diagnosing. The increased interest in improving reliability resulted in two additional influential

instrumental criteria (Feighner et al., 1972; L. Robins, 1966, as cited in Crego & Widiger, 2015).

The DSM-III was the first with explicit sets of criteria, and a combination of instrumental criteria

were added to DSM-III (e.g., the inclusion of the conduct disorder prerequisite, financial

irresponsibility, aggressiveness, and recklessness). Due to lack of structured interview, ASPD

was the only clinical assessment within personality disorders that remained reliable (Mellsop et

al., 1982, as cited in Crego & Widiger, 2015). This was largely due to Hare’s (1980)

development of the Psychopathy Checklist (PCL), which, as a conceptual framework based on

Cleckley’s (1976), added contributions to his description of psychopathy. Inconsistencies began

to appear between the traits from instrumental measures and DSM-III diagnostic criterion (e.g.,

PCL did not require the presence of conduct disorder). Additionally, the DSM assessed

behaviors, while the PCL assessed traits. Psychopathy began to slowly drift; instead of the

consideration of traits of psychopathy, the DSM had begun to focus on a series of antisocial acts

(Hare, 1986; as cited in Crego & Widiger, 2015). Most criteria from DSM-I and II were

ultimately removed, and the diagnosis transitioned from a disorder of personality to one of

behavior (Gurley, 2009). Characteristics that reflected psychopathy had all been deleted from the

criteria; however, their inclusion of the term “Sociopathic Personality” in the index, with a note

to “see antisocial personality disorder” kept psychopathy as an association with the disorder.

DSM-III-R (1987) and DSM-IV (1994) consisted of little change, with the exception of obvious

shortened criteria and adjusted diagnosis closer to the new PCL-R conceptualization (Widigen &

Corbitt, 1993, as cited in Crego & Widiger, 2015), and DSM-IV-TR (2000) also had little to no

change for the diagnosis of ASPD. Despite the separation of ASPD and psychopathy by the
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release of DSM-IV (1994) and DSM-5 (2013), as well as the confusion on whether they were

one in the same or different, it was found that there was significantly more research conducted

on psychopathy than on ASPD (Crego & Widiger, 2015). The Work Group for DSM-5 proposed

to change the name from “antisocial” to “antisocial/psychopathic” (Skodol, 2010, as cited in

Crego & Widiger, 2015). The proposal was ultimately dropped before the official release due to

lack of empirical support for validity or reliability (Widiger, 2011, as cited in Crego & Widiger,

2015). Instead, the proposal was replaced with the alternative hybrid model, which was a

combination of deficits of interpersonal relatedness and sense of self with seven maladaptive

personality traits obtained from a five-domain dimensional trait model (Krueger et al., 2011, as

cited in Crego & Widiger, 2015). The four deficits included impairment to intimacy, self-

direction, identity, and empathy. The seven traits from Krueger et al.’s (2011) model were risk

taking, impulsivity, and responsibility from the disinhibition domain, and callousness, hostility,

manipulativeness, and deceitfulness from the antagonism domain. Among those in the field,

some attention was drawn to DSM-5 with its exclusion of Hare and Cleckley’s conceptualization

of psychopathy and instead its inclusion of a brand-new model of psychopathy with three

constructs (meanness, disinhibition, and boldness), which they had identified as essential to

understand psychopathy (Triarchic Psychopathy Measure [TriPM]; Patrick et al., 2009). More

concerns were raised in respect to further revisions made on the DSM-5 website with the

proposed alternative model criterion set, as it added new components for a psychopathy specifier

(i.e., low anxiousness, low social withdrawal, and high attention-seeking) (APA, 2013). Not only

were those components separate from Cleckley (1941, 1976) and Hare’s (2003) PCL-R, but they

“[were] largely components of normal, adaptive functioning” (Marcus et al., 2012, as cited in

2015).
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In addition to the changes made throughout the years to DSM editions, some of the

confusion around ASPD and psychopathy might be attributed to continued criticisms made by

researchers and individuals within the field of psychology. ASPD has long been criticized as

being a diagnosis that has steadily differentiated itself from Cleckley’s (1941) teachings (Hare et

al., 2012, as cited in Crego & Widiger, 2015). However, Crego & Widiger (2015) argued that “it

would be a rather dogmatic scholasticism to require that all future conceptualizations of

psychopathy be consistent with one developed by a particular clinician from the 1940s” (p. 671).

