.1192/bjp.153.4.505Access the most recent version at doi: 1988, 153:505-512.BJP R Blackburn psychopathic personality revisited. On moral judgements and personality disorders. The myth of permissions Reprints/ permissions@rcpsych.ac.ukto To obtain reprints or permission to reproduce material from this paper, please write to this article at You can respond http://bjp.rcpsych.org/cgi/eletter-submit/153/4/505 from Downloaded The Royal College of PsychiatristsPublished by on December 17, 2011http://bjp.rcpsych.org/ http://bjp.rcpsych.org/site/subscriptions/ go to: The British Journal of PsychiatryTo subscribe to BritishJournalofPsychiatry(1988),153,505â€"512 Lecture On Moral Judgements and Personality Disorders The Myth of Psychopathic Personality Revisited RONALDBLACKBURN Psychopathic personality has always been a conten tious concept, but it continues to be used in clinical practice and research. It also has its contemporary synonyms in the categories of antisocial personality disorder in DSM-III (American Psychiatric Associa tion, 1980) and â€oe¿personalitydisorder with pre dominantly asocial or sociopathic manifestationsâ€• in ICDâ€"9(World Health Organization, 1978), and some overlap between these and the legal category of psychopathic disorder identified in the English Mental Health Act 1983 is commonly assumed. Although the literal meaning of â€ ¿psychopathic'is nothing more specific than psychologically damaged, the term has long since been transmogrified to mean socially damaging, and as currently used, it implies a specific category of people inherently committed to antisocial behaviour as a consequence of personal abnormalities or deficiencies. The most frequent objection to the concept has beenthatsuchacategoryisafiction. Vaillant(1975), for example, regards it as a misleading stereotype, while Karpman (1948) claimed that it is â€oe¿amyth... a nonexistent entityâ€•. Similarly, Wulach (1983) suggests that the notion of a specifically antisocial personality exaggerates the difference between the deviant and the conforming, while minimising indivi dual variations among the antisocial. Counterclaims that the term is clinically meaningful commonly rest on anecdote, but Cleckley's concept of psychopathic personality has inspired research that seems to validate it to some extent (Cleckley, 1976; Hare, 1986). However, research fmdings have not been sufficiently consistent to eradicate suspicions that the term remains a speculative construct (Blackburn, 1983a). This paper reappraises the current utility of the concept as a diagnostic category of personality disorder. Blashfield & Draguns (1976) have noted that to fulfil the communicative and predictive purposes of psychiatric classification, a category within a diagnostic scheme should denote a homo geneous group whose members share a set of reliably identified characteristics. Homogeneity is clearly central to the issue of whether psychopathic personality is more than a mythical entity, and the present discussion therefore examines the extent to which current uses of the term identify a homo geneous category. Homogeneity and classification Homogeneity is a relative term denoting similarity between members of a group. Psychiatric diagnosis now recognises polythetic classes whose members need not display all characteristics defining a cate gory (Spitzer et a!, 1978; American Psychiatric Association, 1980). In these terms, a homogeneous class is one defined by a minimal set of attributes possessed to some extent by all its members, and not possessed by members of other classes. A group will be heterogeneous if some of its members lack the set of defining attributes or possess the attributes defining other classes. A class concept derives its meaning within a particular universe of discourse. For example, democrats form a class within the universe of political believers, while blue-eyedness is a class within the universe of eye colour. Groups that are homogeneous in terms of one domain will not be so when classified in terms of another. Thus, the class of democrats will contain individuals who are heterogeneous in eye colour, as will the class of autocrats. A major issue in evaluating homogeneity, therefore, lies in specifying the universe of charac teristics across which homogeneous groups are to be sought. Clearly, eye colour is not an appropriate characteristic for defining membership in a class of political beliefs, since eye colour neither entails nor precludes the holding of such beliefs. In this instance, the relationship between universes is one of conjunc tion, since a person may be assigned to classes of eye colour and political belief. Conversely, it is appropriate to enquire whether a person is blue-eyed or brown-eyed, but not whether he is blue-eyed or democratic. To yield homogeneous groups, then, a classification system must be based on the attributes Based on an invited address to the annual conference of the Northern Ireland Branch of the British Psychological Society's annual conference, Donegal, Bire, May 1986 505 506 BLACKBURN of a single universe. Only if there were grounds for believing that classes from different universes coincide (e.g. all autocrats are blue-eyed), would it be appro priate to introduce criteria from another universe. This issue is particularly critical in the case of a theoretical construct such as psychopathic persona