I Psychopathic Personality Traits

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Year: 2018

Psychopathic personality traits: assessment and genetic correlates

Hollerbach, Pia Sofie

Posted at the Zurich Open Repository and Archive, University of Zurich ZORA URL: https://doi.org/10.5167/uzh-161129 Dissertation Published Version

Originally published at: Hollerbach, Pia Sofie. Psychopathic personality traits: assessment and genetic correlates. 2018, Univer- sity of Zurich, Faculty of Arts.

PSYCHOPATHIC PERSONALITY TRAITS:

ASSESSMENT AND GENETIC CORRELATES

Thesis (cumulative thesis) presented to the Faculty of Arts and Social Sciences

of the University of Zurich

for the degree of Doctor of Philosophy

by Pia Sofie Hollerbach

Accepted in the fall semester 2018

on the recommendation of the doctoral committee:

Prof. Dr. Dr. Andreas Maercker (main supervisor)

Prof. Dr. Andreas Mokros

Prof. Dr. Boris Quednow

Zurich, 2018

ACKNOWLEDGMENTS

I would like to give my sincere thanks to the people who have supported me during my PhD period. First of all, I want to express my deepest gratitude to Prof. Dr. Andreas Mokros, who has given me the opportunity to work in this intriguing field of research and who has con- stantly and patiently provided me with professional and interpersonal support not only during my PhD, but throughout the last six years. Moreover, I want to sincerely thank Prof. Dr. Dr.

Andreas Maercker who paved the way for this dissertation in the first place by making possible for me to be affiliated with the Division for Psychopathology and Clinical Intervention of the University of Zurich and being part of my doctoral committee. Furthermore, I want to sincerely thank Prof. Dr. Boris Quednow for taking the time to discuss genetic issues with me and being part of my doctoral committee.

I also want to express my sincere gratitude to Prof. Dr. Elmar Habermeyer for giving me the opportunity to pursue the completion of this thesis while working at the Department for Forensic Psychiatry of the University Hospital of Psychiatry in Zurich. Moreover, I thank my dear colleagues from the department for creating such a warm and welcoming work at- mosphere.

Special thanks also go to my collaborators from Germany and Finland, and to Prof.

Dr. Craig Neumann for always sharing his piece of advice. Moreover, I want to thank all those people who helped us in organizing and completing the data collections, and, of course, to all those who participated in the studies.

Last, but surely not least I want to thank all the people in my private life who accom- panied me through the years. I wholeheartedly thank my family for supporting me in every respect from the beginning on, and my dear friends, especially Sophia and Nicole, for always taking the time to provide me with mental support, inspiring discussions, and a good laugh.

III

ABSTRACT

Psychopathy is characterized by a range of features pertaining to personality, behavior, and delinquency, such as callousness, shallow affect, manipulative skills, impulsivity, irresponsibility, and antisocial and criminal behavior. Psychopathic individuals are relatively rare, but account for a substantial number of violent crimes and present with an increased risk of violent recidivism. In light of the threat that these individuals pose to the community, research on psychopathic traits is of great relevance. This thesis contributes to this field of research by addressing putative genetic correlates and validating the German version of the Psychopathy

Checklist-Revised (PCL-R) based on three studies.

Study 1 and Study 2 addressed genetic correlates of psychopathy with regard to variation in the monoamine oxidase A (MAOA) and serotonin transporter (SLC6A4) genes. To this end, the associations between polymorphisms of these two genes (MAOA uVNTR and 5-

HTTLPR, respectively) and psychopathy were examined. In contrast to most previous research, the impact of the rs25531 polymorphism on the transcriptional efficacy of the 5-

HTTLPR was accounted for. In addition, potential interaction effects between the MAOA uVNTR and childhood trauma on psychopathy were examined. Moreover, heterogeneity between and within psychopathic individuals was taken into account by deriving subtypes and comparing them with regard to the frequencies of the MAOA uVNTR genotype and 5-

HTTLPR/rs25531 haplotype. The outcomes suggested that the MAOA uVNTR was associated with psychopathic traits in women, whereas the 5-HTTLPR/rs25531 was specifically linked to interpersonal deficits such as deceitfulness and grandiosity in men. Furthermore, childhood trauma predicted psychopathic traits, particularly with respect to social deviance, but did not interact with the MAOA uVNTR genotype.

With regard to the validation of the German version of the PCL-R, a hierarchical structure with four facets and two higher-order factors representing the components psycho-

IV pathic core personality traits and social deviance showed excellent fit in a parcel model. The notion that the factors and facets show differential associations with external measures was supported by a range of correlational analyses including a multitrait-multimethod matrix and a canonical correlation analysis. The correlative analyses of convergent and discriminant validity were based on self-reported psychopathic traits as well as on measures of antisocial personality disorder, alexithymia, the Big Five personality domains, and impulsivity. In addition, potential response biases caused by socially desirable responding were examined.

Within the scope of this thesis, the relevant concepts are introduced, the current literature is reviewed, and research questions are derived. The findings of the three studies are then integrated and discussed with regard to conceptual and methodological aspects. Against this backdrop, implications for clinical and therapeutic interventions are derived, and suggestions for further research questions and conceptualizations of future studies are made.

ZUSAMMENFASSUNG

Psychopathie ist gekennzeichnet durch Besonderheiten im Hinblick auf Persönlichkeit, Ver- halten und Delinquenz, wie beispielsweise Herzlosigkeit, geringe Empfindungsfähigkeit, manipulatives Geschick, Sprunghaftigkeit, Verantwortungslosigkeit sowie kriminelles und antisoziales Verhalten. Obwohl psychopathische Persönlichkeiten relativ selten vorkommen, sind sie für eine erhebliche Anzahl von Gewaltstraftaten verantwortlich und weisen ein er- höhtes Risiko für gewalttätige Rückfälle auf. Angesichts der Gefahr, die diese Personen für die Gesellschaft darstellen, ist die Erforschung der psychopathischen Persönlichkeit von gro-

ßer Bedeutung. Die vorliegende Arbeit soll auf Grundlage von drei Studien im Bereich genetischer Korrelate von Psychopathie und der Validierung der deutschen Version der Psycho- pathy Checklist-Revised (PCL-R) einen Beitrag zu diesem Forschungsgebiet leisten.

In Studie 1 und Studie 2 wurden genetische Korrelate von Psychopathie im Hinblick auf unterschiedliche Ausprägungen des Monoaminooxidase A- (MAOA) und Serotonintrans- porter-Gens (SLC6A4) untersucht. Zu diesem Zweck wurden Zusammenhänge zwischen Po- lymorphismen dieser beiden Gene (MAOA uVNTR beziehungsweise 5-HTTLPR) und Psy- chopathie untersucht. Im Gegensatz zu den meisten bisher veröffentlichten Untersuchungen wurde der Einfluss des rs25531-Polymorphismus auf die Transkriptionseffizient des 5-

HTTLPR berücksichtigt. Außerdem wurden potenzielle Interaktionseffekte zwischen dem

MAOA uVNTR und traumatischen Kindheitserfahrungen auf die Ausprägung psychopathischer Merkmale im Erwachsenenalter untersucht. Weiterhin wurden die unterschiedlichen

Ausprägungen psychopathischer Merkmale zwischen und innerhalb von Personen berück- sichtigt, indem Subgruppen gebildet und hinsichtlich der Häufigkeiten des MAOA uVNTR-

Genotyps und des 5-HTTLPR/rs25531-Haplotyps verglichen wurden. Die Ergebnisse der

Studien deuteten darauf hin, dass der MAOA uVNTR-Genotyp mit psychopatischen Merkma- len bei Frauen assoziiert war, während der the 5-HTTLPR/rs25531-Haplotyp bei Männern

VI spezifisch mit Defiziten im interpersonellen Bereich, wie beispielsweise Falschheit und über- steigertem Selbstwert, zusammenhing. Außerdem ließen sich anhand traumatischer Kind- heitserfahrungen psychopathische Merkmale, insbesondere im Bereich sozialer Abweichung, vorhersagen, wobei sich jedoch keine Wechselwirkungen zwischen traumatischen Kindheits- erfahrungen und dem MAOA uVNTR-Genotyp beobachten ließen.

Im Hinblick auf die Validierung der deutschen Version der PCL-R zeigte ein Parcel-

Modell mit einer hierarchischen Struktur mit vier Facetten und zwei Faktoren zweiter Ord- nung, die zum einen psychopathische Kernpersönlichkeitsmerkmale und zum anderen soziale

Abweichung reflektieren, eine exzellente Passung. Die Annahme, dass die Facetten und Fak- toren verschiedenartige Zusammenhänge zu externen Konstrukten aufweisen, wurde anhand verschiedener korrelativer Analysen, darunter eine Multitrait-Multimethod-Matrix sowie eine kanonische Korrelationsanalyse, gestützt. Die korrelativen Analysen der konvergenten und diskriminanten Validität basierten auf Selbstberichten psychopathischer Merkmale sowie auf

Verfahren zur Erfassung der Antisozialen Persönlichkeitsstörung, Alexithymie, der Big Five-

Persönlichkeitseigenschaften und Impulsivität. Zusätzlich wurden potenzielle Verzerrungen aufgrund sozial erwünschter Antworttendenzen erfasst.

Im Rahmen der vorliegenden Arbeit werden die relevanten Konzepte vorgestellt, ein

Überblick über die aktuelle Literatur gegeben und Forschungsfragen abgeleitet. Die Ergeb- nisse der drei Studien werden anschließend hinsichtlich konzeptueller und methodischer As- pekte integriert und diskutiert. Auf dieser Grundlage werden Implikationen für klinische und therapeutische Interventionen abgeleitet und Anregungen für weitere Forschungsfragen und die Konzeptualisierung zukünftiger Studien diskutiert.

VII

LIST OF TABLES

Table 1 Items and Factor Structure of the PCL-R according to Hare, 2003 ………. 11 Table 2 Main and Interaction Effects of Childhood Trauma and MAOA Genotype on Psychopathy …………………..………………..……………..……… 75 Table 3 Main Effects of MAOA Genotype on Childhood Trauma ………………… 76 Table 4 Total Allele Numbers and Frequencies in the Male and Female Sample … 82 Table 5 Total Numbers of Genotypes in the Female Sample …………………...… 82 Table 6 Main and Interaction Effects of the Covariate Age on Psychopathy ……... 85 Table 7 Main and Interaction Effects of Childhood Trauma and MAOA uVNTR Genotype on Psychopathy .…………………..………………..…………. 87 Table 8 Main and Interaction Effects of the Covariate Age on Psychopathy …...… 88 Table 9 Standardized Differences Between Latent Factor Means of the 3-Repeat and 4-Repeat Genotype Groups of the MAOA uVNTR ………………… 89 Table 10 Main Effects of the Psychopathy on Childhood Trauma Separated by Genotype Group …………………..………………….…………………… 90 Table 11 Main and Interaction Effects of the Covariate Age on Psychopathy……… 92 Table 12 Psychopathy Factors Regressed on MAOA uVNTR Genotype and 5- HTTLPR/rs25531.………………..……………………………………...… 107 Table 13 Means, Standard Deviations, Minimum, and Maximum Scores of the PCL: SV Facets for the Clusters Derived from a Four-Class Solution...... 108 Table 14 Means and Standard Deviations of the BEFKI, ASPD, and SRP by Clus- ters…………………………………………………………………………. 110 Table 15 Allele, Genotype, and Haplotype Frequencies for the MAOA uVNTR, 5HTTLPR, and rs25531 ………………..……………..……..……….…… 115 Table 16 Model fit for the LPA (N = 343) …………………..……………………… 115 Table 17 Frequencies of the MAOA uVNTR Genotype and 5-HTTLPR Haplotype by Cluster …………………..………………..……………..….………… 116 Table 18 Correlation Between ASPD Symptom Count and PCL-R Facets, Factors, and Total Score (N = 118) …………………..………………….…………. 125 Table 19 Multitrait Multimethod Matrix …………………..………………..…….… 126 Table 20 Correlations Between PCL-R and TAS-26, NEO-FFI, and UPPS ……..… 127 Table 21 Canonical Loadings of PCL-R Factors, TAS-26 Total Score, NEO-FFI Personality Dimensions, and UPPS Subscales (N = 109) ………………… 129

VIII

LIST OF FIGURES

Figure 1 Structural equation model with latent variables including the CTQ-SF and SRP-III-a general and group factors and associated items ………..... 73 Figure 2 Interaction effects of age and physical and sexual abuse on general psychopathy …………………....…………………..……………………. 84 Figure 3 Interaction effects of age and neglect and emotional abuse on general psychopathy ……..……………..…………………..……………………. 84 Figure 4 Measurement model of psychopathy (PCL: SV) ……………...………… 106 Figure 5 Profiles of the four latent classes (C1, C2, C3, C4) on the four PCL: SV facets …………………..…………………..…………………………….. 109 Figure 6 Nested parcel model of the PCL-R with four facets and two factors (N =118) …………………..…………………..…………………...……. 124

LIST OF ABBREVIATIONS

ADHD Attention Deficit Hyperactivity Disorder ASPD Antisocial Personality Disorder BIDR Balanced Inventory of Desirable Responding CCA Canonical Correlation Analysis CFA Confirmatory Factor Analysis CTQ Childhood Trauma Questionnaire CU Callous-unemotional DSM Diagnostic and Statistical Manual of Mental Disorders GxE Gene x Environment GxExE Gene x Environment x Environment GxGxE Gene x Gene x Environment HTTLPR Serotonin-Transporter-Linked Polymorphic Region IAT Implicit Association Test ICD International Classification of Diseases LPA Latent Profile Analysis MAOA Monoamine Oxidase A MTMM Multitrait Multimethod NEO-FFI NEO [Neuroticism, Extraversion, Openness] Five Factor Inventory PCL-R Psychopathy Checklist – Revised PCL: SV Psychopathy Checklist: Screening Version PCL: YV Psychopathy Checklist: Youth Version RQ Research Question SEMs Structural Equation Models SLC6A4 Serotonin Transporter Gene (Solute Carrier Family 6 Member 4) SNP Single Nucleotide Polymorphism SRP Self-Report Psychopathy Scale SSRI Selective Serotonin Reuptake Inhibitor TAS Toronto Alexithymia Scale UPPS Urgency, Premeditation, Perseverance, Urgency uVNTR Upstream Variable Number of Tandem Repeats

TABLE OF CONTENTS

1. Introduction ...... 1 2. Theoretical Background ...... 4 2.1 The Modern Psychopathy Construct ...... 4 2.1.1 Conceptualization of Psychopathy ...... 4 2.1.2 Psychopathy and Antisocial Personality Disorder ...... 7 2.1.3 Prevalence ...... 8 2.2 Assessment of Psychopathic Traits ...... 9 2.2.1 Conceptualization of the PCL-R ...... 9 2.2.2 Use of the PCL-R ...... 12 2.2.3 Psychometric Properties of the PCL-R ...... 13 2.2.4 The German Version of the PCL-R ...... 14 2.2.5 Derivatives of the PCL-R...... 16 2.3 Etiology of Psychopathic Traits ...... 18 2.3.1 Childhood Trauma ...... 18 2.3.2 Genetic Correlates ...... 21 3. The Present Thesis ...... 27 3.1 Aims and Research Questions ...... 27 3.2 Summary of Study 1 ...... 29 3.3 Summary of Study 2 ...... 30 3.4 Summary of Study 3 ...... 32 4. Discussion ...... 35 4.1 Genetic Correlates of Psychopathy ...... 35 4.1.1 Genetic Main Effects on Psychopathy ...... 35 4.1.2 GxE Effects on Psychopathy ...... 38 4.1.2 Genetic Correlates of Psychopathic Subtypes ...... 39 4.1.4 Summary of Genetic Correlates ...... 41 4.2 Assessment of Psychopathy with the PCL-R ...... 42 4.3 Methodological Considerations ...... 47 4.4 Clinical Implications ...... 48 4.5 Limitations ...... 53 4.6 Implications for Future Studies ...... 55 4.6 Conclusion ...... 59 5. Publications ...... 60 5.1 Study 1 ...... 60 5.2 Study 2 ...... 61 5.3 Study 3 ...... 84 6. References ...... 100

1. Introduction

In the 19th century, psychiatrists in Europe and in the United States started to develop largely independent concepts of psychopathy and personality disorders (Saß & Felthous,

2008). As early as 1809, Philippe Pinel described a category called mania without delirium

(originally manie sans délir) based on the progressive notion that some disorders were characterized by emotional and behavioral abnormalities rather than intellectual impairments

(Pinel, 1809). Similarly, the British physician James Prichard assumed that moral insanity (in terms of affective insanity) did not necessarily imply cognitive abnormalities (Prichard,

1835). In Germany, the term psychopathy was used to describe a range of abnormal personalities by influential psychiatrists such as Emil Kraepelin (1909) and Julius Koch (1891). As

Saß and Felthous (2008) point out, psychopathy was to some extent associated with social devaluation and even forensic aspects such as dissocial and delinquent behavior in the writ- ings of Kraepelin, Koch, and also Karl Birnbaum (1926). Kurt Schneider (1950) described a subtype called the affectionless psychopath (originally gemütloser Psychopath), which is characterized by callousness and a lack of empathy and thus resembles the current conceptualization of the psychopathic personality. North American psychiatrists associated psychopathy with impulsiveness and other dissocial behavior caused by intra-personal neurotic con- flicts (Saß & Felthous, 2008). In 1941, Hervey Cleckley paved the way for the modern conceptualization of psychopathy. Based on case studies, he gradually derived initially 21 and later 16 criteria related to emotional deficits, insincerity, and socially deviant behavior

(Cleckley, 1941, 1976). Based on the work of Cleckley and a number of other influential researchers, Robert Hare and his colleagues developed the 22-item Psychopathy Checklist

(Hare & Frazelle, 1980; Hare, 1980; Hare, Neumann, & Mokros, 2018). In 1991, a revised version of the Psychopathy Checklist comprising 20 items was published (PCL-R; Hare,

1991) and reissued a decade later (Hare, 2003). Initially intended for solely diagnostic pur-

1 poses, the PCL-R proved to be a valid instrument for risk assessment (Yang, Wong, & Coid,

2010). Today, it is among the most frequently used tools for diagnostic and prognostic purposes (Hare et al., 2018; Singh et al., 2014). The prognostic validity of the PCL-R is particularly relevant given the fact that psychopathic individuals constitute a group with high risk for criminality, particularly in terms of general and violent recidivism (Leistico, Salekin,

DeCoster, & Rogers, 2008; Olver et al., 2018). With regard to the latter, psychopathic offenders were found to have a more than twofold increased recidivism rate compared to offenders in general (Mokros, Vohs, & Habermeyer, 2014). The identification of psychopathy as a risk factor has also sparked a plethora of studies on the mechanisms that contribute to the development of psychopathic features. Putative etiological factors stretch across several domains, among them genetic disposition and environmental influences. A growing number of studies provide evidence that the manifestation of psychopathic traits is subject to variation in serotonergic genes and aversive childhood experiences (Beaver et al., 2013; Craparo,

Schimmenti, & Caretti, 2013; Fowler et al., 2009; Kolla et al., 2013; Sadeh et al., 2010;

Sadeh, Javdani, & Verona, 2013; Tikkanen et al., 2011; Wells et al., 2017; Zhang et al.,

2017). Compared to the large number of studies on the closely related concept of antisocial behavior, however, the etiological factors that contribute to the development of psychopathy remain an understudied field of research.