They also indicated that much of what the field has based psychopathy on (i.e., Cleckey’s

description of the prototypic psychopath) included participants who do not fit the current mold of

what a true prototypic psychopath is. They described Cleckley’s cases as having been

“essentially drifting ne’er-do-wells who were not particularly aggressive, cruel, or viscous”

(Crego & Widiger, 2022, pp. 680-681)… and that not one of Cleckley’s psychopath cases “had

committed murder or rape, let alone serial rape or serial murder” (p. 681). Even so, some

additional arguments continued, with some having stated that “boldness” should not be

considered a feature of psychopathy, while others complained that “meanness” was not included

in prototypical psychopathy (Miller & Lynam, 2012; Lilienfeld et al., 2015, as cited in Crego &

Witiger, 2022). Even the PCL-R, which was once referred to as “the gold standard in

psychopathy research” (Western & Weinberger, 2004, as cited in Crego & Witiger, 2022) had

been replaced by newer models and measures that severely differed from PCL-R. All of the

different discrepancies seemed to also trickle down to the general public’s confusion on

psychopathy, as some of the figures they attributed as being psychopathic had bits and pieces of

various traits and behaviors that were at one point considered to have been representative of the

prototypic psychopath. That confusion was reflected perfectly in Crego & Widiger’s (2022)
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study, which obtained ratings of psychopathic traits of six specific public figures. They used the

five-factor model, Cleckley’s (1941, 1976) criteria, as well as the newer traits from newer

models (e.g., fearlessness and boldness). In their results, the traits that were evident for all six

figures were excitement-seeking, feels invulnerable, fearlessness, boldness, and thrill-seeking.

However, while three individuals clearly presented as an obvious psychopath (i.e., Clyde

Barrow, Ted Bundy, and Bernie Madoff), the other three were figures who would not have been

said to be psychopathic (i.e., Chuck Yeager, Sherlock Holmes, and James Bond). While the

addition of a psychopathic specifier in the AMPD seemed exciting, they explained why its added

traits of boldness and fearlessness were worrisome, stating, “perhaps then it is precisely these

traits of fearlessness and boldness that contributes to an inaccurate perception that these persons

are psychopathic” (p. 680). While understanding how a human being could be so “evil” is a valid

concern, it is impossible to accurately answer, as there is still lack of consensus on a set

definition or description of the disorder (Widiger & Crego, 2021). In the end, they suggested that

no single trait is sure to be a pathognomic trait.

The second focus of the paper pertains to the DSM-5 alternative model for personality

disorders (AMPD) and its operationalization on ASPD and its relation to the psychopathic

specifier construct. Specifically, “it is a hybrid dimensional categorical system, which

conceptualizes personality disorders as a combination of impairment in self and other

functioning (Criterion A) and pathological traits (Criterion B)” (Anderson & Kelley, 2022, pp.

397-398). In addition to the categorical classification and ASPD trait operationalization, it also

included a psychopathy specifier. Few et al. (2015) stressed the importance of that inclusion, as

psychopathy has not been recognized in any official capacity within the last four editions of the

DSM as its own entity. The inclusion assumes that psychopathy is an aspect or variant of ASPD.
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The DSM-5 described the specifier by “a lack of anxiety or fear and by a bold interpersonal style

that may mask maladaptive behaviors” (APA, 2022, p. 885) and characterized by low

Withdrawal, low Anxiousness, and high Attention-Seeking. Indeed, as stated previously, the

debate on the inclusion of ‘boldness’ have made the specifier questionable to many (Lilienfeld et

al., 2016, as cited in Anderson & Kelley, 2022). Crego & Widiger (2015) debated that there was

a missed opportunity for the AMPD to reunite psychopathy and ASPD, as well as having stated

that the specifier ultimately failed to reflect models established of psychopathy and that the new

added traits were too adaptive. Nonetheless, previous studies have concluded that AMPD traits

in Section III successfully reflected the personality disorders listed in Section II (Anderson et al.,

2014, as cited in Anderson & Kelley, 2022). Their current study aimed to decipher whether

AMPD trait conceptualization of ASPD exceeded its Section II counterpart in the measurement

of psychopathy. This had already been proven consistently within past studies (Wygant et al.,