lily, since in the early stages of classification, the appropriate universe may not be clearly delineated. Several competing definitions have been proposed in the literature, and since the lists of defining attributes vary considerably, an immediate question is whether they are drawn from a single universe or domain. In ICD-9 and DSMâ€"III, the relevant categories are among several classes within the universe of personality disorders. Their defining attributes should therefore logically be deviant personal dispositions. However, mcluded in the defmi tion of antisocial personality disorder in DSM-III are specific features, such as expulsion from school, or irresponsible parenting, which may or may not be a consequence of deviations of personality, but which are not in themselves personality character istics. They appear to belong in a different domain, and employing such criteria in the definition of a disorder of personality raises the same issues for the identification of a homogeneous class as would classifying democrats by reference to eye colour. Several writers have drawn attention to two traditions in the history of the concept (Anderson, 1959; Pichot, 1978; Millon, 1981). It will be argued here that these traditions focus on different universes of discourse, the confounding of which has resulted in concepts of psychopathic personality that do not defme a homogeneous class. This history is recapitu lated here to indicate how current conceptions have been influenced by it. First, however, the basis for distinguishing the different conceptual universes involved is examined in more detail. The universes of personal and social deviance In psychological theory, personality does not denote an entity, but rather refers to behavioural consis tencies that distinguish and differentiate individuals, i.e. dispositions or traits, and to the psychological structures and processes proposed by various theories to account for these consistencies. Although persona lity is reified in ICD-9 (the personality), traits are central to the DSM-III concept of personality disorder. They are defined as â€oe¿enduringpatterns of perceiving, relating to, and thinking about the environment and oneselfâ€•,and constitute personality disorder when they are â€oe¿inflexibleand maladaptive and cause either significant impairment in social or occupational functioning or subjective distressâ€•. In DSM-III, the requirement that clinicians make diagnoses on both Axis I (clinical syndromes) and Axis II (personality disorders) makes it explicit that different criteria are involved in these two sets of disorder, i.e. that the symptoms of major syndromes differ in kind rather than degree from the traits that define personality disorders, and that the two may therefore coexist. This distinction was anticipated by Foulds (1971), who argued that personal illness (mental illness) and personal deviance (personality disorder) belong in different universes of discourse, and that a person may display either, neither, or both. The former represents departures from intra individual norms, the latter from interpersonal norms. Previously, Foulds (1965) distinguished personality traits from the symptoms of illness, on the grounds that, in contrast to symptoms, traits are universal (i.e. vary throughout the population), enduring (i.e. relatively consistent), and non distressing. In his later paper, he modified this distinction to allow for deviant traits, which may be associated with distressing states (e.g. dispositions to experience guilt or tension) or which are prominent in personality disorder (e.g. hostility or lack of empathy). Traits describe inferred tendencies, and are there fore distinct from specific acts or occurrences. Deserting a marital partner or committing a crime are specific occurrences that do not in themselves permit the inference of a tendency. However, not all behavioural tendencies are personality traits, since traits also describe the manner, or the â€ ¿how'of behaving. Descriptions of antisocial or asocial tendencies, which appear in some definitions of psychopathic personality, do not take this form, nor do they describe universal or enduring tendencies. They do not, therefore, fall in the universe of personality traits. Illegal acts or failure to honour financial obligations, for example, do not describe the â€ ¿how'of behaviour, and are neither traits nor symptoms in Foulds' terms. Moreover, these are not so much descriptions of behaviour as judgements of its appropriateness. For example, whether the spanking of a child is judged as â€ ¿abuse'or â€ ¿legitimate punishment' depends on the context in which it occurs. The identification of such tendencies is, then, dependent on a moral frame of reference, which identifies departures from sociocultural norms of what constitutes acceptable conduct. They therefore belong in a different universe of discourse, which can be described as that of social deviance. Given that membership of the universe of personal deviance neither entails nor precludes membership of the universe of social deviance, a person may belong in either, neither, or both. Research has 507MORAL JUDGEMENTS AND PERSONALITY DISORDERS clearly established that social deviance does not coincide with personal deviance, since socially deviant populations are heterogeneous with respect to personality deviation. For example, research