The aim of this thesis is to examine and integrate aspects related to genetic correlates and the assessment of psychopathic traits. To this end, three empirical research articles (labeled Study 1, Study 2, and Study 3) will be presented and discussed. In Study 1, the main and interaction effects of the monoamine oxidase A (MAOA) gene and childhood trauma on psychopathic features were modeled. In Study 2, main effects of variation in the MAOA gene and the serotonin transporter gene (solute carrier family 6 member 4; SLC6A4) on psychopathy were examined based on variable-centered (i.e., structural equation modeling) and per-

2 son-centered (i.e., derivation of subtypes) approaches. Study 3 summarizes the validation of the German translation of the PCL-R with regard to factor structure, convergent and discriminant validity, and potential response bias.

The present thesis is composed of three major parts. First, an overview of the most important literature with respect to the effects of childhood trauma and variation in serotonergic genes on psychopathy, subtypes of psychopathy, and the assessment of psychopathic features is provided in the Theoretical Background chapter. Against this backdrop, the research questions that present the rationale for the thesis are derived and a short summary of the three studies is given in the Current Thesis chapter. The major findings of the studies are then discussed and integrated, along with their practical implications, suggestions for future research, and a short outline of the limitations in the Discussion chapter. Subsequently, the three manuscripts are provided in full length.

2. Theoretical Background

In the following chapter, the modern conceptualization of psychopathy, prevalence rates, and the relation to antisociality are outlined. Furthermore, the PCL-R and its derivatives are described. Finally, the associations between environmental and genetic factors in terms of childhood trauma and variation in serotonergic genes with psychopathic traits are discussed.

2.1 The Modern Psychopathy Construct

2.1.1 Conceptualization of Psychopathy

Initially used as an umbrella term for a range of different disorders and types of abnormal personalities, the concept of psychopathy has been greatly refined in recent decades

(Hervé, 2003). With his seminal treatise “The mask of sanity,” Cleckley (1941) made a significant contribution toward a more well-defined take on psychopathy as a specific clinical syndrome. He put together a list of 16 traits1 that he assumed to be characteristic for a more precise conceptualization of psychopathy (i.e., Cleckley’s clinical profile). These traits served as the foundation for the work of Robert Hare and colleagues, who ultimately provided an operationalization with the Psychopathy Checklist and its revised version, the PCL-R (Hare,

1991, 2003; Hare et al., 2018). Hare postulated that psychopathy is a combination of interpersonal, affective, behavioral, and legal aspects (Hare, 2003; Hare, Clark, Grann, & Thornton,

2000). Within that conceptual framework, he described features such as grandiosity, manipulative skills, shallow affect, a lack of empathy, guilt, or remorse, irresponsibility, impulsivity,

1 The list included the following traits: 1) superficial charm and good intelligence, 2) absence of delusions and other signs of irrational thinking, 3) absence of nervousness or psychoneurotic manifestations, 4) unreliability, 5) untruthfulness and insincerity, 6) lack of remorse and shame, 7) inadequately motivated antisocial behavior, 8) poor judgment and failure to learn by experience, 9) pathologic egocentricity and incapacity for love, 10) general poverty in major affective reactions, 11) specific loss of insight, 12) unresponsiveness in general interpersonal relations, 13) fantastic and uninviting behavior with drink and sometimes without, 14) suicide threats rarely carried out, 15) sex life impersonal, trivial, and poorly integrated, 16) failure to follow any life plan.

4 disregard for social norms, and delinquency (Hare, 1991, 2003; Hare et al., 2000). Even though strong manifestations of psychopathy are rare and not all psychopathic individuals become delinquent (some of them even achieve considerable success in politics, media, or business), psychopaths constitute a high-risk group due to their proneness to violent crime and recidivism (Benning, Venables, & Hall, 2018; Hare et al., 2000; Laurell, Belfrage, &

Hellström, 2010; Olver et al., 2018).

There is accumulating evidence that individuals with pronounced psychopathic features do not present a homogeneous group. As early as 1929, Karpman pioneered this notion with his differentiation between primary and secondary psychopathy, where he only assumed the former to represent a genuine form of psychopathy (Karpman, 1929). He further divided primary psychopathy into an aggressive/predatory and a passive/parasitic subtype (Karpman,

1956). Arieti (1963) followed up on this differentiation by describing idiopathic in contrast to symptomatic psychopathy, and further distinguished between simple and complex variants of idiopathic psychopathy. The taxonomies suggested by Karpman (1929, 1956) and Arieti

(1963) are largely congruent: Karpman’s primary psychopathy corresponds to Arieti’s idiopathic psychopathy, and the simple vs. complex variants mirrors the aggressive/predatory vs. passive/parasitic subtypes.

Some decades later, this differentiation received support from Mealey (1995a), who suggested differential etiological pathways for primary psychopathy and secondary psychopathy. She subsequently referred to secondary psychopathy as sociopathy, a label first used by Karl Birnbaum (Birnbaum, 1909; Mealey, 1995b), in order to better distinguish two constructs whose resemblance may be only superficial. According to Mealey (1995a), the manifestation of primary psychopathy can be traced back to genetic disposition, whereas sociopathy is the result of adverse environmental conditions. Hence, primary psychopathy occurs less frequently, but independently from age, culture, and socio-economic and envi-

5 ronmental conditions. In addition, primary psychopaths consistently display a deceitful, callous interactional style despite normal cognitive development. The number of sociopaths, in contrast, depends on age and culture, and is higher under disadvantageous socio-economic and environmental conditions. In addition, sociopaths alternate between cooperative and deceitful interactional strategies depending on the situation. In contrast to psychopaths, sociopaths do not necessarily show a complete lack of emotions, but have difficulties with emotion regulation (Mealey, 1995a).

These clinical and theoretical considerations have brought about a number of empirical studies that investigated subtypes and variants of psychopathy using various measures and samples (for an overview, see Mokros, Hare, Neumann, & Habermeyer, in press). In the following, examinations based on the PCL-R will be briefly outlined. A detailed overview of the

PCL-R items and factor structure is given in section 2.2, Assessment of Psychopathic Traits.

Nevertheless, it should be mentioned at this point that the PCL-R comprises four facets, which are labeled Interpersonal (e.g., deceitfulness and grandiosity), Affective (e.g., shallow affect and lack of remorse and guilt), Lifestyle (e.g., irresponsibility and impulsivity), and

Antisocial (e.g., poor behavior control and legal convictions; Hare, 2003). The Interpersonal and Affective facets (or first-order factors) constitute a higher-order factor which represents psychopathic core personality traits, and the Lifestyle and Antisocial facets load on a second higher-order factor mapping social deviance (Hare, 2003).

Examinations based on PCL-R facet scores of highly psychopathic male offender samples (i.e., PCL-R scores of at least 26, which is indicative of high levels of psychopathy according to Hare, 2003) produced at least two clusters that mirrored primary psychopathy and sociopathy (Hervé, 2003; Mokros et al., 2015; Olver, Sewall, Sarty, Lewis, & Wong,

2015; Poythress et al., 2010; Skeem, Johansson, Andershed, Kerr, & Louden, 2007). Three studies provided evidence for a further differentiation between variants of psychopaths,

6 namely classic (or prototypic), manipulative, and explosive psychopaths (Hervé, 2003), manipulative and aggressive psychopaths (Mokros et al., 2015), and fearful psychopaths

(Poythress et al., 2010). Notably, most of these studies were based on the traditional four- factor conceptualization of the PCL-R, which includes the four aforementioned facets Inter- personal, Affective, Lifestyle, and Antisocial. Poythress et al. (2010), in contrast, used a three-factor model including the Interpersonal, Affective, and Lifestyle facets (Cooke &

Michie, 2001), and Hervé (2003) considered both the three- and four-factor models, but did not find substantial differences in the emerging patterns. Neumann, Vitacco, and Mokros

(2016) as well as Krstic et al. (2017) examined samples with comparatively broad ranges of severity in psychopathic features and found four subtypes which they labeled psychopaths

(i.e., high scores on all four facets), callous-conning offenders (i.e., higher scores on Interper- sonal and Affective facets compared to Lifestyle and Antisocial facets), sociopaths (higher scores on Lifestyle and Antisocial facets compared to Interpersonal and Affective facets), and general offenders (comparatively low scores on all four facets). Thus, the current empirical literature corroborates the notion that psychopathy and sociopathy are distinct concepts, and that there are variants of psychopathy.

2.1.2 Psychopathy and Antisocial Personality Disorder

The two most well-established psychiatric classification systems, the Diagnostic and

Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) and the International Classification of Diseases (ICD-10; World Health Organization, 2004) do not list psychopathy as a discrete diagnosis but as synonymous with Dissocial (ICD-10) or

Antisocial (DSM-5) Personality Disorder, respectively. In contrast to its precursors, the

DSM-5 includes a section on alternative DSM-5 models for personality disorders (American

Psychiatric Association, 2013) where psychopathy is assumed to be a variant of Antisocial

Personality Disorder (ASPD). This conceptualization is in conflict with the notion that ASPD and psychopathy are overlapping but distinct constructs (Patrick & Brislin, 2015; Yoon,

Krüppel, Mokros, & Zimmermann, in press). This is illustrated by the asymmetrical relationship between psychopathy and ASPD. Two thirds of psychopathic offenders are diagnosed with ASPD, whereas only one third of offenders with ASPD additionally meet the criteria for psychopathy (Mokros, Hollerbach, Nitschke, & Habermeyer, 2017). In addition, ASPD is strongly correlated to anxiety, with between 36% and 54% of ASPD individuals suffering from comorbid lifetime anxiety disorder, especially with regard to social phobia and posttraumatic stress disorder (Goodwin & Hamilton, 2003; Sareen, Stein, Cox, & Hassard, 2004).

Individuals with pronounced psychopathic traits, in contrast, typically show low levels of fear and anxiety (Birbaumer et al., 2005; Mokros et al., 2015).

2.1.3 Prevalence

The prevalence of psychopathic features strongly varies between community and forensic samples. Assessment with the PCL-R requires inspection of collateral information such as clinical files and legal documents, and is thus not suitable for use with community samples. In contrast, its progeny, the Psychopathy Checklist: Screening Version (PCL: SV; Hart,

Cox, & Hare, 1995), does not necessitate file information and hence can be used for research purposes in non-forensic samples. A meta-analysis of data from three studies conducted in the US, Great Britain, and Germany yielded a prevalence rate of 1.5% with a confidence in- terval (CI) of 0.6% to 2.7% (Mokros et al., 2017). Prevalence estimates for women range between 0% and 1.2% (Coid, Yang, Ullrich, Roberts, & Hare, 2009; Neumann & Hare,

2008). In these studies, a sum score of at least 13 was regarded as indicative of possible psychopathy. The PCL: SV consists of 12 items that can be rated with 0 to 2 points, resulting in a

8 minimum total score of 0 and maximum total score of 24 points (for a more detailed description of the PCL: SV see section 2.2.5, Derivatives of the PCL-R).

While psychopathy is a rare phenomenon in the general population, psychopathic individuals are clearly overrepresented in forensic settings. Prevalence estimates in male offenders based on PCL-R total scores of at least 30 points, which is indicative of high to very high levels of psychopathy (Hare, 2003; see section 2.2.2, Use of the PCL-R), revealed rates between 20% and 25% in male offenders, and between 9% and 17% in female offenders

(Hare, 2003, 2006; Jackson, Rogers, Neumann, & Lambert, 2002; Mokros et al., 2017;

Vitale, Smith, Brinkley, & Newman, 2002; Warren et al., 2003). Within forensic samples, the prevalence of psychopathy additionally differs depending on the type of offenders. For example, psychopathic individuals (as indicated by a PCL-R total score of at least 30) are less frequently found among child molesters compared to rapists (Porter et al., 2000).

2.2 Assessment of Psychopathic Traits

2.2.1 Conceptualization of the PCL-R

A range of measurement instruments for the assessment of psychopathic traits has been developed in recent decades. As far as self-report measures are concerned, questionnaires such as the Triarchic Psychopathy Measure (Patrick, 2010), the Levenson Self-Report

Psychopathy Scale (Levenson, Kiehl, & Fitzpatrick, 1995), the Psychopathic Personality In- ventory-Revised (Lilienfeld & Widows, 2005), and the Self-Report Psychopathy Scale 4

(Paulhus, Neumann, & Hare, 2016) allow for quick and economic assessment. The general shortcomings of self-report measures, however, seem to carry even greater weight when it comes to the assessment of psychopathy. Not only does deceitfulness represent an integral component of psychopathic features, but psychopathic individuals also often fail to reflect on the impact their behavior might have on others, and to fully experience and thus give account

9 of emotional states (Sellbom, Lilienfeld, Fowler, & McCrary, 2018). These disadvantages can be countered with the use of observer ratings such as the PCL-R, which serves to assess the manifestation of psychopathic features based on 20 items that are rooted in the traits described by Cleckley (1941, 1976).

Initially, exploratory factor analyses were indicative of a superordinate factor, and of two correlated factors that represented interpersonal and affective deficits (Factor 1) and an unstable lifestyle and antisocial behavior (Factor 2; Hare, 1991; Harpur, Hare, & Hakstian,

1989). While Factor 1 captures psychopathic core personality traits such as callousness, narcissism, and manipulative skills, Factor 2 is characterized by social deviance in terms of impulsivity, irresponsibility, and delinquency (Harpur et al., 1989). In 2003, the second edition of the PCL-R was published along with descriptive and validation data for different groups

(e.g., male and female offenders, forensic-psychiatric patients, and substance abusers). Based on these data, a new conceptualization including four correlated factors (facets) labeled In- terpersonal, Affective, Lifestyle, and Antisocial was derived empirically by virtue of confirmatory factor analysis (CFA). Item 11 and item 17 were not allocated to a facet or factor. An alternative second-order model with the Interpersonal and Affective facets loading onto Fac- tor 1 and the Lifestyle and Antisocial facets loading onto Factor 2 revealed excellent fit

(Hare, 2003; Hare & Neumann, 2008). Table 1 shows the factorial structure of the second- order model and the respective items.

Table 1

Items and Factor Structure of the PCL-R according to Hare, 2003

Factor 1: Psychopathic core personality traits

Facet 1: Interpersonal Facet 2: Affective 1. Glibness/superficial charm 6. Lack of remorse or guilt 2. Grandiose sense of self-worth 7. Shallow affect 4. Pathological lying 8. Callous/lack of empathy 5. Conning/manipulative 16. Failure to accept responsibility for own actions

Factor 2: Social deviance

Facet 3: Lifestyle Facet 4: Antisocial 3. Need for stimulation/proneness to 10. Poor behavioral controls boredom 12. Early behavior problems 9. Parasitic lifestyle 18. Juvenile delinquency 13. Lack of realistic, long-term goals 19. Revocation of conditional release 14. Impulsivity 20. Criminal versatility 15. Irresponsibility

Items that do not load on any facet/factor: 11. Promiscuous sexual behavior 17. Many short-term marital relationships

In contrast to the two-factor model, Cooke and Michie (2001) suggested an alternative hierarchical factor structure with a superordinate factor, and the three facets Arrogant and

Deceitful Personal Style, Deficient Affective Experience, and Impulsive and Irresponsible

Behavioral Style. The rationale behind this approach was that Cooke and Michie (2001) considered criminality (which is purportedly captured by the Antisocial facet) to be among the sequelae of psychopathy rather than representing a core element. Neumann, Hare, and Pardini

(2015) countered this assumption by arguing that antisocial behavior is also engrained in traits such as deceitfulness, lack of empathy, or irresponsibility, and is thus essential for the

11 psychopathy construct. They reinforced this notion by estimating structural equation models

(SEMs) based on the four-factor conceptualization of psychopathy with data from multiple international samples. Model fit as well as associations between the Antisocial facet and the

Interpersonal, Affective, and Lifestyle facets of the PCL-R were supportive of the presump- tion that antisociality presents an integral part of the psychopathy construct. Given that the present thesis also includes analyses of genetic components of psychopathy, it is further noteworthy that the overlap between psychopathy and antisocial behavior can be explained by a shared common genetic factor (Larsson et al., 2007). Taken together, there is strong evidence that antisociality is an indispensable component of psychopathy. For this reason, the subsequent chapters of this thesis will be based on the four-factor conceptualization of psychopathy.

2.2.2 Use of the PCL-R

The 20 items of the PCL-R are rated based on information drawn from a semi- structured interview as well as from file and collateral information (e.g., verdicts, police records, or patient records). The items are scored on a three-point rating scale (0 = no, 1 = may- be/in some respects, 2 = yes), so that the sum score can range between 0 and 40 points. On the condition that the available file information is reliable, ratings may be exclusively obtained from file review. For example, Mokros et al. (2017) reported excellent inter-rater reliability for file-based ratings among five studies that used the PCL-R. Such file-based evaluations, however, usually underestimate the severity of psychopathic features since raters do not get an immediate impression of affective deficits during the interview (Bolt, Hare, Vitale, &

Newman, 2004). Importantly, ratings may not be obtained based on the interview alone (i.e., without any collateral information).

In light of taxometric studies, psychopathy is considered to be a dimensional construct

(Mokros et al., in press; Mokros et al., 2017). Accordingly, PCL-R scores are usually interpreted in a dimensional fashion, so that higher scores indicate more severe expressions of psychopathic features. Sometimes, however, it is necessary to treat psychopathy as a categorical phenomenon, for example when categories of psychopathic vs. non-psychopathic individuals are required for research purposes. For this aim, Hare and colleagues suggested a cutoff score of 30, which lies one standard deviation above the mean total score of the pooled male forensic samples described in the original manual (Hare, 1991).

2.2.3 Psychometric Properties of the PCL-R

The PCL-R has shown to be a reliable and valid measure. The interrater reliability based on intraclass correlation coefficients (ICC) of a two-way-mixed effects model for sin-

2 gle ratings (ICC(3,1); Shrout & Fleiss, 1979) ranged between moderate and almost perfect agreement3 for the total score (.86), Factor 1 (.75), Factor 2 (.85), and facet scores (Interper- sonal: .71, Affective: .67, Lifestyle: .75, Antisocial: .84) in male offenders (Hare, 2003). In addition, the convergent and divergent validity of the PCL-R has been examined based on a number of measures. For example, the PCL-R total score shows positive moderate4 to strong correlations with ASPD and narcissistic personality disorder (Hare, 2003; Hart & Hare, 1989;

Khalifa & Howard, 2015). On the factor level, Factor 1 strongly correlates with narcissistic personality disorder and weakly and negatively correlates with avoidant personality disorder, whereas Factor 2 is strongly associated with ASPD (Khalifa & Howard, 2015).