2016, 2020, as cited in Anderson & Kelley, 2022) and psychopathy seemed to be well-

represented in the AMPD for ASPD. Despite the fact of contention in regard to the “boldness”

centrality of the specifier, previous studies suggested that the specifier successfully captured the

boldness construct (Wygant, 2020, as cited in Anderson & Kelley, 2022). They, however,

described the decision to make the construct the differentiating feature of psychopathy as “lighter

fluid in the psychopathy forest fire” (p. 399). Though imperfect, they suggested that the AMPD

gave way to rejoin psychopathy into the field of psychopathology. Similarly, Few et al. (2015)

found that the diagnostic approach for ASPD in the AMPD converged more successfully with

the psychopathy construct, from which ASPD was originally born. The results of their study

suggested that the approach used in Section III to diagnose ASPD accounted for significantly

higher variance in scores of psychopathy than the approach in Section II…and that the trait of
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callousness was the most consistent contributor to the scores of psychopathy. However, they

found little added variance in regard to the traits included in the psychopathy specifier. Like

Anderson & Kelley, they also believed that the more trait-based approach featured in the AMPD

might bring ASPD and psychopathy closer together. For those who argued too much similarity in

the two approaches, they contended that while nominal content was similar, the assessment

approach was significantly different… that the new approach relieed less on explicit markers of

behavior and more on open construct. Clark & Watson (2022) indicated their slight criticism

with the AMPD, stating that in the current state of literature, the vast majority were based on one

self-report measure, the Personality Inventory for DSM-5 (PID-5; Krueger et al., 2012). They

believed this constituted the measure to be the model, and their recommendations for future

research was for more focus on additional existing measures of the AMPD and/or the

development of more measure formats so that the model itself was measured, rather than a

specific operationalization if it. Wygant et al., (2016) argued that psychopathy is very important

within the criminal justice system, as research clearly established the effectiveness of it being a

predictor of violent behavior, sexual aggression, recidivism, and criminal behavior. While DSM-

5 operationalized psychopathy as being ASPD, the ability to test psychopathy in criminal settings

was difficult due to ASPDs lack of capability to “capture the full psychopathy construct” (p.

229). They felt the choice made by the APA Board of Trustees to place the AMPD into Section

III was unfortunate because it had better promise than its Section II counterpart to cover the

psychopathic personality. In their own study, their goal was to determine whether the

operationalization of ASPD in Section III had moved closer to the more traditional construct of

psychopathy in comparison to its Section II variant. Their findings affirmed this, as Section III

outperformed Section II in the prediction of psychopathic traits. Additionally, they found that
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personality impairment (Criterion A) increased the prediction of psychopathy and ASPD far

larger than personality traits (Criterion B). Thus, in Wygant et al.’s (2016) study, in addition to

others listed, results suggested that Section III’s ASPD was more aligned with psychopathy than

Section II’s behaviorally oriented model. They recommended further avoidance on overlap

between the different personality disorder profiles, with the indication that it might help

discontinue the use of the personality disorder model used in Section II of DSM-IV and DSM-5.

In conclusion, historical changes within diagnostic criteria manual editions have skewed

perceptions of psychopathy and its relationship to ASPD or psychopathology among both

individuals within the psychological field and public population alike. The continuous changes

of traits and behaviors have created differentiating opinions on which truly represent the

prototypic psychopathic profile. This might explain why specific public figures are often

associated with psychopathy, like Lykken (1982), who suggested that Chuck Yeager, a highly

successful pilot, and the typical psychopath “are twigs from the same branch,” due to both

having shared the fearlessness trait (as cited in Crego & Widiger, 2022). The inclusion of the

AMPD in Section III of DSM-5 has provided guidance to bring both terms back together and

potentially weed out unhelpful traits within Section II. As studies proved the AMPD for ASPD to

be a better indication of psychopathy variants, it had some help from the psychopathic specifier.

Although the specifier essentially began to bring psychopathy back together with ASPD in a way

that has not been seen since before the release of DSM-IV, its associated adaptive characterized

traits have not consistently supported the specifier to positively predict psychopathic traits.

Further research on this specifier will indicate whether those traits should be changed, as its

current continued failure to augment AMPD ASPD traits in the prediction of psychopathy has

created skepticism for its inclusion into the alternative model.

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