with serious delinquents (McManus eta!, 1984) and drug abusers (Kosten et a!, 1982; Khantzian & Treece, 1985) has indicated heterogeneity in terms of DSMâ€"IIIpersonality disorders. Similarly, cluster analyses of self-reported personality deviation have demonstrated four distinct patterns among mentally disordered offenders (Blackburn, 1975, 1986), female offenders (Widom, 1977), and violent male criminals (McGurk, 1978; Henderson, 1982). Since social deviance may be found in conjunction with several forms of personality deviation, or with none, it is neither necessary nor sufficient to identify a persona lity disorder. The contribution of personality characteristics to antisocial behaviour is an empirical question that can only be answered if the two are identified indepen dently. Defining a disorder of personality in terms of social deviance confounds the two universes, and makes it unlikely that a class that is homogeneous in terms of personality deviation will be identified. However, the concept of psychopathic personality has variously described social deviance, personal deviance, or a mixture of the two. These differing uses of the term will be considered to determine whether a homogeneous category of deviant persona lity is distinguishable. Psychopathic personality as social deviance The origins of recent notions of psychopathic personality are commonly traced to Prichard's (1837) concept of moral insanity (Maughs, 1941). Prichard merely elaborated the proposals of 18th century physicians, and his use of the term â€ ¿moral'went beyond that of â€ ¿ethical'(Walker & McCabe, 1973; Millon, 1981). Although his illustrative cases included only a few for whom antisocial conduct was the chief reason for inferring moral insanity, he nevertheless launched attempts to explain socially objectionable behaviour, in the form of an inability to conduct oneself â€oe¿withdecency and propriety in the business of lifeâ€•,by reference to moral â€oe¿perversionâ€•.Moral insanity was thus a hypothetical cause of social deviance, and much of the subsequent debate in the 19th century centred on how a diseased â€oe¿moral facultyâ€•could explain criminal behaviour. The adjective â€ ¿psychopathic'first appeared in mid-19th century Germany, but Walker & McCabe (1973) detect three differing uses of the term. Initially, it had the etymologically precise meaning of â€ ¿psychologicallydamaged', hence comprising all forms of psychopathology. In 1891, however, Koch described psychological abnormalities that did not amount to strict insanity, as â€oe¿constitutionalpsycho pathic inferiorityâ€•(Koch, 1891). This was an explicit rejection of the notion of moral insanity, and an attempt to specify a biological basis for non psychotic disorders. The third use of the term was its restriction to mean â€ ¿unethical',which is attributed to Meyer's influence in the USA, and that of Henderson in Britain. Walker & McCabe note this use in the report of a trial in St Petersburg in 1885, but this narrow application did not become widespread for several decades. In Britain, attempts to introduce moral insanity into the law resulted in the category of moral imbecile in the 1913 Mental Deficiency Act, but psychiatrists resorted to the term psychopath to describe chronic offenders who were not mentally deficient, but who were nonetheless assumed to be morally defective. This practice was sanctioned by Henderson, who wrote: â€oe¿Aflaw in a person's moral structure may constitute a disease as truly as some form of physical involvementâ€• (Henderson, 1955). This use was eventually formalised in the category of psychopathic disorder in the English Mental Health Act of 1959, which was defined as â€oe¿adisorder or disability of mind.. . which results in abnormally aggressive or seriously irresponsible conduct on the part of the patient, and requires or is susceptible to medical treatmentâ€•. This permits the circular inference of a â€oe¿disorderof mindâ€• from the â€oe¿abnormally aggressive or seriously irresponsible conductâ€• it supposedly causes, and as Mayer-Gross et a! (1969) observed, it effectively equates â€ ¿psychopathy'with antisocial conduct. Walker & McCabe (1973) suggest that the original intention was for psychopathic disorder to be a generic label for non-psychotic psychiatric disorders, but that the more specific antisocial connotations had become too entrenched. In practice, those who fall in the category tend to have committed socially abhorrent crimes, and are somewhat indiscriminately labelled â€ ¿psychopaths'. The label has dissatisfied many psychiatrists, and in the view of the Butler Committee (Home Office/Department of Health and Social Security, 1975), â€oe¿Theclass of persons to whom the term â€ ¿psychopathicdisorder' relates is not a single category identifiable by any medical, biological, or psychological criteriaâ€•.This has been confirmed in research that shows that those in the cate gory are heterogeneous (Blackburn, 1975, 1979). The Committee tentatively suggested replacing the term with the generic â€ ¿personalitydisorder', but when the Act was revised in 1983, the label was retained. 