2 In the original manual (Hare, 2003, p.63), the ICC based on a two-way-mixed effects model for a single rating is denoted as ICC1. According to the nomenclature suggested by Shrout & Fleiss (1979), however, a two- way-mixed effects model for a single rating is labeled ICC(3,1).

3 Coefficients were interpreted based on the classification suggested by Landis and Koch (1977b), with values of .00 to .02 indicating slight, .21 to .40 fair, .41 to .60 moderate, .61 to .80 substantial, and .81 to 1.00 almost perfect agreement.

4 According to Cohen (1988), correlation coefficients of .10 are interpreted as small, coefficients of .30 are interpreted as moderate, and coefficients of .50 or more indicate a strong association. 13

With regard to predictive validity, the PCL-R has been shown to be a powerful predictor of violent recidivism across studies (Mokros et al., 2014; Yang et al., 2010). Mokros et al.

(2014) calculated a likelihood ratio (in terms of odds or chances) of 2.4 for violent recidivism in individuals with a PCL-R total score of 25 or more (which corresponds to a high level of psychopathy) based on seven studies conducted in German-speaking countries. From a dimensional perspective, the rate of general, violent, and sexual recidivism increased with the severity of psychopathy in a large sample of offenders from Austria (Mokros & Eher, 2017).

In the majority of studies, the PCL-R Factor 2 was a stronger predictor of violent recidivism, whereas Factor 1 did not have predictive validity (Olver, Neumann, Wong, & Hare, 2013;

Yang et al., 2010). In contrast, Olver, Lewis, and Wong (2013) found that the Affective facet of Factor 1 predicted violent relapse in a highly psychopathic sample. This ties in with Hare et al. (2000), who pointed out that the predictive value of the two factors depends on the kind of sample under investigation.

2.2.4 The German Version of the PCL-R

The PCL-R is a frequently used instrument for the assessment of psychopathic traits in German-speaking countries (Singh et al., 2014). Recently, Mokros et al. (2017) provided a

German adaptation of the PCL-R that included a translation of the manual as well as reference data based on a forensic sample of adult male offenders. The average total scores reported in the original manual and the German manual did not differ significantly. Accordingly, the cutoff score for the German version was fixed at 30 points, which corresponds to the cutoff score suggested in the original manual (Hare, 2003; Mokros et al., 2017).

In addition, reliability of the German version was assessed. PCL-R interviews, file reviews, and ratings were conducted by four experienced raters. In order to evaluate interrater agreement, a total of 35 participants were interviewed by two pairs of independent raters.

Based on these data, the weighted Kappa coefficient κw (Cohen, 1968) was calculated. In addition, the ICC was calculated for (sub-) totals taking into account that there were different pairs of raters (ICC(1,1), one-way random effects, single measure; Shrout & Fleiss, 1979). The

κw and ICC(1,1) coefficients indicated substantial agreement (.77) for the sum score, moderate to substantial agreement for the two factor subtotals (F1: .50, F2: .82), and moderate to almost perfect agreement at the facet level (Interpersonal: .61, Affective: .55, Lifestyle: .90,

Antisocial .91). Given the ordinal structure of the data and varying factor loadings, internal consistency was examined based on a polychoric correlation matrix (Graham, 2006; Zumbo,

Gadermann, & Zeisser, 2007). Alpha coefficients indicated good internal consistency (.85) for the total score, acceptable internal consistency for the two factors (F1: .82, F2: .84), and acceptable to good internal consistency for the four facets (Interpersonal: .77, Affective: .80,

Lifestyle: .78, Antisocial: .73; Mokros et al., 2017).

In addition, construct validity was assessed based on the reference data of the German sample. As this research subject is described in detail in Study 3, only a short outline is given at this point. Factor analyses yielded excellent fit for a hierarchical model with two factors and four facets. Convergent and divergent validity were assessed based on relations between the PCL-R and measures of psychopathy, ASPD, alexithymia, personality dimensions, and impulsivity. In addition, the correlation between socially desirable responding and PCL-R scores was examined and yielded no support for the hypothesis that higher psychopathy scores are associated with a socially desirable response style.

2.2.5 Derivatives of the PCL-R

In recent decades, the PCL-R has been adapted for use under different conditions.

First, a screening version (PCL:SV) with 12 items5 based on the PCL-R was published by

Hart et al. (1995). The items of the PCL: SV are answered on a three-point scale that is anal- ogous to the rating scale of the PCL-R. Comparisons of four-factor and two-factor models that conceptually correspond to the PCL-R factor models (see section 2.2.1, Conceptualiza- tion of the PCL-R) revealed better fit for the four-factor solution (Hill, Neumann, & Rogers,

2004; Vitacco, Neumann, & Jackson, 2005). The PCL: SV can be used as a screening instrument in forensic samples. Moreover, it can also be used for research purposes in non-forensic settings since file review is not necessarily required (Hart et al., 1995). Normally, the PCL:

SV total score provides a dimensional benchmark for the severity of psychopathic features. A cutoff of at least 18 points, however, has been recommended if a differentiation between psychopathic and non-psychopathic individuals is needed (Hart et al., 1995). The PCL: SV has shown acceptable to good interrater reliability and internal consistency with regard to total and factor scores (Hart et al., 1995). With regard to validity, the PCL: SV shows moderate to strong correlations to the PCL-R and symptoms of ASPD. Moreover, convergent and discriminant validity of the PCL: SV were corroborated by correlations with a range of personality- and behavior-related measures. For example, PCL: SV total scores were positively linked to

ASPD and other Cluster B personality disorders as well as alcohol and drug abuse. With regard to personality traits, PCL: SV total scores were negatively correlated with conscientiousness and openness, but positively linked to dominance and cold-heartedness. Discrimi- nant validity was confirmed based on correlations between the PCL: SV and measures of depression and anxiety (Hart et al., 1995). The predictive validity of the PCL: SV in terms of

5 Items of the PCL: SV (numbers of brackets indicate the corresponding items of the PCL-R): 1) Super- ficial (1), 2) Grandiose (2), 3) Deceitful (4, 5), 4) Lacks remorse (6), 5) Lacks empathy (7, 8), 6) Does not accept responsibility (16), 7) Impulsive (3, 14), 8) Poor behavior control (10), 9) Lacks goals (9, 13), 10) Irrespon- sible (15), 11) Adolescent antisocial behavior (12, 18), 12) Adult antisocial behavior (19, 20; Hart et al., 1995). 16 violent reoffending has been confirmed in two meta-analyses by Yang et al. (2010) and

Mokros et al. (2014).

In addition, the PCL-R was adapted for use in children and adolescents aged 12 to 18 years (Psychopathy Checklist: Youth Version [PCL: YV]; Forth, Kosson, & Hare, 2003). The

PCL: YV consists of 20 items6 that tap into psychological traits and behavioral dispositions, and are rated on a three-point scale based on an interview and file as well as collateral information (Forth et al., 2003). The structure of the PCL: YV is well represented by four correlated factors (Neumann, Kosson, Forth, & Hare, 2006). The PCL: YV has shown high internal consistency for total factor scores, and acceptable to excellent interrater reliability for total and factor scores (Forth et al., 2003). The PCL: YV has been adapted for use in German- speaking samples (Sevecke & Krischer, 2014).

Notably, the PCL-R has not only been the basis for the development of observer ratings such as the PCL: SV and PCL: YV, but also for the Self-Report Psychopathy Scale

(SRP). Originally conceptualized as an experimental scale (Hare, 1985), the fourth edition of the SRP (SRP 4) has recently been published (Paulhus et al., 2016). The SRP 4 is a questionnaire that comprises a total of 64 items which are answered on a five-point scale. The items load onto four factors (Interpersonal, Affective, Lifestyle, and Antisocial) that are conceptually congruent with the PCL-R factors (Paulhus et al., 2016). With regard to psychometric properties, the SRP 4 has shown good test-retest reliability for the total score and acceptable to good test-retest reliability for the facet scores in a mixed-gender student sample (N = 48).

Alpha coefficients indicated good to excellent internal consistency for total and factor scores, and acceptable to good internal consistency for facet scores across forensic and community

6 Items of the PCL: YV: 1) Impression management, 2) Grandiose sense of self-worth, 3) Stimulation seeking, 4) Pathological lying, 5) Manipulation for personal gain, 6) Lack of remorse, 7) Shallow effect, 8) Callous/lacking empathy, 9) Parasitic orientations, 10) Poor anger tolerance, 11) Impersonal sexual behavior, 12) Early behavior problems, 13) Lacks goals, 14) Impulsivity, 15) Irresponsibility, 16) Failure to accept responsibility, 17) Unstable interpersonal relationships, 18) Serious criminal behavior, 19) Serious violations of conditional release, 20) Criminal versatility (Forth et al., 2003). 17 samples. Moreover, SRP 4 total scores are associated with global personality dimensions, particularly with regard to low levels of conscientiousness and agreeableness, as well as measures of narcissism and Machiavellianism (Paulhus et al., 2016). Mokros, Geiger,

Olderbak, and Wilhelm (2016) recently provided a German version of the SRP, which is strongly correlated with the PCL-R, and shows good internal consistency in samples of male offenders from Germany (Bärwaldt, Geiger, Olderbak, Mokros, & Wilhelm, 2016; Mokros et al., 2017). Convergent and discriminant validity of the German version of the SRP 4 was illustrated by positive correlations with measures of psychopathy, Machiavellianism, and impulsivity, and by negative correlations with global personality dimensions such as agreeableness and conscientiousness (Geiger, Olderbak, Mokros, & Wilhelm, 2015).

2.3 Etiology of Psychopathic Traits

2.3.1 Childhood Trauma

Among the environmental factors that presumably contribute to the development of psychopathic features, traumatic childhood experiences have been subject to a range of studies. Different types of childhood trauma have been described, among them emotional and physical neglect, and emotional, physical, and sexual abuse (Bernstein et al., 2003). Porter

(1996) suggested differential etiological pathways for the development of affective deficits based on the distinction between primary and secondary psychopathy (cf. Mealey, 1995a).

Porter (1996) assumed that primary psychopaths were congenitally unable to fully experience emotionality, whereas emotional detachment in secondary psychopathy was the result of an unfavorable developmental process in childhood. More precisely, he argued that repeated traumatic experiences lead to affective inhibition, which in turn serves as a dissociative cop- ing strategy to reduce distress and pain. Thus, traumatized children learn to numb down their emotional response, which serves as the basis for the subsequent development of antisocial

18 behavioral patterns (Porter, 1996). This notion has received empirical support from Kerig,

Bennett, Thompson, and Becker (2012), for instance, who found that the association between traumatic experiences and callous-unemotional traits in adolescents was mediated by emotional numbing. Notably, callous-unemotional (CU) traits in children and adolescents are considered to precede psychopathic traits in adulthood and hence play an important role in the investigation of etiological pathways leading to psychopathy (Frick & Marsee, 2018;

Frick, Ray, Thornton, & Kahn, 2014; Lynam, Caspi, Moffitt, Loeber, & Stouthamer-Loeber,

2007). A range of studies support the notion that traumatic experiences in terms of abuse and neglect are associated with CU traits in children and adolescents. For example, the expression of CU traits and emotional deficits has been specifically associated with neglectful experiences in general (Sullivan, Carmody, & Lewis, 2010) and emotional neglect in particular

(Kimonis, Cross, Howard, & Donoghue, 2013), but also with physical and sexual abuse

(Kahn et al., 2013; Krischer & Sevecke, 2008), and both neglect and abuse (Kimonis, Fanti,

Isoma, & Donoghue, 2013; Watts, Donahue, Lilienfeld, & Latzman, 2017). Traumatic childhood experiences, however, have not only been linked to affective deficits, but also to antisocial behavior and other conduct problems in children and adolescents (Grella, Stein, &

Greenwell, 2005; Stouthammer-Loeber, Loeber, Homish, & Wei, 2001; Watts et al., 2017;

Young et al., 2006). With regard to the different types of childhood trauma, physical abuse, and, to a weaker extent, sexual abuse and neglect have been linked to violence, delinquency, and other externalizing behaviors (Farina, Holzer, DeLisi, & Vaughn, 2018; Kotch et al.,

2008; Lansford et al., 2007; Maas, Herrenkohl, & Sousa, 2008).

Importantly, age at time of maltreatment seems to play a crucial role in the manifestation of externalizing behavior. For example, Craparo et al. (2013) found that earlier maltreatment was linked to stronger manifestations of psychopathic traits. More precisely, emotional maltreatment during early infancy has been linked to aggressive behavior, whereas

19 physical abuse has been associated with aggression when experienced during pre-school age

(Manly, Kim, Rogosch, & Cicchetti, 2001).

The emotional and behavioral deficits that some children and adolescents display as a result of traumatic experiences can translate into problematic behavior in adulthood. Weiler and Widom (1996) published an influential study that corroborated the notion that neglectful and abusive childhood experiences are linked to psychopathic traits in adults. In this piece of research, however, types of childhood trauma and facets of psychopathy were not taken into account. A growing amount of research has since been conducted in order to fill this gap and shed light on the specific relationships between types of abuse and neglect and facets of psychopathy. Most of these more detailed analyses revealed an association between childhood trauma and social deviance in terms of an unstable lifestyle and/or antisocial behavior in female and male offenders (Dargis, Newman, & Koenigs, 2016; Graham, Kimonis,

Wasserman, & Kline, 2012; Kimonis et al., 2010; Kolla et al., 2013; Poythress, Skeem, &

Lilienfeld, 2006; Schimmenti, Di Carlo, Passanisi, & Caretti, 2015), and men and women from a community sample (Gao, Raine, Chan, Venables, & Mednick, 2010). Specific relationships between childhood trauma and emotional detachment, however, were less frequently reported (Graham et al., 2012; Schimmenti et al., 2015). With regard to the type of trauma, physical neglect and abuse have been linked to antisocial behavior and PCL-R total scores

(Dargis et al., 2016; Gao et al., 2010; Graham et al., 2012; Kolla et al., 2013; Schimmenti et al., 2015), whereas emotional abuse and neglect were associated with interpersonal and/or affective deficits, but also with impulsivity and antisociality (Graham et al., 2012;

Schimmenti et al., 2015). Sexual abuse was related to all aspects of psychopathy except for the affective component (Graham et al., 2012).

In summary, there is accumulating evidence that a history of abuse and neglect is linked to psychopathic features in adulthood. Nevertheless, previous research has presented a

20 mixed picture with regard to specific associations between types of trauma and facets of psychopathy.

2.3.2 Genetic Correlates

In addition to environmental factors, genetic influences on psychopathic traits have gained more and more attention throughout the last years (Waldman, Rhee, LoParo, & Park,

2018). There is evidence that serotonergic function is involved in the expression of psychopathic traits, presumably influencing arrogant and deceitful as well as impulsive and antisocial traits (Dolan & Anderson, 2003). Two serotonergic genes have gained special attention when it comes to antisocial and psychopathic behavior: The monoamine oxidase A gene

(MAOA) and the serotonin transporter gene (SLC6A4; Ficks & Waldman, 2014; Gunter,

Vaughn, & Philibert, 2010). The MAOA gene is located on the short arm of the X chromosome, which is why men have one copy, whereas women have two copies of it. The MAOA gene encodes the MAOA enzyme which is involved in the degradation of neurotransmitters such as serotonin and norepinephrine (Sabol, Hu, & Hamer, 1998). The MAOA gene is polymorphic, which means that in can occur in different forms. The most frequently studied polymorphism is the upstream variable number of tandem repeats (uVNTR), which has several variants that differ in how often a sequence of 30 base pairs (bp) is continuously repeated

(Sabol et al., 1998). In their seminal report, Sabol et al. (1998) found four alleles (variants) of the MAOA uVNTR: 3 repeats (3R), 3.5 repeats (3.5R), 4 repeats (4R), and 5 repeats (5R). In subsequent studies, additional rare alleles with 2 repeats (2R) and 6 repeats (6R) were described (Deckert et al., 1999; Huang et al., 2004). In contrast, Deckert et al. (1999) did not find an allele with 3.5 repeats (i.e., 3 repeats + 15 bp), but a variant with 3 repeats + 18 bp, which they named 3a. The 3R and 4R alleles are the most common variants, with the former being present in around 36%, and the latter in around 62% of Caucasian individuals, but dis-

21 tributions differ in relation to ethnic groups (Deckert et al., 1999; Sabol et al., 1998). The

3.5R/3a and 4R alleles have higher transcriptional efficiency compared to the 2R and 3R alleles, which is why the former are often termed MAOA-H (for high), while the latter are termed MAOA-L (for low). Reports on the transcriptional efficiency of the 5R allele have been inconsistent (Deckert et al., 1999; Guo, Ou, Roettger, & Shih, 2008; Sabol et al., 1998).

The second gene of interest is the serotonin transporter gene (SLC6A4). It is located on the autosomal chromosome 17 and codes for the serotonin transporter (SERT or 5-HTT), a protein that conveys serotonin from the synaptic cleft back into the neuron (Heils et al.,

1995). The SLC6A4 gene has a 44 bp insertion/deletion polymorphism with a 20-23 bp repeat unit in the promoter region, which results in two primary alleles: A short allele with 14 repeats (in the following termed 5-HTTLPR-S), and a long allele with 16 repeats (5-HTTLPR-

L). Similar to the MAOA uVNTR, the 5-HTTLPR-S shows lower transcriptional activity than its long counterpart (Heils et al., 1996). Although subsequent investigations revealed twelve additional alleles, a substantial amount of research has focused on the 14-repeat and 16-repeat variants (Nakamura, Ueno, Sano, & Tanabe, 2000). Frequencies of these two alleles differ between ethnic groups, with the majority of Caucasians (around 60%) carrying the long allele, and around 40% carrying the short allele (Gonda et al., 2009; Kunugi et al., 1997; Lesch et al., 1996). The 5-HTTLPR-L has a single nucleotide polymorphism (SNP) called rs25531 with a single base substitution from adenine to guanine, which results in three combinations:

7 5-HTTLPR-L + G (LG), 5-HTTLPR-L + A (LA), and 5-HTTLPR-S . Importantly, the rs25531 bolsters the effect of the 5-HTTLPR, so that the LA combination results in higher gene expression compared to the LA and S variants (Chang, Chang, Fang, Chang, & Huang, 2017; Hu et al., 2006).

7 The rs25531 SNP has also been linked to the short variant of the 5-HTTLPR; however, this combination is extremely rare (Bryant et al., 2010). 22

The MAOA uVNTR and 5-HTTLPR have been linked to aggressive and antisocial behavior in a meta-analysis across 31 (MAOA uVNTR) and 18 (5-HTTLPR) studies on male and female children, adolescents, and adults from non-clinical samples (Ficks & Waldman,

2014). Low-activity variants of the MAOA uVNTR and the short variant of the 5-HTTLPR were associated with more aggressive and antisocial behavior. It has to be noted, however, that not all included studies were able to replicate a direct effect of these two alleles on risk behavior.