508 BLACKBURN The English concept of â€ ¿psychopathicdisorder', then, is a legacy of Prichard's â€oe¿moralinsanityâ€•. Although wickedness or moral depravity are no longer explicit, an unspecified mental abnormality is inferred from social deviance. The result is a heterogeneous group of deviant personalities. American use of the concept of psychopathic persona lity was initially influenced by German concepts originating with Koch, but became increasingly narrowed with the development of psychoanalysis and sociology (Millon, 1981). Partridge (1930) noted that it included â€oe¿allpersonality deviations of whatever kindâ€•,but his use of the term personality was global and non-specific. He proposed to use the term sociopathy to cover â€oe¿anythingdeviated or pathological in social relationsâ€•.Essential sociopaths were those of the broad category of psychopathic personalities showing â€oe¿chronicmaladjustment... in direct relation to anti-social motivationâ€•.Like the notion of moral insanity, this assumes that objection able behaviour implies psychological abnormality, although no specific personality deviationisidentified. This term has gained acceptance in the USA, and â€ ¿sociopath'is commonly used interchangeably with â€ ¿psychopath'.Robins (1966), defined sociopathic personality in terms of a number of forms of social rule violation. Her approach has influenced some workers in Britain (Watts & Bennett, 1978), but is seen most explicitly in the DSMâ€"IIIcriteria for antisocial personality disorder. However, in the first edition of DSM in 1952, â€ ¿sociopathicpersonality disturbanceâ€•was a generic category which included antisocial reaction, dyssocial reaction, sexual deviation, and addictions (American Psychiatric Association, 1952). It was dropped in 1968, when antisocial personality became a distinct category of personality disorder in DSM-II, while in DSM-III, sexual deviations and addictions are among the Axis I disorders. Psychopathic personality as personal deviance A generic category of psychopathic personalities was first proposed by Kraepelin (1904). Of several similar typologies that followed, the most influential has been that of Schneider (1950), which first appeared in 1923. Schneider's concept of psychopathic personality refers to a heterogeneous group divided into ten specific types or classes. He explicitly excludes antisocial behaviour from the criteria of abnormal personality, which refers to statistical deviations from the average in terms of excesses or deficits. Psychopathic personalities are those abnormal personalities who cause â€ ¿suffering'to themselves or others. While this includes some who break the law, their antisocial behaviour is secondary to personality deviation. Although it is often suggested that his psychopathic personalities include â€ ¿neurotics',he distinguished â€ ¿abnormalreactions' to external events or inner conflicts from abnormal dispositions. His psychopathic personalities are, in fact, described mainly in terms of traits (or deviant traits), although some resemble the â€ ¿character neuroses' of psychodynamic writers. Schneider acknowledged that his typology was â€ ¿unsystematic',and it has received little research attention. Nevertheless, the classes of personality disorder in ICD-8 and ICDâ€"9and in DSMâ€"IIare essentially his psychopathic personalities. As Pichot (1978) notes, it is paradoxical that the term psycho pathic personality has been reserved in English and American psychiatry for the narrower â€ ¿antisocial' category. While the â€ ¿sociopathic'personality disorder of ICDâ€"9resembles Schneider's affectionless type, the inclusion of antisocial behaviour in the criteria violates his principle of classifying by reference to personality deviation alone. The Axis II personality disorders of DSMâ€"III are also equivalent to psychopathic personalities in Schneider's generic sense. This typology of trait clusters was based on the proposals of Millon (1981), whose model of personality postulates eight distinct â€ ¿copingpatterns'. However, the fmal version departed from this model in several ways, adding three categories (schizotypal, borderline, and paranoid), which Millon views as more severe variants of his basic patterns. A major departure lies in the criteria for antisocial personality dis order. In Millon's scheme, the corresponding category is the â€ ¿aggressive'pattern, characterised by hostile affectivity, assertive self-image, inter personal vindictiveness, hyperthymic fearlessness, and malevolent projection. These attributes clearly belong in the universe of personality traits, and Millon asserts that although antisocial behaviour may be a correlate, only a minority showing this pattern will exhibit flagrant antisocial behaviour. In contrast, DSM criteria for antisocial personality are predominantly antisocial types of behaviour, the only traits referred to being irritability and aggressiveness, impulsivity and recklessness, none of them being essential to the diagnosis. This is inconsistent with the avowed aim of DSM to describe personality disorder in terms of traits, and Millon comments that this category is â€oe¿anccusatory judgement rather than a dispassionate clinical formulationâ€•.However, Millon's aggressive pattern does not seem to identify a homogeneous group, since it overlaps with his histrionic and narcissistic patterns (Millon, 1983). 