Comparatively less research has been conducted concerning psychopathic features beyond antisocial behavior, and results are largely inconsistent (Gunter et al., 2010). Regard- ing MAOA-L, Beaver et al. (2013) investigated whether young adult men of African-

American origin who carried the 2R allele reported higher levels of psychopathy and antisocial behavior in a longitudinal study. In line with previous research, the low-activity 2R allele was linked to antisociality in terms of violence and incarceration. Carriers of the 2R allele, however, did not report elevated psychopathic personality traits. These findings largely correspond to those of Tikkanen et al. (2011), who compared PCL-R total and factor scores in

Caucasian adult violent offenders with a history of alcohol abuse/dependence. Carriers of 3R and 4R alleles of the MAOA uVNTR did not differ with regard to total scores, psychopathic core personality traits, or social deviance. Offenders with the 4R allele, however, tended to be at higher risk for violent reconvictions. Furthermore, Fowler et al. (2009) found a link between the MAOA uVNTR and 5-HTTLPR genotypes and psychopathy, in that MAOA-L (in terms of 2R and 3R alleles) and 5-HTTLPR-S were specifically associated with emotional dysfunction as operationalized through the Affective facet of the PCL: YV in a community sample largely composed of male Caucasian adolescents with attention deficit hyperactivity disorder (ADHD). This is in contrast to findings by Sadeh et al. (2010), who reported that carriers of the 5-HTTLPR-S genotype displayed higher levels of impulsivity in a sample of

23 male and female youth mainly of European-American origin. In a subsequent investigation, however, Sadeh et al. (2013) found that the MAOA uVNTR and 5-HTTLPR genotypes were differentially associated with the two factors of the PCL: SV, with the 5-HTTLPR-S being linked to Factor 1 (i.e., psychopathic core personality traits), and the MAOA-L being associated with Factor 2 (i.e., socially deviance) in a sample of adult men with a history of convictions, most of them of African American and European American origin. The authors based their analyses on the two- and three-factor models of the PCL: SV. Notably, the initial association between 5-HTTLPR-L and Factor 1 of the PCL: SV did not reach statistical significance anymore when Factor 2 was included in the model. Similarly, the relationship between

MAOA-L and Factor 2 of the PCL: SV was rendered insignificant when Factor 1 was added to the model. Once the three-factor model was employed, however, MAOA-L was consistently associated with impulsivity and irresponsibility.

In summary, the relatively sparse literature on the main effects of variation in the

MAOA and SLC6A4 genes on psychopathic features has drawn a somewhat mixed picture with contradictory findings. In addition, not every child who faces traumatic experiences becomes a psychopathic adult. Rather, it has been suggested that the way a child responds to stressors such as childhood trauma depends on her or his genetic disposition (Caspi &

Moffitt, 2006). Against this backdrop, Caspi et al. (2002) tested the hypothesis that an interaction between MAOA uVNTR genotype and childhood maltreatment predicts antisocial behavior. Indeed, Caspi et al. found that male carriers of the MAOA-L genotype who had been physically abused as children were at higher risk of developing antisocial behavior. A potential explanation for this effect is that the presence of a low-activity variant of the MAOA uVNTR is associated with specific structural or functional characteristics in the brain, which, in turn, render the child particularly sensitive for the adverse influence of environmental factors such as maltreatment (Byrd & Manuck, 2014; Lee & Ham, 2008).

The notion of such a gene x environment (GxE) interaction (Plomin, DeFries, Knopik,

& Neiderheiser, 2013) entailed a plethora of replication studies and meta-analyses. So far, at least two meta-analyses addressed putative effects of serotonergic genes and childhood trauma on antisocial behavior (Byrd & Manuck, 2014; Kim-Cohen et al., 2006). Across five GxE studies, Kim-Cohen et al. (2006) found that boys with the MAOA-L genotype who had been physically abused displayed more health-related problems in terms of ADHD, antisocial behavior, and emotional problems. Importantly, they also provided evidence that these effects were truly due to a GxE interaction (i.e., carriers of different genotypes react differently to environmental influences) rather than a gene-environment correlation. The latter occurs when antisocial parents transmit a genetic predisposition for antisocial behavior to their children, and additionally create a disadvantageous environment (passive), or when a child is genet- ically predisposed to antisocial behavior, and hence provokes harsh parenting (evocative;

Kim-Cohen et al., 2006; Plomin et al., 2013). This finding was corroborated in a meta- analysis by Byrd and Manuck (2014) that included 27 studies with non-clinical and non- forensic samples. Maltreatment in terms of sexual or physical abuse or neglect was associated with aggressive and antisocial outcomes in male, but not in female, carriers of an MAOA-L genotype.

Importantly, these meta-analyses restricted their focus to the MAOA uVNTR, and did not consider psychopathic features beyond antisocial behavior. To fill this gap, Sadeh et al.

(2013) examined putative interaction effects between childhood trauma in terms of physical and sexual abuse and the MAOA uVNTR as well as 5-HTTLPR genotypes in a sample of 237 adult male offenders, but found no evidence for an interaction between childhood maltreatment and the two genotypes on psychopathic features. On a related note, however not with a specific focus on childhood trauma, Sadeh et al. (2010) examined putative interaction effects between the 5-HTTLPR genotype and socioeconomic status on psychopathy. Based on a

25 mixed forensic/community sample (N = 118, 58% male) and a community sample (N = 178,

55% male), Sadeh et al. discovered and replicated an interaction effect, in that carriers of the homozygous 5-HTTLPR-L genotype who were reared under disadvantageous socioeconomic conditions displayed more pronounced callous-unemotional and narcissistic traits than those raised under more advantageous conditions.

In conclusion, there is a growing body of research examining the effects of traumatic childhood experiences and variation in the MAOA and SLC6A4 genes on psychopathic features, but results have been largely inconsistent. Studies linking antisocial behavior to the interplay of childhood trauma and the MAOA uVNTR have given rise to the question of whether this GxE effect might also be relevant for the expression of psychopathic features, but this specific research objective has been addressed in only one study by Sadeh et al.

(2013) so far.

3. The Present Thesis

3.1 Aims and Research Questions

The present thesis has two main objectives. The first objective is the investigation of genetic correlates of psychopathy. As outlined in the Theoretical Background chapter, research on the relationship between serotonergic genes and psychopathy is still in its infancy.

Variation in the MAOA and SLC6A4 genes has been associated with different components of psychopathy, but the number of studies addressing this specific question is small and findings have been inconsistent. In addition, these studies have not accounted for the bolstering effect of the serotonergic rs25531 SNP (Ficks & Waldman, 2014; Glenn, 2011). Thus, the first aim was to expand the current literature on genetic main effects of the MAOA uVNTR and 5-

HTTLPR, and additionally include the rs25531 SNP. Against this backdrop, the following research question (RQ) was derived:

RQ 1.1: Are the MAOA uVNTR genotype and/or the 5-HTTLPR/rs25531 haplotype associated with the severity of psychopathic traits?

In light of the scant number of previous studies that specifically addressed psychopathy and heterogeneous outcomes (see section 2.3.2, Genetic Correlates), no prediction was made with respect to which genotypes or haplotypes putatively confer risk in terms of elevations on psychopathic traits.

As pointed out before, the investigation of GxE interaction effects has gained attention. Within the framework of this ongoing debate concerning the contributions of nature and nurture to the manifestation of psychopathy, the MAOA uVNTR and childhood trauma have become promising research objectives (Blair, Mitchell, & Blair, 2005; Viding & McCrory,

2012). Putative interaction effects of the MAOA uVNTR and childhood trauma on psychopathic traits have been addressed in only one previous study so far, but no significant interaction was found (Sadeh et al., 2013). Thus, the following research question was derived:

RQ 1.2: Are psychopathic traits in adulthood associated with an interaction of childhood trauma and MAOA uVNTR genotype?

Moreover, it is conceivable that heterogeneity in previous examinations of genetic effects on psychopathy does not only come about through the influence of potential environmental moderators, but might also be caused by treating psychopathic individuals as a homogeneous group. In view of the evidence that there are variants of psychopathy that may be characterized by differential etiological paths, however, it seems crucial to account for this heterogeneity in the examination of genetic correlates (Mealey, 1995b; Mokros et al., 2015;

Neumann et al., 2016). With this in mind, the two following research questions were derived:

RQ 1.3: Do empirically derived subtypes of individuals with psychopathic traits show differential distributions of the MAOA uVNTR genotypes and 5-HTTLPR/rs25531 haplotypes?

While the examination of genetic correlates of psychopathy falls into the domain of basic research, the second objective of this thesis is of highly practical value. The PCL-R is one of the most frequently used instruments for the assessment of psychopathy (Singh et al.,

2014), but until recently, users had to rely on the original reference data (Hare, 2003). Alt- hough low in prevalence, psychopathic individuals account for a substantial amount of violence in the general population, and present with an increased risk for violent recidivism

(Bonta, Blais, & Wilson, 2014; Coid & Yang, 2011). In addition, the diagnosis of psychopathy impacts the way individuals are perceived and judged, for example in court (Brook,

2015). Thus, the thorough assessment of psychopathic traits based on a valid measure and appropriate reference data is indispensable. Therefore, the following research question was derived:

RQ 2: Does the German version of the PCL-R represent a valid instrument for the assessment of psychopathic features in male forensic samples?

3.2 Summary of Study 1

Main and interaction effects of childhood trauma and the MAOA uVNTR polymorphism on psychopathy

Background: Previous research linked antisocial behavior to childhood trauma, the MAOA uVNTR, and an interaction between these two. Comparatively less research, however, addressed the question whether these mechanisms are also relevant for the expression of psychopathic traits beyond antisocial behavior. Although there is a growing body of evidence that childhood trauma is associated with psychopathy, examinations of the main effects of the

MAOA uVNTR and of the interplay between childhood trauma and the MAOA uVNTR genotype are sparse and outcomes have been inconsistent. Thus, the aim of the present study was to expand the current literature on main and interaction effects of childhood trauma and the

MAOA uVNTR genotype on psychopathic features.

Method: Data were drawn from the large-scale, population-based Genetics of Sexuality and

Aggression project which was conducted in Finland and targeted adult twins and their sib- lings (Johansson et al., 2013). Based on the MAOA uVNTR genotype, self-reported information on psychopathic traits (assessed with a short version of the SRP-III-a described by

Neumann, Schmitt, Carter, Embley, & Hare, 2012), and traumatic childhood experiences assessed retrospectively with a short form of the Childhood Trauma Questionnaire (CTQ-SF;

Bernstein et al., 2003), SEMs were estimated for 1,531 men and 1,265 women. Childhood trauma and psychopathy were operationalized through bifactor models with a general and two group factors, respectively.

Results: Childhood trauma was associated with the overarching psychopathy construct, and, more specifically, with the group factor covering social deviance in men and women. The

MAOA uVNTR genotype was associated with the general psychopathy factor, in that female carriers of the homozygous MAOA-L genotype reported slightly higher levels of psychopathy compared to their MAOA-H counterparts. No main effect of the MAOA uVNTR genotype was found in the male sample. The interaction terms between childhood trauma and the MAOA uVNTR genotype did not predict psychopathic features in either gender.

Conclusion: Findings corroborated the notion that childhood trauma predicts psychopathy in adulthood, and provided evidence for a gender-specific effect of the MAOA uVNTR genotype on psychopathy. Given the relatively low prevalence of traumatic childhood experiences and pronounced psychopathic traits in community samples, these results need further validation in larger correctional and forensic-psychiatric samples. In addition, putative main or interaction effects of additional genes, such as the SLC6A4, should be investigated.

3.3 Summary of Study 2

Associations of the MAOA uVNTR genotype and the 5-HTTLPR/rs25531 haplotype with psychopathic traits

Background: A growing body of research suggests that variation in the MAOA and SLC6A4 genes is involved in the expression of psychopathic traits. Previous examinations of the corresponding polymorphisms, MAOA uVNTR and 5-HTTLPR, however, yielded inconsistent

30 findings. These discrepancies might come about through treating psychopathy as a homogeneous construct, even though theoretical and empirical work supports the notion of distinct subtypes, or variants, of psychopathic individuals. In addition, the synergetic effects between the 5-HTTLPR and the closely linked rs25531 SNP have been largely neglected so far (Ficks

& Waldman, 2014; Glenn, 2011). Hence, the twofold aim of the study was 1) to investigate the associations between the MAOA uVNTR genotype and 5-HTTLPR/rs25531 haplotype, and 2) to identify and validate subtypes of psychopathic individuals and compare them with regard to the frequency of the two genotypes/haplotypes.

Method: Psychopathy was assessed with the PCL: SV (Hart et al., 1995), and external validation was conducted based on the SRP 4 (Geiger et al., 2015; Paulhus et al., 2016), ASPD symptom count (First, Gibbon, Spitzer, Williams, & Benjamin, 1997; Fydrich, Renneberg,

Schmitz, & Wittchen, 1997), and figural intelligence assessed with the Berlin Test for the

Assessment of Fluid and Crystalized Intelligence (BEFKI; Wilhelm, Schroeders, & Schipo- lowski, 2014). Data were available for 343 male offenders and community volunteers. In the first step, SEMs were estimated with psychopathy modeled in a bifactor fashion with a general factor and group factors capturing interpersonal deficits and lifestyle/antisocial traits, respectively. All psychopathy factors were regressed on the MAOA uVNTR genotype and 5-

HTTLPR/rs25531 haplotype variables. In the second step, a latent profile analysis (LPA) were conducted based on the four PCL: SV facets, and the emerging clusters were validated based on SRP 4 scores, ASPD symptom count, and intelligence. The clusters were then compared with regard to the distribution of the MAOA uVNTR genotype and 5-HTTLPR/rs25531 haplotype.

Results: The SEMs revealed a significant effect of the 5-HTTLPR/rs25531 haplotype on the group factor capturing interpersonal deficits, in that carriers of the low-activity haplotype displayed higher levels of traits such as manipulative skills and deceitfulness. There was no

31 effect of MAOA uVNTR genotype. With regard to the LPA, a solution with four classes was deemed to represent the empirical data parsimoniously. In accordance with previous research

(Krstic et al., 2017; Neumann et al., 2016), the emerging clusters were labeled 1) non- psychopaths, 2) sociopaths, 3) callous-conning, and 4) psychopaths. External validation largely corroborated hypothesized differences between the clusters. Comparisons between the clusters revealed that the HTTLPR/rs25531-S haplotype was significantly more frequent in the callous-conning compared to non-psychopathic cluster.

Conclusion: The results support the notion that carriers of the HTTLPR/rs25531-S haplotype display higher levels of interpersonal deficits, and that this haplotype is significantly more frequent in a subtype characterized by callous-conning traits. Notably, the results suggest that this haplotype is specifically associated with interpersonal and emotional impairments rather than the overarching psychopathy construct.

3.4 Summary of Study 3

Construct Validity of the German Version of the Hare Psychopathy Checklist-Revised

Background: The PCL-R is among the most frequently used tools for the assessment of psychopathic traits in Germany (Singh et al., 2014). German-speaking users of the PCL-R, however, have had to rely on the original normative data from North America so far. To fill this gap, a German version of the PCL-R including a translation and extension of the manual and normative data for male forensic samples was prepared. The aim of the study was to assess the construct validity of the German version of the PCL-R in terms of factor structure as well as convergent and discriminant validity. Furthermore, potential response bias due to socially desirable responding was assessed.

Method: Based on data from 118 male prison inmates and forensic-psychiatric inpatients, the factor structure of the PCL-R was examined through confirmatory factor analysis (CFA).

Convergent validity was assessed based on associations with the SRP 4 (Geiger et al., 2015;

Paulhus et al., 2016) and ASPD symptom count (First et al., 1997; Fydrich et al., 1997). A multitrait multimethod (MTMM) matrix composed of observer ratings and self-reports of psychopathic traits served to assess convergent validity at the facet level. Discriminant validity was examined through associations with measures of alexithymia (assessed with the To- ronto Alexithymia Scale 26 [TAS-26]; Kupfer, Brosig, & Brähler, 2001; Taylor, Ryan, &

Bagby, 1985), the Big Five personality dimensions (assessed with the NEO Five Factor In- ventory [NEO-FFI]; Borkenau & Ostendorf, 2008; Costa & McCrae, 1985), and impulsivity

(assessed with the Urgency Premeditation Perseverance Sensation Seeking [UPPS] questionnaire; Keye, Wilhelm, & Oberauer, 2009; Whiteside & Lynam, 2001). In addition, a canonical correlation analysis (CCA) was conducted to test the differential associations between the aforementioned measures and psychopathic core personality traits vs. social deviance (i.e.,

PCL-R Factor 1 and Factor 2 subtotals). Moreover, associations between PCL-R scores and socially desirable responding assessed with the Balanced Directory of Desirable Responding

(BIDR; Musch, Brockhaus, & Bröder, 2002; Paulhus, 1984) were examined.

Results: CFA indicated excellent fit for a nested, hierarchical parcel model with two correlated factors and four facets. Evaluation of the MTMM matrix and correlations between the

PCL-R and SRP 4 total scores as well as ASPD symptom count were indicative of the convergent validity of the German PCL-R. With regard to discriminant validity, psychopathic core personality traits were associated with emotional robustness, whereas social deviance was characterized by impulsivity as well as low levels of agreeableness and conscientiousness. Impression management was negatively associated with PCL-R total scores to a moderate degree.

Conclusion: Based on behavioral and personality-related measures, the convergent and divergent validity of the German version of the PCL-R was corroborated through a number of

33 correlational analyses. Thus, it can be assumed that the PCL-R presents a valid instrument for the assessment of psychopathic features in German-speaking samples of male offenders.

4. Discussion

In the following chapter, the four research questions will be addressed by discussing and integrating the major study findings with special regard to methodological and conceptual aspects. In addition, implications for clinical practice are outlined and suggestions for future research are made based on the shortcomings of the three studies. The chapter closes with an overarching conclusion.

4.1 Genetic Correlates of Psychopathy

4.1.1 Genetic Main Effects on Psychopathy

RQ 1.1 revolved around putative main effects of the MAOA uVNTR genotype and the

5-HTTLPR/rs25531 haplotype on psychopathic features. This objective was addressed in

Study 1 and Study 2 by estimating SEMs, which offer the advantage of controlling for measurement error. Furthermore, SEMs make assumptions about the measurement of latent constructs as indicated by observable variables both explicit and testable. In both studies, psychopathy was operationalized through a bifactor model, so that all items loaded on one general factor, and on two group factors that represented psychopathic core personality traits

(i.e., interpersonal and affective deficits [Study 1] or just interpersonal deficits [Study 2]) on the one hand, and social deviance (i.e., an unstable lifestyle and antisocial behavior) on the other hand. This operationalization is different from a traditional hierarchical model where the items load on the respective facets, which, in turn, load on two correlated second-order factors that represent psychopathic core personality traits and social deviance (Hare &

Neumann, 2008). In a bifactor model, the general factor represents the overarching construct, whereas the group factors account for variance that is not explained by the general factor, and

35 all factors are mutually uncorrelated (Chen, Hayes, Carver, Laurenceau, & Zhang, 2012).