509MORAL JUDGEMENTS AND PERSONALITY DISORDERS Although the DSM-III classification of personality disorder draws on a theoretical model, it owes little to empirical research. Taxonomic studies of persona lity deviation have been rare, but Presly & Walton (1973) and Tyrer & Alexander (1979) examined the interrelationships of selected deviant traits. Both studies found that these could be reduced to a small number of dimensions, the first being similar across studies. This includes such traits as impulsiveness, egocentricity, callousness, and irritability, and is labelled â€ ¿socialdeviance' in the former study, and â€ ¿sociopathy'in the latter. Cluster analysis of patterns across these dimensions yielded groups that do not correspond closely to conventional categories of personality disorder. However, one of four groups identified by Tyrer & Alexander scored highly on the sociopathy dimension, and it included those diagnosed â€ ¿antisocial'and â€ ¿explosive'by ICDâ€"8criteria. Subjects in this study were psychiatric out-patients and not specifically antisocial, and the â€ ¿sociopathic' group appears to meet the requirements of a homo geneous class of personality deviation. However, a similar study by Blackburn & Maybury (1985) found evidence for two â€ ¿psychopathic'groups rather than one. Hybridconceptsofpsychopathicpersonality Several concepts of psychopathic personality have emerged that denote a specific type of deviant personality characterised by social deviance. These are mainly of American origin. Karpman (1948) analysed the concept from a psychodynamic perspec tive. He considered that the psychopaths described by Henderson (1955) and Schneider (1950) were a heterogeneous group having in common only a record of antisocial behaviour. Heterogeneityinthis context, however, is relative to psychodynamic mechanisms and processes. He proposed that most of Schneider's types did not merit classification as psychopathic, since their antisocial behaviour was secondary to, or symptomatic of, neurosis. There was, he maintained, a small group of primary or idiopathic psychopaths, who are â€ ¿allantisocial', and who are characterised by a constitutional incapacity to develop a conscience. He regarded this latter group as â€ ¿true'psychopaths, although he proposed the term â€ ¿anethopath'. Karpman's (1948) argument is confused. He starts by equating psychopathic with antisocial, and his assertion that psychopathic personality is a â€ ¿mythical entity' is directed towards this use of the term. This is logically correct to the extent that antisocial people are heterogeneous in terms of psychodynamics. However, this is not relevant to Schneider's use of the term. Karpman proposes to substitute motivational explanation for description, but in doing so, changes the meaning of psychopathic to an inferred cause of deviance, i.e. lack of conscience. His primary psychopath is hence a psychological type, since he or she is defined not by the occurrence of antisocial behaviour, but by the person's dynamic structure. For Karpman, then, psychopathic personality becomes abnormal personality. Primary psychopaths are â€ ¿true'psychopaths because this is the only form of abnormal personality that he distinguishes from neurosis or psychosis. The primary-secondary distinction is thus the outcome of his refusal to recognise personality disorders as a separate group. The primary-secondary terminology has been adopted by several researchers since Lykken (1957) divided â€ ¿sociopaths'into these subgroups on the basis of differences in level of trait anxiety. The distinction has been shown to be empirically justified by Blackburn (1975, 1986), who found that within an antisocial population, impulsive and aggressive people fall into non-anxious and anxious subgroups, which were accordingly labelled primary and secondary psychopaths. These are homogeneous categories, and insofar as those in the primary group are less troubled by emotional problems, they might seem to warrant Karpman's description of â€ ¿true' psychopaths. However, the secondary group is distinguished by deviant traits rather than neurotic symptoms. The two groups thus represent distinct types of deviant personality, and hence contradict Karpman's assertion that only one type of abnormal personality is uniquely associated with antisocial behaviour. The primary-secondary distinction is therefore misleading, and the notion of a â€ ¿true' psychopath is gratuitous. In attempting to expose a myth, Karpman merely narrowed its focus. Cleckley's influential analysis of psychopathic personality is similar to that of Karpman, although not explicitly psychodynamic. Cleckley also criticises earlier typologies, and proposes that most categories of personality disorder can be relegated to the neuroses or psychoses. He considers that the DSM-I and DSM-II descriptions of antisocial reaction or personality correspond to his own use of the term psychopathic personality. Like Karpman's primary psychopath, this is said to be â€ ¿adistinct clinical entity'. Cleckley argues that psychopathy should not be equated with criminality, delinquency, sexual deviation, hedonism, or alcoholism. He proposes 16 criteria, which include traits such as superficial charm, egocentricity, insincerity, affective poverty, and interpersonal unresponsiveness, although not all of his criteria are personality traits. For example, suicide rarely carried out, impersonal sex life and â€ ¿fantasticand uninviting behaviour with drink' 510 BLACKBURN clearly describe socially objectionable behaviour. Cleckley is nevertheless attempting to define a personality type. His criteria have been employed by several researchers, notably Hare, and there is recent evidence that a general factor runs through them. Central to this seems to be a lack of interpersonal warmth (Hare, 1980; Blackburn & Maybury, 1985). However, Blackburn & Maybury found that when assessed in the broader context of personality deviation, offenders meeting Cleckley's criteria fell into two distinguishable clusters. Both exhibit a lack of warmth, but one is impulsive and aggressive, the other socially withdrawn. Cleckley's criteria, then, do not identify a homogeneous category. These also correlate significantly with the DSMâ€"IIIdiagnosis of antisocial personality disorder (Hare, 1983, 1985). However, a direct correspondence between Cleckley's concept of psychopathic personality and antisocial personality disorder is unlikely, since his criteria appear among those for other DSM-III personality disorders, such as histrionic (superficial charm, insincerity, egocentricity, empty suicidal gestures), narcissistic (lack of empathy), and schizoid, paranoid, and compulsive (lack of warmth). If Cleckley's concept refers to a â€ ¿clinicalentity', as he claims, it would seem to be broader than that of antisocial personality disorder. Although heavily weighted with criteria of social deviance, the DSM antisocial personality-disorder category is also a hybrid that purports to define a personality type. Not surprisingly, a substantial proportion of people in socially deviant populations, such as incarcerated criminals (Hare, 1983), delin quents (McManus et a!, 1984), or addicts (Kosten et a!, 1982) meet the criteria for the disorder. However, this category is itself heterogeneous, since a majority within it also meet the criteria for other personality disorders, such as borderline, histrionic, or narcissistic (Kosten et a!, 1982; Khantzian & Treece, 1985; Pfohl eta!, 1986). This is as would be expected given that the criteria for antisocial persona lity disorder are drawn mainly from the universe of social deviance, and hence do not mutually exclude other classes of personality disorder. Hare (1980) has developed an empirically based psychopathy checklist, which includes several of Cleckley's criteria, but which also includes items of social deviance, such as delinquency, promiscuous sexual relations, and â€ ¿manytypes of offence'. As might be anticipated, this measure correlates signifi cantly with diagnosis of antisocial personality (Hare, 1983, 1985). However, analysis of the checklist indicates that factors of personal deviance (impulsive life-style, egocentricity) are distinguishable from factors of social deviance (inappropriate sexual and parenting behaviour, antisocial history, and inade quately motivated criminal acts: see Hare, 1980; Raine, 1985). This suggests that among those catego rised as psychopaths by the checklist, some will be personally deviant, some will be socially deviant, and some will be both. It therefore seems likely that the checklist tends to identify as psychopathic an anti social group that is heterogeneous in personality deviation. Category or dimension? It has been noted that a general factor has emerged in some studies which is defined by traits such as egocentricity, impulsivity, hostility, and lack of warmth, and which has been labelled as psychopathy or sociopathy (Presly & Walton, 1973; Quay, 1978; Tyrer & Alexander, 1979; Hare, 1980; Blackburn & Maybury, 1985). While this may appear to validate the concept of psychopathic personality, it is a dimension of personality, not social deviance. Furthermore, a dimension is not the same as a discrete type, and extremes on one dimension may characterise several personality types that differ significantly on other dimensions. The traits claimed by Cleckley and others to identify a â€ ¿distincten ity' may therefore represent a personality dimension that is common to more than one class of personality disorder. Blackburn & Maybury (1985) demonstrated that the â€ ¿psychopathy'dimension corresponds to a dimension of hostility that, together with an independent dimension of dominance-submission, forms the basic element of the interpersonal system of personality description originating with Leary and subsequently developed by others (Wiggins, 1982). Several writers have proposed that this model provides a means of describing personality deviation that has several advantages over the current categorical classification of personality disorders (Carson, 1970; McLemore & Benjamin, 1979; Blackburn, 1983b; Widiger & Frances, 1985). In this system, segments of the circle around the hostility and dominance dimensions define different interpersonal styles, which have clear parallels in the categories of personality disorder. However, as these segments are continuous and do not have precise boundaries, the notion of discrete classes becomes simply a convenient fiction. Such a system more realistically portrays the conti nuity between normal and abnormal personality, and between different forms of personality deviation. Figure 1 indicates how the DSM-III categories might relate to this scheme. The continuous circle of interpersonal traits is marked by summary labels of MORAL JUDGEMENTS AND PERSONALITY DISORDERS Hostile a homogeneous class uniquely associated with anti social deviance. While some studies have isolated an wittvia impulsive, aggressive, and