Originally developed by Holzinger and Swineford (1937), bifactor models have gained popu- larity in the structural conceptualization of psychopathology (see Caspi et al., 2014, for example). As Bonifay, Lane, and Reise (2017) point out, however, the application of bifactor models presents with some challenges. For example, the interpretation of group factors is hampered by the fact that they are orthogonal to the general factor (Bonifay et al., 2017;

Rodriguez, Reise, & Haviland, 2016). In addition, bifactor models tend to produce better fit indices compared to other models. Importantly, this does not mean that bifactor models are superior in representing the data, but that they might overfit the data (Bonifay et al., 2017).

Nevertheless, bifactor models offer the advantage of measuring a common latent trait (i.e., the general factor) and simultaneously accounting for the influence of other factors (i.e., the group factors; Reise, Moore, & Haviland, 2010). Thus, on the condition that results are interpreted cautiously and validated with external measures, bifactor models present a noteworthy alternative to, for example, higher-order modeling approaches (Bonifay et al., 2017; Chen,

West, & Sousa, 2006)

The MAOA uVNTR was associated with the general psychopathy factor in the female sample (Study 1), in that female carriers of the homozygous low-activity MAOA uVNTR genotype described themselves as slightly more psychopathic compared to their high-activity counterparts. In contrast, there was no main effect in the male sample, indicating a sex- specific effect of the MAOA uVNTR. It is conceivable that this sexual dimorphism comes about through incomplete X-inactivation of the MAOA gene in women. Since women have two copies of X-linked genes, the genes on one of the X-chromosomes are usually inactivat- ed. In some cases, however, the seemingly silenced genes escape X-inactivation, which results in altered gene expression (Carrel & Willard, 2005). Another possible explanation for this gender-specific effect taps into the domain of endocrinology. For example, Sjöberg et al.

(2008) suggested that an interaction between the MAOA uVNTR genotype and the male sex hormone testosterone predicts aggression and ASPD in men, whereas the MAOA uVNTR alone does not. This ties in with Fowler et al. (2007), who reported that MAOA uVNTR genotype was not directly associated with MAOA activity in the brain in a sample of healthy adult men. Instead, it has been assumed that MAOA-related serotonergic functioning plays an important role during early stages of brain development, and that this mechanism might vary between men and women (Åslund et al., 2011; Fowler et al., 2007; Oreland, Nilsson,

Damberg, & Hallman, 2007).

Notably, the sample in Study 1 was composed of men and women from the general population, whereas the sample in Study 2 included male forensic inpatients, prison inmates, and community volunteers. Thus, the effect of the MAOA uVNTR on women could not be examined in Study 2. Given the diversity of the samples included, however, it seems likely that the missing main effect of the MAOA uVNTR in men is not exclusively attributable to sample characteristics.

In Study 2, the 5-HTTLPR/rs25531 haplotype was examined in addition to the MAOA uVNTR genotype. The 5-HTTLPR/rs25531 haplotype predicted the interpersonal group factor, in that carriers of the low-activity variant showed more interpersonal deficits such as grandiosity and deceitfulness. Notably, the haplotype was not associated with the general psychopathy factor in terms of the overarching psychopathy construct. To some extent, this finding ties in with Fowler et al. (2009), who found that carriers of the 5-HTTLPR-S genotype had higher total scores and higher scores on the Affective facet of the PCL: YV compared to carriers of the long genotype. Interestingly, the association between total scores of psychopathy and the 5-HTTLPR genotype lost significance after controlling for the Affective facet, indicating that the 5-HTTLPR-S genotype is specifically associated with emotional dysfunction. It has to be noted, however, that Fowler et al. did not include the Interpersonal

37 facet in their analyses. Nevertheless, the Affective and the Interpersonal facet jointly form the domain of psychopathic core personality traits, leaving open the possibility that they might, at least to some extent, be influenced by the same genes.

4.1.2 GxE Effects on Psychopathy

RQ 1.2 addressed the hypothesis that psychopathic traits might be caused by an interaction between the MAOA uVNTR and early traumatic experiences (Study 1). The general trauma factor, but not the group factors predicted both the general psychopathy factor and the group factor of social deviance in men and women. This means that traumatic childhood experiences as a whole are associated with psychopathy in terms of an overarching construct, but also explain specific variance with respect to socially deviant behavior such as impulsivity, irresponsibility, and antisocial or delinquent behavior. This corresponds to recent work linking PCL-R total scores as well as impulsivity and antisociality to composite measures of childhood trauma (Dargis et al., 2016; Oshri et al., 2017; Wells et al., 2017). It is also in line with earlier considerations concerning the differential pathways leading to core psychopathy vs. antisocial behavior, in that the latter mainly comes about through environmental adversities (Mealey, 1995a).

Childhood trauma, however, did not interact with the MAOA uVNTR genotype in men and women. This is in accordance with a previous null finding with respect to the moderating effect of childhood abuse on the relation between the MAOA uVNTR genotype and psychopathy in a sample of adult male offenders (Sadeh et al., 2013). In their paper, Sadeh et al. proposed that the lack of GxE interaction effect might be due to the sample characteristics which included high levels of childhood adversity and psychopathic features. By replicating the findings in a community sample with comparatively low levels of childhood trauma and psychopathy, Study 1 provided additional evidence that psychopathy might not be predicted

38 by the interplay between MAOA uVNTR and childhood trauma. It is conceivable that other parameters influence the relationship between MAOA function and the expression of psychopathic features. There is a broad range of potential moderators, among them external factors like parental care, family discord, and even fetal exposure to cigarette smoke, but also internal factors such as hormones and epigenetic mechanisms (Åslund et al., 2011; Kinnally et al., 2009; Sjöberg et al., 2008; Vanyukov et al., 2007; Wakschlag et al., 2010).

Wells et al. (2017) recently suggested that traumatic childhood experiences increase emotional responsiveness to stressful events in later life, which in turn increases risk for antisocial and criminal conduct. Indeed, Wells et al. found that an interaction of MAOA uVNTR genotype, childhood abuse, and proximal adversities predicted criminal and delinquent behavior in two male community samples in terms of a GxExE interaction. In contrast, Zhang et al. (2017) suggested that an interaction between MAOA uVNTR, 5-HTTLPR, and sexual abuse increased aggressive behavior in healthy adolescents in terms of a GxGxE interaction.

Notably, these two studies did not explicitly address psychopathic features, but nevertheless suggest that more complex interactions might be involved in the expression of traits that are related to psychopathy.

4.1.2 Genetic Correlates of Psychopathic Subtypes

RQ 1.3 addressed the question of whether empirically derived subtypes of individuals with psychopathic features differ with regard to the frequencies of the MAOA uVNTR and the

5-HTTLPR/rs25531. In order to examine this issue, an LPA was conducted to identify homogeneous latent classes. In LPA, probabilities of belonging to each of the latent classes are provided for each individual (Vermunt & Magidson, 2002). The best tradeoff between model fit and parsimony was found for a solution with four latent classes. Based on the probabilities of belonging to the latent classes, individuals were assigned to manifest clusters. The profiles

39 of the four clusters highly resembled those reported for samples of men with varying levels of psychopathic features (Krstic et al., 2017; Neumann et al., 2016), and were accordingly labeled as non-psychopathic (low scores on all facets), sociopathic (high levels of social deviance and lower levels of psychopathic core personality traits), callous-conning (high levels of psychopathic core personality traits and lower levels of social deviance), and psychopathic

(high scores on all four facets). Evaluation of the PCL: SV facet scores as well as external validation based on SRP 4 scores, ASPD symptom count, and figural intelligence indicated that the four clusters represented distinct subtypes. These subtypes not only differ in the severity of overall psychopathic traits but also with respect to the pattern of psychopathic core personality traits and social deviance, or antisociality.

Notably, the sociopathic and callous-conning clusters had very similar PCL: SV total scores, but presented with different profiles based on their average facet scores. On average, the sociopathic individuals did not meet the diagnostic cutoff for psychopathy (i.e., a PCL:

SV total score of 18 or higher), but the diagnostic cutoff for ASPD (i.e., three items or more were rated with a 3), and thus represented a clearly antisocial subtype. Similarly, the average total score of the individuals assigned to the callous-conning cluster was below the cutoff for psychopathy, although they were characterized by high levels of psychopathic core personality traits such as shallow affect and interpersonal manipulation. This ties in with Neumann et al. (2016), who emphasized that callous-conning individuals must be distinguished from manipulative psychopaths.

The four clusters did not differ with respect to the frequencies of the MAOA uVNTR genotype, even though previous studies linked the MAOA uVNTR to antisocial behavior (see meta-analysis by Ficks & Waldman, 2014). A disproportionate share of MAOA-L carriers could have been expected in the clusters composed of sociopathic and psychopathic individuals, since these two are characterized by pronounced antisociality. Nevertheless, this finding

40 corresponds to the results reported for the SEMs in Study 1 and Study 2, according to which the MAOA uVNTR was not associated with psychopathic traits in men.

In contrast, the non-psychopathic and callous-conning clusters differed significantly with regard to the relative frequencies of the 5-HTTLPR/rs25531 haplotypes, in that the low- activity variant of the 5-HTTLPR/rs25531 haplotype was more frequent in the callous- conning cluster than in the non-psychopathic cluster. This means that a significantly larger portion of individuals with elevations on features such as callousness and deceitfulness carried the 5-HTTLPR/rs25531 haplotype in comparison to non-psychopathic individuals. Nota- bly, this difference was not observable between the non-psychopathic and the psychopathic clusters. In conjunction with the finding that the low-activity 5-HTTLPR/rs25531 haplotype was associated with higher self-reported scores on the interpersonal group factor (see section

4.1.1, Genetic Main Effects on Psychopathy), the results suggest that this haplotype might be specifically linked to interpersonal and emotional impairments. On the one hand, this is in accordance with the notion that the emotional dysfunction component of psychopathy is more pronounced in carriers of the short 5-HTTLPR genotype (Fowler et al., 2009). It is, however, at odds with Glenn (2011), who hypothesized that the long allele of the 5-HTTLPR rather than the short allele is related to psychopathy. Thus, the conclusions drawn from Study 1 and

Study 2 add to a rather inconsistent body of research and need further validation. Neverthe- less, the examination of the genetic correlates of empirically derived subtypes presents a novel and promising objective in the field of psychopathy research.

4.1.4 Summary of Genetic Correlates

Given that the examination of genetic correlates included several different approaches and tackled domains such as environmental factors and subtypes of psychopathy, a short intermediate summary seems reasonable at this point. The conclusions drawn from Study 1 and

Study 2 illustrate the complexity of the relationship between genetics and psychopathy. There is partial evidence for a direct involvement of the MAOA uVNTR in the expression of psychopathic traits in women, but not in men. Moreover, there was no evidence that carriers of a certain MAOA uVNTR genotype were more likely to develop psychopathic traits when ex- posed to traumatic childhood experiences. The 5-HTTLPR/rs25531 haplotype, in contrast, was specifically associated with interpersonal deficits in men, and was more frequent in individuals characterized by callous-conning traits. These findings support the notion that the 5-

HTTLPR/rs25531 haplotype might be involved in the expression of a set of traits that tap into shallow affect and manipulative skills, rather than the overarching psychopathy construct.

With a view to the comparatively small number of studies that have shed light on the influence of serotonergic genes on psychopathy and the rather inconsistent findings, the results presented herein should be regarded as preliminary. Furthermore, the need for further examination and validation should be emphasized.

4.2 Assessment of Psychopathy with the PCL-R

RQ 2 addressed the question of whether the German version of the PCL-R (Mokros et al., 2017) represents a valid instrument for the assessment of psychopathic features in forensic samples. With regard to construct validity, a nested hierarchical, four-facet, two-factor structure showed excellent fit to the empirical data. The PCL-R and SRP 4 total scores were strongly correlated. Evaluation of the MTMM matrix composed of the four PCL-R facets and their SRP 4 counterparts corroborated the notion that the two instruments indeed measure the same construct. The most pronounced differences between self-reported traits and observer ratings occurred on the Interpersonal and Affective facets/scales. On a related note, callous- conning individuals had lower self-reported total, interpersonal, and affective scores on the

SRP 4 compared to sociopaths in Study 2. This was surprising given that the callous-conning

42 cluster was characterized by higher levels of interpersonal and emotional deficits compared to the sociopathic cluster based on observer ratings. Taken together, the results of the external validation with the SRP 4 in Study 2 and evaluation of the MTMM matrix in Study 3 support previous reports which indicate that correlations between the SRP and PCL-R scales and facets are stronger for social deviance than for psychopathic core personality traits (Tew,

Harkins, & Dixon, 2015). With regard to methodological aspects, it is conceivable that the

SRP 4 and PCL-R facets and scales capturing interpersonal and affective deficits do not measure exactly the same aspects of these traits, albeit each of them presents with high internal consistency (Tew et al., 2015).

In addition, it has been postulated that psychopathy often goes hand in hand with a lack of insight, in that psychopathic individuals are unable to see themselves the way others see them (Sellbom et al., 2018). Miller, Jones, and Lynam (2011), however, challenged the notion of a lack of insight in psychopaths by reporting moderate to high convergence between self-reports and informant-reports of psychopathic traits in a community sample. It has to be noted, however, that informant-reports were provided by partners, friends, or family members rather than based on validated instruments such as the PCL-R.

Moreover, the term semantic aphasia is noteworthy at this point. This brain condition described by Head (1926) is characterized by deficits in the understanding of the meaning of words and phrases. Drawing an analogy, Cleckley (1976) assumed that psychopathic individuals use emotionally connoted words or phrases without actually being able to feel these emotions (Lilienfeld, Watts, Smith, Patrick, & Hare, in press; Patrick, 2006). In one of his case studies on a psychopathic man, Cleckley described the following: “Something left out of his experience made it impossible for him to see that the words he used did not refer to such emotional actualities as they would in another. One might say this constitutes a kind of strange and paradoxical sincerity, something a little like the report of a color-blind man

(without knowledge of his defect) who after investigation swears conscientiously that the horizon is gray, though it actually blazes with all the colors of the sunset” (Cleckley, 1976, p.150). Importantly, Sellbom et al. (2018) assumed that this “emotional color-blindness” can affect the self-assessment of psychopathic traits, in that psychopathic individuals might have learned to label emotions despite being unable to actually fully experience them.

In addition to putatively unconscious response biases in terms of semantic aphasia and a lack of insight, the relationship between psychopathy and socially desirable responding was analyzed. In accordance with previous findings (Ray et al., 2013; Verschuere et al., 2014), offenders with higher PCL-R total scores showed less impression management in terms of faking good. A possible explanation for this inverse relationship taps into the concept of boldness, in that highly psychopathic individuals care less about the impression they make on others (Berg, Lilienfeld, & Sellbom, 2017; Lilienfeld et al., 2016). Notably, the participants in Study 3 did not have to expect that their responses would have any disadvantageous consequences. In other situations (e.g., risk assessments or release from prison), willingness to fake good might be higher (Sellbom et al., 2018). On a related note, Rogers et al. (2002) could show that adolescent offenders were able to substantially decrease their PCL: YV scores if instructed to do so.

Further analyses of the convergent validity of the PCL-R included the relationship between PCL-R scores and ASPD symptom count assessed with the German version of the

Structured Clinical Interview for DSM-IV (First et al., 1997; Fydrich et al., 1997). The opera- tionalizations of ASPD included in the DSM-IV and DSM-5 emphasize the role of impulsive, irresponsible, and antisocial behavior, but also take features such as deceitfulness, callousness, and remorselessness into account (American Psychiatric Association, 1994, 2013). Ac- cordingly, correlations between ASPD symptom count and the PCL-R facets covering social deviance, but also, to a lesser extent, to interpersonal and affective deficits, were expected.

Indeed, social deviance was strongly correlated to symptoms of ASPD, whereas psychopathic core personality traits showed a moderate association with ASPD. Notably, the Affective and

Antisocial facets were both similarly strongly correlated to ASPD symptom count (r = .44, p

< .05 and r = .48, p < .05, respectively). Although ASPD in terms of secondary psychopathy has been linked to features that contrast psychopathic core personality traits, such as anxiety

(Skeem et al., 2007), there is evidence that secondary psychopathy, like primary psychopathy, does not represent a unitary construct. Yildirim (2016) describes two non-mutually ex- clusive subtypes of antisociality, where he introduces one subtype labeled as detached secondary psychopathy that presents a severe variant of ASPD characterized by socio-emotional detachment that manifests itself in narcissism as well as low levels of neuroticism and anxiety. Unstable secondary psychopathy, in contrast, rather taps into the concept of borderline personality disorder, in that it is marked by emotional instability and negative emotionality

(Yildirim, 2016). Thus, associations between the respective facets of psychopathy and ASPD might vary depending on the distribution of detached and unstable secondary psychopaths.

The discriminant validity of the German version of the PCL-R was examined based on its differential relations to alexithymia assessed with the TAS-26, the NEO-FFI personality dimensions (neuroticism, extraversion, openness, agreeableness, and conscientiousness), and impulsivity assessed with the UPPS. The PCL-R factor capturing social deviance was positively correlated to the UPPS total score and the Urgency, Lack of Premeditation, and

Sensation Seeking scales, and with low levels of agreeableness and conscientiousness. These findings are in line with previous outcomes, and underline that social deviance is associated with traits such as impulsivity and unreliability, and low levels of goal-oriented behavior

(Hare, 2003; Lynam & Widiger, 2007; Pereira, Huband, & Duggan, 2008). Psychopathic core personality traits, on the other hand, were associated with low levels of neuroticism, supporting the notion that the prototypical psychopath is emotionally stable, but detached. This con-

45 dition is also reflected in Cleckley’s assumption that “the psychopath is nearly always free from minor reactions popularly regarded as 'neurotic' or as constituting 'nervousness.' The chief criteria whereby such diagnoses as hysteria, obsessive-compulsive disorder, anxiety state, or 'neurasthenia' might be made do not apply to him” (Cleckley, 1976, p.339).

Moreover, given that both alexithymia and psychopathy are characterized by deficits in empathy and insight, positive correlations between the two constructs could have been expected. Alexithymic individuals, however, are typically anxious and socially conforming, whereas psychopathic individuals are characterized by low anxiety and a tendency to violate norms and rules (Haviland, Sonne, & Kowert, 2004). This differentiation is supported by the positive association between alexithymia and social deviance reported in Study 3. On a related note, alexithymia has been positively associated with antisocial behavior, and negatively associated with affective deficits (Pham, Ducro, & Luminet, 2010; Sayar, Ebrinc, & Ak,

2001; Zimmermann, 2006). The inverse relationship between psychopathy and alexithymia is also illustrated by the fact that alexithymia, etymologically and phenomenologically, is characterized by the inability to identify and describe emotions, whereas psychopathic core traits have been associated with the description of emotions without truly feeling them (Hare, 2003;

Sellbom et al., 2018; Taylor et al., 1985).