relatively unemotional personality type, other patterns of personality devia tion are common among socially deviant populations. The prominence of â€ ¿secondarypsychopaths' and of borderline, histrionic, and narcissistic disorders in Submissive these populations clearly indicates that there is no single type of abnormal personality that is prone to chronic rule violation. Nor, of course, are these categories confined to the antisocial. Compliant it must be concluded that the current concept of psychopathic or antisocial personality remains â€ ¿a mythical entity'. The taxonomic error of confounding different universes of discourse has resulted in a diagnostic category that embraces a variety of deviant personalities. Such a category is not a meaningful focus for theory and research, nor can it facilitate clinical communication and prediction. Indeed, a disorder defmed by past history of socially deviant behaviour is permanently fixed, and cannot provide a point of reference for clinical intervention. Such a concept is little more than a moral judgement masquerading as a clinical diagnosis. Giventhe lackof demonstrablescientificor clinical utility of the concept, it should be discarded. This is not to arguethat sociallydeviant behaviouris unrelated to personality characteristics, but the nature of such a relationship is a question for theory and research. To define a disorder of personality in terms of socially deviant behaviour is to prejudge the issue. Our understanding of how the attributes of the person contribute to socially deviant or other problematic behaviour willonly progress when we have an adequate system for describing the universe of personality deviation. Focus on an ill-conceived category of psychopathic personality has merely served to distract attention from the development of such a system. Coercive Dominant Sociable Friendly Fio. I Hypothesised relation of DSM-III personality disorders to the interpersonal circle hostile, withdrawn, etc. The inner circle represents the normal range, and the outer circle the more extreme variations corresponding to Schneider's excesses or deficits, and the â€ ¿inflexible'traits of personality disorder. DSM categories are represented as stylesreflectingdifferentcombinationsof hostility and dominance. Primary and secondary â€ ¿psycho paths' would be those occupying adjacent positions around the hostile-dominant quadrant. Millon's notion of an â€ ¿aggressive'pattern is preferred to that of â€ ¿antisocial',since in this scheme, antisocial personality is a redundant concept. While styles in the hostile-dominant quadrant might be associated with increased likelihood of conflict with others, there is no necessary association between socially deviant behaviour and any particular interpersonal style. Conclusions In the course of its history, the concept of psycho pathic personality has clearly varied both in specificity and content. Schneider's generic concept embraced several specific categories defmed by deviations of personality, and has become the general category of personality disorders in ICD-9 and DSM-III. Within English-speaking psychiatry, however, psychopathic disorder and sociopathic personality have referred to a narrower,but stillheterogeneouscategoryidentified predominantly by socially objectionable behaviour. The more specificâ€ ¿antisocial'ategoriesof lCD and DSM, as well as the concepts of psychopathy developed by Karpman (1948), Cleckley (1976), and Hare (1980) represent hybrids of these traditions in which a distinct entity is defined by combinations of deviant personality traits and socially deviant behaviour. None of these has been shown to identify References AMERICAN PSYCHIATRIC ASSOCIATION (1952) DiagnostIc and Statistical Manual of Mental Disorders (1st edn) (DSM-I). Washington, DC: APA. â€"¿ (1980) DIagnostic and Statistical Manual of Mental Disorders (3rd edn) (DSMâ€"III),Washington, DC: APA. ANDERSON,E. W. (1959) Preface. In Clinical Psychopathology. (5thedn)(ed.K. Schneider).New York:Grune& Stratton. B@cxBuari, R. (1975) An empirical classification of psychopathic personality. British Journal of Psychiatry, 127, 456-460. â€"¿ (1979) Cortical and autonomic arousal in primary and secondary psychopaths. Psychophysiology, 16, 143-150. â€"¿ (1983a) Psychopathy, delinquency and crime. In Physiological Correlates of Human Behaviour (ads A. Gale & J. Edwards). London: Academic Press. â€"¿ (1983b) Are personality disorders treatable? In Mental Disorder and the Law: effects of the New Legislation. Issues in Crimonological and Legal Psychology, No. 4(eds J. Shapland & 1. Williams).Leicester:BritishPsychologicalSociety. 512 BLACKBURN â€"¿ (1986) Patterns of personality deviation among violent offenders: replication and extension of an empirical taxonomy. British Journal of Criminology, 26, 254-269. â€"¿ & MAYBURY, C. (1985) Identifying the psychopath: the relation of Cleckley's criteria to the interpersonal domain. Personality and Individual Differences, 6, 375-386. BLASHFIELD,R. K. & DRAGUNS,J. G. (1976) Evaluative criteria for psychiatric classification. Journal of Abnormal Psychology, $5, 140-150. CARSON, R. C. (1970) Interaction Concepts of Personality. London: Allen & Unwin. CLECKLEY, H. (1976) The Mask of Sanity (6th edn). St Louis: Mosby. FoulDs, G. A. (1965) Personality and Personal Illness. London: Tavistock. â€"¿ (1971) Personality deviance and personal symptomatology. Psychological Medicine, 1, 222â€"233. HARE, R. D. (1980) A research scale for the assessment of psychopathy in criminal populations. Personality and Individual Differences, 1, 111â€"119. â€"¿ (1983) Diagnosis of antisocial personality disorder in two prison populations. American Journal of Psychiatry, 140, 887â€"890. â€"¿ (1985) A comparison of procedures for the assessment of psychopathy. Journal of Consulting and Clinical Psychology, 53, 7-16. â€"¿ (1986) Twenty years of experience with the Cleckley psychopath. In Unmasking the Psychopath: Antisocial Personality and Related Syndromes (ads W. H. Reid, D. Dorr, J. Walker & J. W. Bonner). New York: Norton. HENDERSON, D. (1955) The classification and treatment of psycho pathic states. British Journal of Delinquency, 6, 5â€"14. HENDERSON, M. (1982) An empirical classification of convicted violent offenders. British Journal of Criminology, 22, 1â€"20. HOME OFFICE/DEPARTMENT OF HEALTH AND SOCIAL SECURITY. (1975) Report of the Committee on Abnormal Offenders. London: HMSO. KARPMAN, B. (1948) The myth of the psychopathic personality. American Journal of Psychiatry, 104, 523â€"534. KHANTZIAN, E. J. & TREECE, C. (1985) DSMâ€"llI psychiatric diagnosis of narcotic addicts: recent findings. Archives of General Psychiatry, 42, 1067-1071. KOCH, J. L. (1891) Die Psychopathischen Minderwertigkeiten. Ravensburg: Maier. KOSTEN, T. R., ROUNSAvILLE, B. J. & KIEBER, H. D. (1982) DSM-1I1 personalitydisordersin opiate addicts. Comprehensive Psychiatry, 23, 572â€"581. KRAEPELIN, E. (1904) Psychiatric: Em Lehrbuch (7th edn). Leipzig: Barth. LYKKEN, D. T. (1957) A study of anxiety in the sociopathic personality. Journal of Abnormal and Social Psychology, 55, 6â€"10. MAUGHS, S. (1941) A concept of psychopathy and psychopathic personality: its evolution and historical development. Journal ofCriminalPsychopathology,2,329â€"356. MAYER-GROSS, W., SLATER, E. & ROTH, M. (1969) Clinical Psychiatry (3rd edn). London: BailliÃ re Tindall & Cassell. MCGURK, B. (1978) Personality types among normal homicides. British Journal of Criminology, 1$, 146-161. MCLEMORE, C. W. & BENJAMIN, L. S. (1979) Whatever happened to interpersonal diagnosis? A psychosocial alternative to DSM-lIl. American Psychologist, 34, 17-34. MCMANUS, M., ALESSI, N. E., GRAPENTINE, W. L. & BRICKMAN, A. (1984) Psychiatric disturbance in serious delinquents. Journal of the American Academy of Child Psychiatry, 23, 602-615. MILLON, T. (1981) Disorders of Personality: DSM-JIJ, Axis II. New York: Wiley. â€"¿ (1983) Millon Clinical Multiaxial Inventory (3rd edn). Minneapolis: Interpretive Scoring Systems. PARTRIDGE, G. E. (1930) Current conceptions of psychopathic personality. American Journal of Psychiatry, 10, 53â€"99. PFOHL, B., CORYELL, W., ZIMMERMAN, M. & STANGL, D. (1986) DSMâ€"IIlpersonality disorders: diagnostic overlap and internal consistency of individual DSMâ€"IIIcriteria. Comprehensive Psychiatry, 27, 21â€"34. PICHOT, P. (1978) Psychopathic behaviour: a historical overview. In Psychopathic Behaviour:Approaches to Research(eds R. D. Hare & D. S. Schalling). Chichester: Wiley. PRESLY, A. S. & WALTON, H. J. (1973) Dimensions of abnormal personality. British Journal of Psychiatry, 122, 269â€"276. QUAY, H. C. (1978) Classification. In H. C. Quay & J. S. Werry (eds). Psychopathological Disorders of Childhood (2nd edn) (ads H. C. Quay & J. S. Werry). New York: Wiley. RAINE, A. (1985) A psychometric assessment of Hare's Checklist for psychopathy on an English prison sample. British Journal of Clinical Psychology, 24, 247-258. ROBINS, L. N. (1966) Deviant Children Grown Up. Baltimore: Williams & Wilkins. SCHNEIDER, K. (1950) Psychopathic Personalities (9th edn). (English translation, 1958) London: Cassell. SPITZER, R. L., ENDIC0rr, J. & ROBINS, E. (1978) Research diagnostic criteria. Archives of General Psychiatry, 35, 773-782. TYRER, P. & ALEXANDER, J. (1979) Classification of personality disorder. British Journal of Psychiatry, 135, 163â€"167. VAILLANT, 0. E. (1975) Sociopathy as a human process: a viewpoint. Archives of General Psychiatry, 32, 178â€"183. WALKER, N. & MCCABE, S. (1973) Crime and Insanity in England, vol. 2. Edinburgh: Edinburgh University Press. WATTS,F. N. & BENNEtT,D. H. (1978) Social deviance in a day hospital. British Journal of Psychiatry, 132, 455â€"462. WIDIGER, T. A. & FRANCIS, A. (1985) The DSMâ€"III personality disorders: perspectives from psychology. Archives of General Psychiatry, 42, 615â€"623. WIDOM, C. 5. (1977) An empirical classification of female offenders. Criminal Justice and Behaviour, 5, 35â€"52. WIociNs, J. 5. (1982) Circumplex models of interpersonal behaviour in clinical psychology. In Handbook of Research Methods in Clinical Psychology (ads P. C. Kendall & J. N. Butcher). New York: Wiley. WORLD HEALTH ORGANIZATION (1967) Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, 1965 revision (8th edn) (ICDâ€"8).Geneva: WHO. â€"¿ (1978) Mental Disorders: Glossary and Guide to their Classification in Accordance with the Ninth Revision of the International Classification of Diseases (ICD-9). Geneva: WHO. WULACH, J. (1983) Diagnosing the DSMâ€"III antisocial personality disorder. Professional Psychology: Research and Practice, 14, 330â€"340. Ronald Blackburn, MA, MSc,PhD,FBPsS,Chief Psychologist, Park Lane Hospital, Park Lane, Maghull, Liverpool L31 IHW