The differential associations between the two psychopathy factors and alexithymia, global personality dimensions, and impulsivity were corroborated by the results of the CCA, where the two canonical functions represented psychopathic core personality traits and social deviance, respectively. The former were most strongly linked to low neuroticism, whereas the latter were associated with high impulsivity. The largest differences between the two canonical loadings emerged for conscientiousness, urgency, and lack of perseverance. This is in line with the notion that psychopathic core personality traits have traditionally been linked to low emotional robustness, whereas social deviance is characterized by traits such as impulsivity,

46 and low levels of agreeableness and conscientiousness (Cleckley, 1976; de Tribolet-Hardy,

Vohs, Mokros, & Habermeyer, 2014; Derefinko & Lynam, 2006; Miller & Lynam, 2012).

These strong associations have fueled the debate on whether psychopathy can be described through a combination of the Big Five personality dimensions (Lynam & Miller, 2015). For example, O'Boyle, Forsyth, Banks, Story, and White (2015) found that the Big Five explain a large share of variance in psychopathic features. Similarly, a substantial proportion of variance in the PCL-R factors (28%) could be explained by the Big Five, impulsivity, and alexithymia in Study 3.

4.3 Methodological Considerations

The three studies illustrate that psychopathy can be conceptualized and analyzed in different ways. With regard to conceptual and methodological aspects, the inclusion of two different modeling approaches is noteworthy. The factor analyses conducted in Study 3 drew on the traditional, higher-order conceptualization of psychopathy, whereas Study 1 and Study

2 employed a different approach by implementing bifactor models of psychopathy for self- report (Study 1) as well as observer ratings (Study 2). In so doing, these studies add to a growing body of research that corroborates the notion that externalizing behavior in general and psychopathy in particular are well represented by a broad, overarching factor, and group

(or nuisance) factors that explain specific variance (Debowska, Boduszek, Kola, & Hyland,

2014; Dotterer et al., 2016; Krueger, Markon, Patrick, Benning, & Kramer, 2007; Patrick,

Hicks, Nichol, & Krueger, 2007). With regard to different data analysis strategies, the studies included within this thesis made use of variable-centered as well as person-centered approaches. This differentiation traces back to William Stern, a German psychologist who, among other types of research, distinguished correlation research (i.e., the association between variables across individuals) from comparison research (i.e., comparing traits between

47 individuals; Woodward, 2013). Neumann et al. (2016) exemplified the difference between these two approaches by comparing them to the rows and columns of an Excel spreadsheet:

The variable-centered approaches refer to the columns which represent different variables, whereas the person-centered approaches target the rows, which represent individual cases. In

Study 1 and Study 2, SEMs were estimated in order to shed light on the associations between different variables such as childhood trauma, genetic polymorphisms, and psychopathy. No- tably, this type of analysis provides information about different traits and their relations across individuals, but does not allow for conclusions about the expression of psychopathic traits within individuals. Thus, Study 2 additionally used LPA, a person-centered approach that provides information on latent classes of individuals. This approach has proven useful in several studies on psychopathic subtypes in community volunteers (Coid, Freestone, &

Ullrich, 2012), offenders (Krstic et al., 2017; Mokros et al., 2015; Neumann et al., 2016), and adolescents with CU traits (Fanti & Kimonis, 2013; Kimonis, Goulter, Hawes, Wilbur, &

Groer, 2017).

4.4 Clinical Implications

The conclusions drawn from the three studies allow for clinical implications that target preventive interventions for children and their families on the one hand, and treatment of adults with psychopathic traits on the other hand. With the regard to the former, the results of

Study 1 suggest that childhood trauma may precede psychopathic features in adulthood.

Thus, aside from treatment programs that address adults with psychopathic features, it seems worthwhile to implement interventions that target potentially abusive parents in order to pre- vent or diminish negative long-term consequences for children at early stages where vulnera- bility is high (Cummings, 2015; Olds, Sadler, & Kitzman, 2007). Among such treatment programs, home visiting by nurses has yielded promising positive effects provided that the inter-

48 vention is of truly preventive nature, in that it starts during or shortly after pregnancy

(Fergusson, Grant, Horwood, & Ridder, 2005, 2006; Koniak-Griffin et al., 2002). In contrast, support for families where abuse and neglect has already happened seem to be less effective

(MacMillan et al., 2005). Further treatment approaches include home visits through volunteers, regular center-based meetings for parents, education for parents, and external childcare

(Olds et al., 2007).

In addition to traumatic childhood events, variation in the serotonergic system has been associated with psychopathic traits in the present thesis. As Glenn (2011) pointed out, serotonergic functioning affects brain areas such as the amygdala and the pre-frontal cortex, which, in turn, are involved in the expression of psychopathic traits. The association between these brain regions and psychopathic traits has been replicated in a range of studies (see meta-analysis by Poeppl et al., in press). Crockett, Clark, Hauser, and Robbins (2010) could show that enhancement of serotonergic functioning through administration of selective serotonin reuptake inhibitors (SSRIs) resulted in increased prosocial behavior in terms of moral judgment in emotional scenarios. Given that moral judgment and empathy have been associated with functioning of the amygdala and the prefrontal cortex (Blair, 2008; Goerlich-Dobre,

Lamm, Pripfl, Habel, & Votinov, 2015; Koenigs et al., 2007), it is conceivable that SSRIs can temporally ameliorate psychopathic features by regulating serotonergic function and thus influencing functioning of the respective brain areas. Notably, the effect reported by Crockett et al. (2010) was more pronounced in individuals with higher baseline empathy, suggesting that psychopathic individuals with poor empathy might not benefit that much from the administration of an SSRI. With regard to aggressive behavior, there is evidence that SSRIs can reduce aggression in patients with intermittent explosive disorder or personality disorders

(Coccaro, Lee, & Kavoussi, 2009; Silva et al., 2010). Despite the notion that neurotransmitters such as serotonin contribute to the manifestation of psychopathic traits, it has to be borne

49 in mind that they only account for a small portion of phenotypic variance in psychopathic traits, and that research addressing the potential of psychopharmacological treatment of traits related to psychopathy is still in its infancy (Ficks & Waldman, 2014; Viding & McCrory,

2018).

In contrast to the comparatively sparse research on pharmacological treatment options for psychopathy, there is a growing body of evidence suggesting that the risk for general, violent, and sexual recidivism in psychopathic individuals can be reduced through intensive and elaborate therapeutic interventions (O’Brien & Daffern, 2016; Olver & Wong, 2009;

Polaschek, 2014; Salekin, 2002). Notably, psychopathy has been regarded as an untreatable condition for a long time. This assumption has not least been fueled by the so-called Oak

Ridge study (Rice, Harris, & Cormier, 1992). In this study, retrospective analyses of data drawn from a therapeutic community program conducted in the 1960s and 1970s suggested that highly psychopathic offenders were at even higher risk of reoffending after completing the treatment program. As measured by current standards, however, the interventions implemented in the treatment program were somewhat unconventional. For example, participation and drop-out were not voluntary, and very little emphasis was put on aspects such as social competence training or changing criminal and violent attitudes (Rice et al., 1992; Skeem,

Monahan, & Mulvey, 2002).

Nevertheless, psychopathic individuals present a challenging clientele characterized by increased drop-out rates and low levels of motivation (Hobson, Shine, & Roberts, 2000), which illustrates the need for interventions tailored to the risks and needs linked to psychopathy. In this context, the differentiation between psychopathic core personality traits and social deviance is of great importance, since it has direct implications for clinical assessment and therapeutic interventions. As pointed out in Study 2, evaluations of measures such as the

PCL-R should not be restricted to total scores, but rather account for facet and factor scores

50 in order to provide information about the specific impairments of the patient. This is important given that psychopathic core personality traits and social deviance are differentially associated with elements of interventions in forensic settings as described by Andrews and

Bonta (2000). Among them, the responsivity principle implies that the patient’s individual characteristics need to be addressed, even if they are not directly related to risk of recidivism

(Wong, Gordon, & Gu, 2007). Individuals scoring high on affective deficits have difficulties establishing a therapeutic alliance, recognizing the harm they might have caused their victims, and taking responsibility for their crimes, which often results in drop-out from treatment programs (DeSorcy, Olver, & Wormith, 2017; O’Brien & Daffern, 2016; Olver, Lewis, et al.,

2013; Olver & Wong, 2011; Yang et al., 2010). Importantly, psychopathic core personality traits are presumably not directly associated with violent recidivism (Yang et al., 2010).

Based on examinations of a sample of male offenders, however, Olver, Lewis, et al. (2013) suggested that in samples characterized by very high levels of psychopathy (indicated by a

PCL-R total score of 25 or more), the Affective facet of the PCL-R was also strongly associated with relapse into violent crime. Finally, although not directly related to violent relapse, the Affective facet of the PCL: SV has been associated with violent behavior in community samples with comparatively low levels of psychopathy (Coid et al., 2009; Neumann & Hare,

2008), which additionally illustrates the need to address affective deficits in therapeutic interventions.

Another important element of forensic therapy is the need principle (Andrews &

Bonta, 2000), which implies that interventions should address the criminogenic needs of patients in order to reduce relapse into delinquency (Wong et al., 2007). This is of particular importance given that high levels of social deviance in terms of impulsivity, irresponsibility, and antisocial attitudes have been directly associated with a higher risk of (violent) recidi-

51 vism compared to psychopathic core personality traits (O’Brien & Daffern, 2016; Yang et al.,

2010).

The differentiation between the responsivity and need components with regard to psychopathic core personality traits and social deviance, respectively, illustrates the need for therapeutic interventions that integrate these components. For example, Wong, Stockdale, and Olver (2017) proposed a two-component model for violence reduction which addresses interpersonal and criminogenic components. With regard to the former, the authors illustrate the need for extrinsic therapy motivation. Given that individuals high on callous-unemotional traits are unlikely to suffer from their impairments, extrinsic factors in terms of external re- wards rather than intrinsic factors are needed in order to enhance treatment motivation

(Mokros & Habermeyer, 2012; Wong et al., 2017). Given the reward-oriented thinking style of psychopathic individuals, therapists and clients should build working alliances through agreeing on common goals and how to achieve them rather than relying on emotional bonding (Galloway & Brodsky, 2003; Ross, Polaschek, & Ward, 2008; Wong et al., 2017). In addition, therapists and other clinical staff should be aware that psychopathic clients, due to their tendency toward conning and manipulative behavior, might try to undermine therapy, for example by playing off staff or crossing personal boundaries. Ideally, therapists are experienced and aware of the destructive tendencies inherent to some psychopathic individuals, and can discuss potential problems with external supervisors (Mokros & Habermeyer, 2012;

Reid & Gacono, 2000; Wong et al., 2017).

With regard to the criminogenic component, Wong et al. (2017) focus on the questions of which risk predictors to work on, and which types of treatment work best. Notably, not all variables that constitute the social deviance factor of the PCL-R are reducible (e.g., number and types of convictions in adolescence and adulthood). In contrast, traits and behaviors such as poor behavioral control, sensation seeking, or irresponsibility present changeable

52 factors that are related to violent reoffending and hence should be addressed in treatment programs (Wong, Gordon, Gu, Lewis, & Olver, 2012). Notably, socially deviant tendencies, in contrast to psychopathic core personality traits, have been shown to lose severity across the life span (Harpur & Hare, 1994; Mokros et al., 2017; Vachon et al., 2013). It has to be noted, however, that the underlying data were cross-sectional, leaving open the possibility that the reported changes might be due to cohort effects.

On a practical level, psychosocial therapeutic interventions that target the reduction of antisocial attitudes and beliefs, interpersonal and problem-solving skills, interpersonal aggression, and cognitive distortions in favor of more prosocial attitudes applied and consoli- dated on a day-to-day basis have been found to decrease violence and violent reoffending in psychopathic, antisocial, and violent offenders (McGuire, 2008; Wong et al., 2012). During the last decades, cognitive-behavioral therapies and therapeutic communities have become prevalent in the treatment of psychopathic and antisocial offenders, which has mainly been attributed to an increased focus on the patient’s needs and the treatment milieu (Wong et al.,

2017).

4.5 Limitations

The studies presented in this thesis have several limitations which should be borne in mind when interpreting the results. The first restriction concerns the assessment of traumatic childhood experiences in Study 1. Retrospective self-report measures of childhood abuse and neglect are generally susceptible to bias caused by measurement error, and tend to underestimate the occurrence of traumatic experiences. On the condition that traumatic events were serious and that items are well operationalized and focus on the occurrence rather than details of the trauma, however, retrospective reports of childhood trauma present a viable approach

(Hardt & Rutter, 2004). In Study 1, traumatic childhood experiences were assessed with the

CTQ-SF (Bernstein et al., 2003). The psychometric properties of the CTQ and its derivatives have been examined in various clinical and community samples from different countries.

Findings were indicative of criterion-related validity in terms of high correspondence between self-reported trauma and therapist ratings as well as good internal consistency and test- retest reliability (Bernstein et al., 2003; Paivio & Cramer, 2004; Scher, Stein, Asmundson,

McCreary, & Forde, 2001; Wingenfeld et al., 2010).

Moreover, the chronicity and the respondents’ age at the time of the traumatic experiences were not assessed. There is evidence that the impact of trauma varies depending on the developmental stage of the child/adolescent. For example, traumatic experiences during childhood have been shown to have less severe consequences in terms of internalizing and externalizing behaviors compared to trauma during adolescence, and persistent maltreatment throughout childhood and youth (Thornberry, Ireland, & Smith, 2001).

In addition to the self-report measure of childhood trauma, psychopathic traits were assessed via self-report in Study 1. Such psychopathy questionnaires present with some shortcomings. For example, the prototypical psychopath tends to lie, be it in order to get a benefit from it or simply for the pleasure of it, a phenomenon called “duping delight” by Paul

Ekman (Ekman, 1985; Sellbom et al., 2018). Moreover, the aforementioned lack of insight and semantic aphasia inherent to psychopathic individuals hamper the assessment of psychopathic traits based on self-reports (Sellbom et al., 2018). Given the large community sample recruited for Study 1, however, the use of an economical, albeit valid measure such as the

SRP-III-a (Neumann et al., 2012) was indispensable. Notably, this limitation was overcome in Study 2 and Study 3, where psychopathic traits were not only assessed with a self-report measure (SRP 4), but also through observer ratings (PCL-R/PCL: SV).

Concerning the choice of genes for the present thesis, the serotonergic system has been shown to be of great relevance in the examination of aggression, impulsivity, and psy-

54 chopathy (Ficks & Waldman, 2014; Viding & McCrory, 2018; Viding & McCrory, 2012).

Nevertheless, it has to be noted that the two genes included in Study 1 and Study 2, like almost all candidate genes, only explain a small portion of phenotypic variance in psychopathy

(Viding & McCrory, 2018). There is strong evidence that a range of other genes (e.g., oxytocin or serotonin receptor genes) and hormones (e.g., cortisol or testosterone) contribute to the expression of psychopathic traits (Cummings, 2015; Glenn & Raine, 2008; Yildirim &

Derksen, 2012). In addition, psychopathic traits are not solely influenced by single genetic polymorphisms, but also by haplotypes. Accordingly, the rs25531 SNP was additionally included in Study 2. It is likely that there are numerous additional haplotypes, for example in terms of the joint effects of polymorphisms in the dopamine and serotonin transporter genes, that should be taken into account (Dadds, Moul, Cauchi, Dobson-Stone, Hawes, Brennan,

Urwin, et al., 2014; Reese et al., 2010; Yildirim & Derksen, 2015).

A final limitation concerns the sample recruited for Study 3, which exclusively consisted of male offenders. The recruitment of a male sample seemed reasonable given the comparatively low prevalence of women with pronounced psychopathic features in correctional settings (Nicholls, Ogloff, Brink, & Spidel, 2005; Verona & Vitale, 2018). This restriction, however, limits the generalizability of the obtained results. For this reason, the conclusions drawn from the various analyses in Study 3 must be confined to male offenders for the time being.

4.6 Implications for Future Studies

The results of the three studies as well as the limitations outlined in the last section provide a range of suggestions for further research objectives and the conceptualization of future studies. First, potential report bias due to retrospective and self-report measures of traumatic experiences in childhood could to some extent be countered by using additional

55 sources of information, such as reports of parents, teachers, or other caregivers, and official reports. It has to be noted, however, that the latter tend to largely underestimate the actual prevalence of childhood maltreatment (Theodore et al., 2005). Ideally, data would not be collected retrospectively, but within the framework of a longitudinal study in order to mini- mize potential bias due to blurred or repressed recollections of aversive events (Hardt &

Rutter, 2004). In this way, information on traumatic experiences could be gathered within temporal proximity to the respective incidents. The use of observer reports in addition to self- reports and/or prospective designs has been implemented in several studies on the effect of childhood maltreatment on antisocial behavior and ASPD (e.g., Johnson, Smailes, Cohen,

Brown, & Bernstein, 2000; Schilling, Aseltine, & Gore, 2007; Sousa et al., 2011), and also in a couple of studies on childhood trauma and psychopathy (e.g., Lang, Af Klinteberg, & Alm,

2002; Weiler & Widom, 1996). Notably, such longitudinal study designs are not only useful for more accurate assessment of childhood trauma and other stressors such as low socioeconomic status (Sadeh et al., 2010), but could also inform more detailed examinations of the relationship between genetic variation and psychopathic traits. For example, based on the finding that the MAOA uVNTR genotype is not related to MAOA activity in the brain in healthy men, it is conceivable that the MAOA uVNTR genotype might be more relevant during fetal and early postnatal developmental stages rather than being directly associated with serotonergic functioning in adults (Fowler et al., 2007). Given that MAOA functioning also varies depending on age (Rothmond, Weickert, & Webster, 2012), close-knit prospective and simultaneous assessment of gene activity and behavioral traits could contribute to a more detailed understanding of the short- and long-term relationships between serotonergic functioning and psychopathic traits.

Of course, such examinations are not limited to the polymorphisms included in this thesis. There are numerous other genes that are supposed to be involved in the expression of

56 psychopathic traits, such as the catechol-O-methyltransferase (COMT) or oxytocin receptor

(OXTR) genes (Dadds, Moul, Cauchi, Dobson-Stone, Hawes, Brennan, & Ebstein, 2014;

Fowler et al., 2009). With regard to the serotonergic system, a number of genes that code for serotonergic receptors and are involved in the synthesis and re-uptake of serotonin have been associated with psychopathic traits (Yildirim & Derksen, 2013). In this context, rather than directly linking psychological disorders to distal genotypes, the investigation of so-called endophenotypes has become a promising subject. Endophenotypes, or intermediate phenotypes, are heritable, quantitative traits that can be used to connect genetic variation to overt phenotypes in terms of behaviors or psychiatric disorders (Gottesman & Gould, 2003). For example, various endophenotypes that span domains such as the endocrine system, structure, reactivity, and connectivity of different brain areas such as the amygdala and the prefrontal cortex, and physiological measures such as skin conductance have been linked to variation in the serotonergic system on the one hand, and to psychopathic and antisocial traits on the other hand (Glenn, 2011; Klasen et al., 2018; Kolla, Patel, Meyer, & Chakravarty, 2017; Poeppl et al., in press; Waldman et al., 2018).

Suggestions for the improvement of future examinations are not restricted to genetic correlates of psychopathy. Rather, the findings obtained in Study 2 and Study 3 illustrate the need for advancements in the field of assessment of psychopathic features. Neither self-report measures nor observer ratings are immune to manipulations through conscious or unconscious distortion (Rogers et al., 2002; Sellbom et al., 2018). This issue has stimulated the development of methods that rely on implicit rather than explicit measures of psychopathic tendencies. A prominent example is the Implicit Association Test (IAT), which measures the associative strength between different constructs and attributes (Greenwald, McGhee, &

Schwartz, 1998). The IAT was adapted for use in correctional settings in order to assess implicit attitudes towards concepts such as guilt and dominance, and behaviors such as aggres-

57 sion, transgression, and violence, and to link them to self-report and observer ratings of psychopathy (Međedović, 2017; Nentjes, Bernstein, Cima, & Wiers, 2017; Snowden, Gray,

Smith, Morris, & MacCulloch, 2004; Suter, Pihet, de Ridder, Zimmermann, & Stephan,

2014; Suter et al., 2017; Zwets et al., 2015). The results of these studies, however, were inconsistent, with some findings indicating a positive relationship between implicit and explicit measures of psychopathy (e.g., Snowden et al., 2004), whereas other studies did not yield positive relations, or even showed negative ones (e.g., Nentjes et al., 2017; Suter et al., 2014).

Given that research on implicit measures of traits related to psychopathy is a relatively recent endeavor, further examinations seem to be worthwile nonetheless.

A final prospect for future studies targets the recruitment of larger and more diverse samples in order to provide reference and validation data not only for male, but also for female offenders from prisons and forensic-psychiatric hospitals for German-speaking countries. Since reference data for female subsamples was provided in the second edition of the PCL-R (Hare, 2003), there is accumulating evidence that the PCL-R is a valid and reliable instrument for the assessment of psychopathic traits in women as well (Neumann et al., 2012; Verona & Vitale, 2018; Vitale & Newman, 2001). Ideally, additional measures could be integrated within the scope of future data collections in order to examine external correlates of of psychopathic core personality traits vs. social deviance (as in Study 3), and of subtypes of psychopathy (as in Study 2). The studies enclosed in this thesis covered measures of self-reported psychopathic traits, intelligence, alexithymia, global personality dimensions, and impulsivity. Based on other studies on the correlates of psychopathy and psychopathic subtypes, the inclusion of instruments that assess anxiety and fearlessness, aspects of the behavioral inhibition and activation systems, and risk of reoffending would additionally contribute to a more differentiated perspective on the properties of psychopathy (Derefinko,

2015; Mokros et al., 2015; Neumann et al., 2016).

4.6 Conclusion

The present thesis aimed to shed light on the genetic correlates of psychopathy, and to provide information about the validity of the German version of the PCL-R. With regard to the former, Study 1 and Study 2 contributed to a small, but growing body of research indicating that the MAOA uVNTR genotype and 5-HTTLPR/rs25531 haplotype are associated with psychopathic traits. By examining genetic correlates based on a variable-centered approach, the two studies provided evidence that these polymorphisms are differentially associated with psychopathic core personality traits and social deviance, and that their effects vary depending on gender. Based on a person-centered approach, the frequencies of the

MAOA uVNTR and 5-HTTLPR/rs25531 were found to differ between subtypes of individuals with differential manifestations of psychopathic traits, which represents a novel finding and hopefully stimulates further research. Moreover, Study 1 and Study 2 illustrated that psychopathy is a complex construct not only linked to genetic correlates, but also to environmental influences such as traumatic childhood experiences.

In light of this complexity and the far-reaching risks and consequences that psychopathic individuals pose, thorough assessment of psychopathic features is indispensible.

This issue was tackled by evaluating the validity of the German version of the PCL-R.

Implementing different data-analytic approaches based on various measures of personality and behavior, Study 3 provided evidence that the PCL-R is a valid instrument for use in

German-speaking male correctional samples.

In summary, the present thesis not only shed light on the genetic correlates and the assessment of psychopathic traits, but also outlined practical implications with respect to clinical and therapeutic interventions and conceptualizations for future research objectives and study designs.

5. Publications

5.1 Study 1

Main and interaction effects of childhood trauma and the MAOA uVNTR polymor-

phism on psychopathy

Hollerbach, P., Johansson, A., Ventus, D., Jern, P., Neumann, C. S., Westberg, L., ... & Mokros, A. (2018). Main and interaction effects of childhood trauma and the MAOA uVNTR polymorphism on psychopathy. Psychoneuroendocrinology 95, 106-112.

5.2 Study 2

Associations of the MAOA uVNTR genotype and 5-HTTLPR/rs25531 haplotype with psychopathic traits

Pia Hollerbach a

Sally Olderbak b

Oliver Wilhelm b

Christian Montag b, c

Sonja Jung b

Craig S. Neumann d

Elmar Habermeyer a

Andreas Mokros e a Department of Forensic Psychiatry, University Hospital of Psychiatry Zurich, Zurich, Switzerland b Ulm University, Institute of Psychology and Education, Ulm, Germany c The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Laboratory for Neu- roinformation, University of Electronic Science and Technology of China, School of Life Science and Technology, Chengdu, China d Department of Psychology, University of North Texas, Denton, USA e Department of Psychology, FernUniversität in Hagen (University of Hagen), Hagen, Germany

This manuscript has been submitted to Psychological Medicine.

Abstract

Background: Polymorphisms of the monoamine oxidase A gene (MAOA uVNTR) and the serotonin transporter gene (5-HTTLPR) have been associated with psychopathic traits, but study outcomes are heterogeneous. We sought to examine these genetic correlates with regard to psychopathic traits across individuals, and to compare the frequencies of the respective polymorphisms between psychopathic subtypes. We also extend previous research by additionally accounting for the rs25531 polymorphism.

Methods: Data was collected in four prisons, four forensic-psychiatric hospitals, and among community volunteers in Germany (N = 347). Structural equation modeling (SEM) and latent profile analysis (LPA) were used to examine relations between observer ratings of psychopathic traits with MAOA uVNTR and 5-HTTLPR/rs25531. SEM examined relations for the whole sample while genotype/haplotype frequencies were compared across the LPA clusters.

Validity of the resulting LPA clusters was additionally corroborated with data on psychopathic traits and antisocial personality disorder, and cognitive performance data.

Results: Through SEM, we found that the 5-HTTLPR/rs25531 low-activity variant was specifically associated with interpersonal deficits beyond the overarching psychopathy construct

(β = .19), whereas the MAOA uVNTR did not yield a significant effect. Through LPA, which yielded four clusters labeled non-psychopaths, sociopaths, callous-conning, and psychopaths, we found that the HTTLPR/rs25531 low-activity haplotype was significantly more frequent in the callous-conning compared to the non-psychopathic cluster (h = .64)

Conclusion: The results expand the finding that the low-activity variant of the 5-

HTTLPR/rs25531 haplotype is associated with interpersonal deficits and suggest that this haplotype is particularly frequent in a subtype characterized by pronounced callous-conning features.

Keywords: Psychopathy; Serotonin; 5-HTTLPR; rs25531; Subtypes; Latent profile analysis;

Structural equation modeling; Psychopathy Checklist: Screening Version

1. Introduction

Psychopathy is characterized by interpersonal and emotional deficits (i.e., psychopathic core personality traits) and impulsivity, irresponsibility, and disregard for social and legal norms (i.e., social deviance; Hare, 2003). Previous research has linked several genes to the manifestation of antisocial behavior and psychopathy (Ficks & Waldman, 2014). Among them, two polymorphic gene loci have gained particular attention. One is the monoamine oxidase A (MAOA), an X-linked gene with a 30-base pair (bp) variable number tandem repeat in the upstream regulatory region (uVNTR). The MAOA gene codes for the MAOA enzyme, which is involved in the depletion of neurotransmitters like serotonin (Sabol et al., 1998). The transcription efficiency of the MAOA gene varies depending on the number of repeats (2, 3,

3.5/3a, 4, 5, or 6), with the 2- and 3-repeat alleles resulting in lower transcription efficiency

(so-called MAOA-L) than the 3.5/3a- and 4-repeat alleles (MAOA-H; Deckert et al., 1999;

Sabol et al., 1998). The second gene of interest is the SLC6A4 gene, which has a 44-bp insertion/deletion polymorphism in the promoter region (5-HTTLPR). The SLC6A4 gene codes for the serotonin transporter protein, which is responsible for the presynaptic reuptake of serotonin. Insertion or depletion in this gene results in two primary alleles, a 14-repeat short allele

(5-HTTLPR-S) with lower transcriptional activity, and a 16-repeat long allele (5-HTTLPR-L) with higher transcriptional activity (Heils et al., 1996). Notably, the transcriptional efficacy of the 5-HTTLPR is influenced by the single nucleotide polymorphism (SNP) rs25531 which has an A/G substitution, with a combination of the 5-HTTLPR long allele and a rs25531 A substitution resulting in higher gene expression (Hu et al., 2006). Despite the close link between these two polymorphisms, the rs25531 has been neglected in the majority of previous publications on antisocial behavior and psychopathy (Ficks & Waldman, 2014).

A range of studies have dealt with the effects of the MAOA uVNTR and 5-HTTLPR on antisocial behavior (see meta-analysis by Ficks & Waldman, 2014), whereas less research

64 has been conducted on the association of these polymorphisms with psychopathic traits, and findings have been inconsistent. Fowler et al. (2009) reported that MAOA-L and 5-HTTLPR-S were linked to higher emotional dysfunction in a sample of adolescents with attention deficit hyperactivity disorder (ADHD). In contrast, Sadeh et al. (2010) found an association between the 5-HTTLPR and psychopathy, in that carriers of the low-activity variant showed more impulsive behavior in a mixed adolescent forensic/community sample. In a study with adult offenders, carriers of the homozygous 5-HTTLPR-L genotype showed stronger affective impairments, whereas carriers of the MAOA-L genotype were more impulsive. The 5-HTTLPR association, however, became insignificant when taking into account the shared variance between Factor 1 and Factor 2 of the PCL: SV (Sadeh et al., 2013). In addition, the high- activity 4-repeat genotype of the MAOA uVNTR has been linked to violent recidivism in psychopathic offenders (Tikkanen et al., 2011). Two other studies did not replicate significant associations between low-activity variants of the MAOA uVNTR and psychopathy (Beaver et al., 2013; Hollerbach et al., 2018).

Importantly, these results were obtained by modeling the relationship between measures of psychopathy and variation in the MAOA uVNTR and 5-HTTLPR without taking into consideration that individuals with psychopathic features constitute a heterogeneous group. There is, however, theoretical and empirical support for the notion of subtypes of psychopathy. As early as in 1941, Benjamin Karpman differentiated between primary (or true) psychopathy and secondary (or symptomatic) psychopathy. While Karpman considered primary psychopaths to be cold and emotionally detached, he regarded secondary psychopathy as a manifestation of neuroticism. More specifically, Karpman postulated two variants of primary psychopathy, namely aggressive/predatory and passive/parasitic psychopaths.

Empirical evaluation corroborated the notion of psychopathic variants. Latent profile analysis (LPA) allowed for identifying subtypes within offender samples based on clinician

65 ratings of psychopathic traits (Hare, 2003; Hare et al., 2018; Mokros et al., 2015; Neumann et al., 2016; Olver et al., 2015). For example, Neumann et al. (2016) analyzed PCL-R facet scores of several offender samples using LPA and identified four distinct clusters. These subgroups were labeled as non-psychopathic general offenders (relatively low scores on all PCL-

R facets), sociopathic, or dissocial, offenders (higher scores on Lifestyle and Antisocial compared to Interpersonal and Affective), callous-conning offenders (elevated scores on Interper- sonal and Affective relative to Lifestyle and Antisocial facets), and prototypic psychopaths

(high scores on all four facets). Consequently, an unstable lifestyle is characteristic of both psychopathic and sociopathic (or dissocial) individuals, whereas callous-unemotional traits

(as evidenced by a high score on the Affective facet) is decisive for psychopaths, but not for sociopathic individuals (Neumann et al., 2016). This finding is commensurate with etiological considerations for psychopathy versus sociopathy, or antisocial personality disorder

(Mealey, 1995b). Notably, Mealey supposed that psychopathy is substantially due to genetic factors, stable throughout the life span, and occurs rarely and independently from socioeconomic status. In contrast, sociopathy likely develops in response to aversive socialization conditions, depends on situational aspects, and thus occurs more frequently, especially under disadvantageous environmental conditions (Mealey, 1995b).

Thus, the aim of the study was to collate knowledge about the relation between serotonergic genes and psychopathy, and about subtypes and variants among individuals with elevations on psychopathic traits. In the first step, a latent variable-centered approach was implemented by testing the associations between the MAOA uVNTR genotype and 5-

HTTLPR/rs25531 haplotype with the overarching psychopathy construct across the whole sample. In the second step, a person-centered approach was used by empirically deriving subtypes of psychopathy, and comparing them with regard to the distributions of the MAOA uVNTR genotype and 5-HTTLPR/rs25531 haplotype.

2. Methods and Materials

2.1 Sample

The initial sample consisted of 347 adult men recruited from four prisons, four forensic-psychiatric hospitals, and among community volunteers in Germany. After excluding four participants who had not properly completed the consent form or were diagnosed with a psy- chotic disorder, the final sample consisted of 343 participants, among them 75 prison inmates

(21.87%), 154 forensic-psychiatric inpatients (42.27%), and 123 men from the general population (35.86%). The average age was 35.69 years (SD = 11.23, ranging from 19 to 80 years).

All participants were briefed about the experiment and gave their informed written consent.

The study protocol was approved by the ethics committee at the Humboldt University of Ber- lin. Ethnicity was reported for 335 participants, among them 89.25% were German.

2.2 Measures

Several measures were administered across two testing sessions. For the purposes of the present paper, we will discuss only those relevant to our research questions. Other results based on this sample can be found at Olderbak, Mokros, Nitschke, Habermeyer, and Wilhelm

(2018) and Künecke, Mokros, Olderbak, and Wilhelm (2018). Observer ratings of psychopathic traits were obtained with the Psychopathy Checklist: Screening Version (PCL: SV;

Hart et al., 1995). The PCL: SV consists of 12 items that are assigned to four facets (Interper- sonal, Affective, Lifestyle, Antisocial), two factors (Interpersonal/Affective and Life- style/Antisocial), and a total sum score. Information is drawn from an interview and file information such as patient/inmate records and judicial verdicts, if available. Interrater agreement was assessed based on 13 double interviews. The one-way random, single measure intraclass correlation coefficient (ICC(1,1); Shrout & Fleiss, 1979) was .80 (95% CI = [.48, .93];

Olderbak et al., 2018), which is indicative of substantial interrater agreement according to

Landis and Koch (1977a). Internal consistency was excellent for the sum score (α = .90), good for the Interpersonal/Affective (α = .85) and Lifestyle/Antisocial (α = .87) scales, and acceptable to good for the Interpersonal (α = .77), Affective (α = .83), Lifestyle (α = .73), and

Antisocial (α = .80) scales in the present sample.

In addition, psychopathic traits were assessed with the Self-Report Psychopathy Scale

(SRP 4; Paulhus et al., 2016; German translation by Mokros et al., 2016). The SRP comprises

64 items that are assigned to four scales (Interpersonal, Affective, Lifestyle, and Antisocial) that correspond to the facets of the PCL-R. Internal consistency was excellent for the total score (α = .92), good for the Interpersonal (α = .82), Lifestyle (α = .80), and Antisocial (α =

.89) facets, and acceptable for the Affective (α = .72) facet.

Symptoms of antisocial personality disorder (ASPD) were assessed using the Struc- tured Clinical Interview for DSM-IV, Part II (SCID-II; First et al., 1997; German translation by Fydrich et al., 1997). The SCID-II comprises 29 items capturing antisocial behavior in childhood, adolescence, and adulthood. The criteria that cover adult antisocial behavior showed good internal consistency (α = .84) for the present sample.

Fluid intelligence in terms of inductive reasoning was measured with the Figural scale of the Berlin Test for the Assessment of Fluid and Crystalized Intelligence (BEFKI; Wilhelm et al., 2014). The Figural scale consists of 16 items with matrix patterns that have to be completed. Internal consistency for the present sample was good (α = .81).

2.3 Genotyping

DNA for genotyping was automatically extracted from buccal mucosa cell samples using a MagNA Pure 96 system and commercial extraction kits (Roche Diagnostics Mann- heim, Germany). Amplification of the MAOA uVNTR sequence was performed via polymer- ase chain reaction (PCR) PCR products were separated by gel-electrophoresis and visualized

68 by ethidium bromide staining and UV light. Gel electrophoresis runs were performed with controls of different repeat variants. Primer sequences (TIB MOLBIOL, Berlin, Germany) were: forward: 5′ACAGCCTGACCGTGGAGAAG-3′; and reverse: 5′-

GAACGGACGCTCCATTCGGA-3′ (Sabol et al., 1998). In contrast to the findings of Sabol et al. (1998)we did not find a 3.5 (3 repeats + 15bp) repeat variant, but the 3a variant (3 repeats + 18 bp) described by Deckert et al. (1999).

Genotyping of the 5-HTTLPR polymorphism was performed by means of PCR, gel- electrophoresis and visualizing by ethidium bromide staining. To detect the SNP rs25531

(A/G), we performed an enzymatic digestion at 37°C for 1.5 hours with MSP1 (New Eng- land Biolabs) after the PCR run. We used the following primer sequences (TIB MOLBI-

OL, Berlin, Germany): forward: 5`-TCCTCCGCTTTGGCGCCTCTTCC-3`; reverse: 5`-

TGGGGGTTGCAGGGGAGATCCTG-3` (Wendland, Martin, Kruse, Lesch, & Murphy,

2006). All samples were evaluated by two independent raters.

The sample was in Hardy-Weinberg equilibrium for the 5-HTTLPR (n = 305, p = .56) and the rs25531 polymorphism (n = 302, p = .96). Carriers of the 5-repeat allele (n = 6) of the

MAOA uVNTR and the 15- and 18-repeat alleles of the 5-HTTLPR (n = 3) were not included in the subsequent analyses. As the 5-HTTLPR long allele with an A substitution on the rs25531 allele (LA) results in higher gene expression compared to LG alleles , haplotypes were classified as follows: long: LA/ LA, intermediate: S/LA, S/LG, LG/LG, LA/LG, short: S/S

(Kruschwitz et al., 2015; Wendland et al., 2006). Allele and genotype/haplotype frequencies can be found in the Supplementary Material.

2.4 Procedure and Analytic Data Strategy

First, the associations between the MAOA uVNTR genotype and 5-HTTLPR/rs25531 haplotype with psychopathy were examined by estimating a bifactor structural equation mod-

69 el (SEM) previously identified as the best-fitting measurement model of psychopathy for this sample (Mokros et al., 2018). Specifically, fit was determined based on the Chi squared test, the Root Mean Square Error of Approximation (RMSEA; Steiger, 1990) and the Comparative

Fit Index (CFI; Bentler, 1990) with values ≤.08 and ≥.90 indicating acceptable model fit for the RMSEA and the CFI, respectively (Kline, 2015). All SEMs were estimated using the weighted least squares, mean- and variance-adjusted (WLSMV) estimator in Mplus, because items which served as indicators of the psychopathy latent variables were categorical. Subse- quently, structural equation models (SEM) including regressions from the psychopathy factors on the dummy-coded genotype/haplotype variables (with the respective low-activity variants serving as the reference category in both instances) were estimated separately for the

MAOA uVNTR genotype and the 5-HTTLPR/rs25531 haplotype. Significance of the regressions was subsequently tested by comparing nested models with and without regression paths constrained to 0 based on Chi squared tests of difference using the DIFFTEST option in

Mplus (Version 7.4, Muthén & Muthén, 2015). Power was estimated for the two models based on the RMSEA (MacCallum, Browne, & Sugawara, 1996).

In addition, we ran an LPA in order to identify homogenous subgroups within the sample using maximum likelihood estimation in Mplus. In line with recommendations for a systematic examination of psychopathic subtypes, the LPA was run based on the four

PCL:SV facets (Neumann et al., 2016). The models were compared based on the Lo-

Mendell-Rubin Adjusted Likelihood Ratio Test (LRT; Lo et al., 2001), and the Bayesian In- formation Criteria (BIC; Schwarz, 1978). For the LRT, a p value < .05 indicates no substantial improvement in model fit (Lo et al., 2001; Merz & Roesch, 2011), whereas for the BIC, smaller coefficients are indicative of better model fit (Merz & Roesch, 2011; Schwarz, 1978).

Based on previous findings in samples covering a broad range of severity with respect to psychopathic traits (Krstic et al., 2017; Neumann et al., 2016), we expected the following

70 classes to emerge: A cluster with low scores on all facets (non-psychopaths), a cluster with higher scores on the Lifestyle and Antisocial facets compared to the Interpersonal and Affec- tive facets (sociopaths, or dissocial individuals), a third cluster showing a reversed pattern with higher scores on the Interpersonal and Affective facets, but lower scores on the Lifestyle and Antisocial facets (callous-conning), and a cluster with high scores on all four facets (prototypic psychopaths).

Upon identifying the model that best represented the empirical data, the emerging clusters were evaluated based on external measures. To this end, the cluster means were compared with respect to self-reported psychopathic traits, ASPD symptom count, and intelligence using SPSS (Version 23.0, IBM Corp., Somers, NY). We expected that 1) prototypic psychopaths would have the highest SRP 4 total scores compared to all other classes

(pooled), 2) callous-conning offenders would have higher SRP Affective scores than sociopaths, 3) sociopaths would have higher SRP Antisocial scores than callous-conning offenders, 4) sociopaths would have higher ASPD symptom counts than callous-conning offenders,

5) callous-conning individuals would perform better in the assessment of intelligence compared to sociopaths, 6) callous-conning individuals would perform better in the assessment of intelligence compared to prototypic psychopaths. These six hypotheses were tested using planned comparisons. The type I error rate was adjusted using the Sidàk-Dunn correction in order to ensure a familywise error rate (FWE) of .05 for all comparisons between LPA clusters. Accordingly, effects were regarded as significant when their p value was lower or equal to .008 (this is equal to a t value of 2.42 or d= .25 for hypotheses 1 to 3, t = 2.48 or d = .39 for hypothesis 4, t = 2.47 or d = .58 for hypothesis 5, and t = 2.47 or d = .59 for hypothesis 6). In the final step, frequencies of the MAOA uVNTR genotypes and 5-HTTLPR/rs25531 haplotypes were compared between the clusters using Chi squared tests in SPSS.

3. Results

3.1 SEM

In accordance with previous research (Dotterer et al., 2016; Patrick et al., 2007), and also in line with recent examinations based on our sample [references removed for anonymity during the peer-review process], a bifactor model was found to best represent the empirical

2 data, showing superior model fit (χ (45) = 61.52, p = .05; RMSEA: .03; CFI: .99) compared to the traditional four-facet and higher-order conceptualizations (Hare & Neumann, 2008; Fit indices of these models can be found in the Supplementary Material). In the measurement model (see Fig. 4), all items loaded on a general psychopathy factor, and on two group factors that were composed of the items constituting the Interpersonal and the Life- style/Antisocial facets, respectively. Notably, the group factors explain variance that is not covered by the general psychopathy factor and all factors are mutually uncorrelated. Internal consistency for the general and group factors was good (General: ωTotal = .96, Interpersonal

ωTotal = .87, Lifestyle/Antisocial ωTotal = .93).

Figure 4. Measurement model of psychopathy (PC: SV). All loadings p < .01.

Model fit was good for the structural models including the MAOA uVNTR (Model 1:

2 2 χ (54) = 80.73, p = .01; RMSEA = .04; CFI = .99) and the 5-HTTLPR/rs25531 (Model 2: χ

(63) = 89.09, p = .02; RMSEA = .04; CFI = .99), respectively. Power was estimated at .66 for

Model 1, and at .65 for Model 2. MAOA uVNTR genotype did not significantly predict any of the psychopathy factors, whereas the low-activity variant of the 5-HTTLPR/rs25531 was associated with the Interpersonal group factor. This means that individuals with the low-activity of the 5-HTTLPR/rs25531 had significantly higher Interpersonal scores (i.e., were rated as more superficial, grandiose, and deceitful), relative to individuals with an intermediate or high-activity haplotype. Regression weights and results of the Chi squared tests for difference testing for each of the tested regressions are listed in Table 12.

Table 12

Psychopathy Factors regressed on MAOA uVNTR Genotype and 5-HTTLPR/rs25531 Haplo- type

Psychopathy Factor β p Χ2 df p General MAOA uVNTR low .04 .51 .43 1 .51 5-HTTLPR/rs25531 intermediate .02 .76 .09 1 .76 5-HTTLPR/rs25531 low .06 .39 .72 1 .39 Interpersonal MAOA uVNTR low .08 .36 .78 1 .36 5-HTTLPR/rs25531 intermediate .11 .28 1.08 1 .28 5-HTTLPR/rs25531 low .19 .04 3.98 1 .04 Lifestyle/Antisocial MAOA uVNTR low -.03 .66 .19 1 .66 5-HTTLPR/rs25531 intermediate .03 .74 .11 1 .74 5-HTTLPR/rs25531 low .11 .21 1.48 1 .21 Note. β = standardized regression weight. χ2 = Chi squared test for difference testing between models with and without regression path fixed to . df = degrees of freedom. MAOA uVNTR low-activity: 2-repeat alleles, high- activity: 3-repeat and 3a-repeat alleles. 5-HTTLPR/rs25531 low activity: S/S, intermediate activity: S/LA, S/LG, LG/LG, LA/LG, high activity: LA/ LA. The low-activity variant of the MAOA uVNTR and 5-HTTLPR/rs25531, respectively, served as reference categories.

3.2 LPA

Models with 1 to 9 classes were fit to the data. According to the LRT, a solution with four latent classes showed a sufficient model fit indicated by no significant improvement in model fit for a model with five in comparison to four classes (p = .07). The BIC, in contrast, did not drop substantially at the transition from 7 (BIC = 5031.74) to 8 (BIC = 5030.91) latent classes anymore. Notably, the solution with 7 classes merely presented a further division of one of the classes of the 4-classes solution, which is why the more parsimonious result was chosen for the subsequent analyses (for details see Supplementary Material). Upon assigning individuals to the cluster for which they had the highest allocation probability, the resulting

74 groups were initially labeled Cluster 1 (C1, n = 143, 41.69%), Cluster 2 (C2, n = 107,

31.20%), Cluster 3 (C3, n = 40, 11.66%), and Cluster 4 (C4, n = 53, 15.45%). C1 had the lowest total score on the PCL: SV, whereas C2 and C3 did not differ with regard to their total scores. The average total score of C4 was indicative of a highly psychopathic subsample (see

Table 13). C1 comprised the most of the non-criminal community volunteers (77.62%), whereas C2, C3, and C4 were largely composed of prison inmates and forensic-psychiatric patients (93.46%, 90.0%, and 98.11%, respectively).

Table 13

Means, Standard Deviations, Minimum and Maximum Scores of the PCL: SV Facets for the

Clusters Derived from a Four-Class Solution

C1 (n = 143) C2 (n = 107) C3 (n = 40) C4 (n = 53) Mean Min/ Mean Min/ Mean Min/ Mean Min/ PCL: SV (SD) Max (SD) Max (SD) Max (SD) Max 0.55 1.43 4.03 4.83 INT 0/3 0/3 2/6 3/6 (0.78) (1.00) (1.03) (1.05) 0.65 2.79 3.73 4.70 AFF 0/4 0/6 0/6 2/6 (0.99) (1.72) (1.75) (1.12) 0.79 3.79 2.53 4.51 LIF 0/4 1/6 0/6 1/6 (0.96) (1.27) (1.58) (1.09) 0.54 4.59 2.18 5.36 ANT 0/4 2/6 0/4 4/6 (0.85) (1.11) (1.15) (.76) Sum 2.54 12.68 12.53 19.51 0/9 6/18 7/18 14/24 Score (2.30) (2.98) (2.78) (2.06) Note. PCL: SV = Psychopathy Checklist Screening Version (Hart et al., 1995); INT = Interpersonal, AFF = Affective, LIF = Lifestyle, ANT = Antisocial; C1 = Cluster 1, C2 = Cluster 2, C3 = Cluster 3, C4 = Cluster 4. SD = Standard deviation; Min = Minimum Score; Max = Maximum Score.

As can be seen in Figure 5, the four clusters showed distinct profiles of psychopathic traits. Members of C1 had equally low scores on all four facets. Individuals in C2 had lower scores on the Interpersonal facet, somewhat higher scores on the Affective facet, and high scores on the Lifestyle and Antisocial facets. In comparison, C3 showed an inverse trend with

75 higher scores on the Interpersonal and Affective facets, and lower scores on the Lifestyle and

Antisocial facets. Participants that were assigned to C4 had very high scores on all facets, especially with regard to antisocial behavior. Based on the nomenclature suggested by

Neumann et al. (2016), we labeled the four classes non-psychopaths (C1), sociopaths (C2), callous-conning (C3), and psychopaths (C4).

C1 C2 C3 C4

2 PCL: FactorSV Means 1

0 Interpersonal Affective Lifestyle Antisocial PCL: SV Factors

Figure 5. Profiles of the four latent classes (C1, C2, C3, C4) on the four PCL: SV facets. Vertical bars indicate standard deviations.

The total scores of the PCL: SV and the SRP 4 were strongly correlated (r = .54, p <

.001). With respect to the expected differences between the clusters, 1) as expected, psychopaths had the highest SRP 4 total scores compared to all other classes (t(334) = 6.08, p < .001 <

FWE, d = .91), 2) against expectation, callous-conning individuals reported slightly lower levels of affective deficits compared to sociopaths (t(334) = -3.29, p < .001 < FWE, d = .58), 3) as expected, sociopaths reported more antisocial behavior than callous-conning offenders

(t(334) = 4.28, p < .001 < FWE, d = .81), 4) as expected, sociopaths showed more ASPD symptoms than callous-conning individuals, although this effect was not significant (t(62.06) =

1.54, p = .13 > FWE, d = .29), 5) as expected, callous-conning individuals perform better than psychopaths (t(73.54) = 1.94, p = .56 > FWE, d = .42) and 6) sociopaths in the assessment of fluid intelligence, but these effects did not reach significance (t(69.42) = .83, p = .41 > FWE, d = .15; see Table 14).

Table 14

Means and Standard Deviations of the BEFKI, ASPD, and SRP 4 by Clusters

C1 C2 C3 C4 Mean (SD) Mean (SD) Mean (SD) Mean (SD) Intelligence (BEFKI) 8.82 (3.88) 6.35 (3.40) 6.88 (3.44) 5.58 (2.78) ASPD symptom count 0.73 (1.37) 3.28 (1.67) 2.75 (1.93) 4.62 (1.44) SRP 4 Total 2.35 (.44) 2.85 (.42) 2.51 (.47) 2.97 (.41) Interpersonal 2.53 (.55) 2.66 (.58) 2.57 (.58) 2.69 (.59) Affective 2.41 (.46) 2.57 (.48) 2.28 (.52) 2.63 (.44) Lifestyle 2.76 (.60) 3.24 (.51) 2.80 (.58) 3.30 (.53) Antisocial 1.70 (.70) 2.91 (.62) 2.39 (.66) 3.26 (.54) Note. BEFKI = Berlin Test for the Assessment of Fluid and Crystalized Intelligence (Wilhelm et al., 2014); ASPD = Antisocial Personality Disorder (First et al., 1997); SRP 4 = Self-Report Psychopathy Scale 4 (Paulhus et al., 2016); C1 = Cluster 1, non-psychopaths; C2 = Cluster 2, sociopaths; C3 = Cluster 3, callous-conning; C4 = Cluster 4, psychopaths.

Information on genotype/haplotype frequencies of the MAOA uVNTR and

5HTTLPR/rs25531 was available for 301 and 302 participants, respectively. The Chi squared tests comparing the genotype distributions across the four clusters were significant for the 5-

HTTLPR/rs25531 haplotype (2 (6) = 16.81, p = .01), but not for the MAOA uVNTR genotype (2 (3) = 2.27, p = .52). Comparisons of the distribution of 5-HTTLPR/rs25531 haplotypes between the clusters revealed a significant difference between non-psychopaths and callous-conning individuals (2 (2) = 16.24, p < .001) which remained significant after the

Bonferroni correction for six pairwise comparisons with a corrected alpha level of .01

(Cohen, 1988). To find out whether these differences occurred between low/high-activity or

77 intermediate haplotypes, we ran two pairwise comparisons and corrected the alpha level accordingly (p = .03). More than a third of the callous-conning individuals (36.10%) carried the

5-HTTLPR/rs25531 low-activity haplotype (2 (1) = 14.03, p < .001 < FWE), whereas only

10.0% of the non-psychopathic participants had this haplotype, which corresponds to a medi- um-sized effect (Cohen’s h = .64; Cohen, 1988). The two clusters did not differ with respect to the frequency of intermediate haplotypes (for details see Supplementary Material).

4. Discussion

The aim of this study was to investigate the associations between the serotonergic

MAOA uVNTR and 5-HTTLPR/rs25531 and psychopathic traits from a variable-centered and person-centered perspective. Estimation of bifactor models indicated that variation in the

MAOA uVNTR was not linked to psychopathic traits. The 5-HTTLPR/rs25531, in contrast, was specifically linked to the interpersonal group factor, indicating that individuals with the low-activity haplotype showed more interpersonal deficits like deceitfulness and manipulation. On a related note, Fowler et al. (2009) found that carriers of the homozygous 5-HTTLPR short genotype had higher emotional dysfunction scores compared to carriers of homozygous long or heterozygous genotypes. Emotional dysfunction and interpersonal deficits both tap into psychopathic core personality traits. Notably, Fowler et al. (2009), did not additionally test for associations between 5-HTTLPR genotype and interpersonal deficits; nevertheless, the findings point into a similar direction.

The failure to replicate effects of the MAOA uVNTR was somewhat unexpected given that MAOA-L has been associated to impulsiveness and irresponsibility in male adult offenders (Sadeh et al., 2013). Notably, our sample was not exclusively composed of offenders, but also included forensic-psychiatric inpatients and community volunteers, suggesting that this null effect might partly be explained by sample characteristics. So far, there are two studies

78 which indicated that the MAOA uVNTR does not affect the expression of psychopathic traits in men from the general population (Beaver et al., 2013; Hollerbach et al., 2018).

In addition to examination of psychopathic traits and their genetic correlates across individuals, subtypes were empirically derived and validated. We identified four classes with distinct profiles of psychopathic traits, which were labeled non-psychopaths (low scores on all PCL: SV facets), sociopaths (high levels of social deviance), callous-conning individuals

(high scores on psychopathic core personality traits), and psychopaths (high scores on all facets). This pattern of findings has recently been reported for a large sample of sex offenders who were assessed with the PCL-R (Krstic et al., 2017). In the current study and the study by

Krstic et al. (2017), sociopaths and callous-conning individuals had very similar PCL: SV

(PCL-R) total scores, but inverse profiles, which illustrates the relevance of considering factor and facet scores in the assessment of psychopathy. Despite their overlap in terms of Inter- personal and Affective features, the class composed of callous-conning individuals had a mean PCL: SV total score below the cutoff for psychopathy (i.e., 18) and thus should not be confused with primary psychopaths (Neumann et al., 2016).

The results of the external validation of the four clusters were largely in line with the a-priori assumptions about group differences with respect to self-reported psychopathic traits and ASPD. As expected, prototypic psychopaths reported the highest levels of psychopathic traits compared to all other subtypes, and sociopaths reported more antisocial behavior than callous-conning offenders. Surprisingly, callous-conning offenders had lower self-reported levels of affective deficits compared to sociopaths. It is conceivable that callous-conning individuals in particular are more prone to socially desirable responding in self-report measures like the SRP 4. This could explain why callous-conning individuals described themselves as less emotionally shallow compared to sociopathic individuals, even though expert assessment with the PCL: SV suggested that their affective deficits were more pro-

79 nounced. Alternatively, the callous-conning individuals may not be aware of the extent of their emotional deficiency (Sellbom, Lilienfeld, Fowler, & McCrary, 2018).

Comparisons between the clusters revealed that the low-activity variant of the 5-

HTTLPR/rs25531 haplotype was more frequent in callous-conning compared to non- psychopathic individuals, whereas the distribution of the MAOA uVNTR did not differ between clusters. Again, these findings are in line with previous research suggesting that the 5-

HTTLPR genotype is associated with emotional deficits, in that carriers of the homozygous 5-

HTTLPR low-activity genotype show stronger emotional deficits than their high-activity genotype counterparts (Fowler et al., 2009). Notably, these differences were not observed between the non-psychopathic and the psychopathic clusters, but between the non-psychopathic and the callous-conning cluster. This observation blends in with the results of the SEMs which linked the low-activity variant of the 5-HTTLPR/rs25531 to higher levels of interpersonal deficits compared to carriers of the high-activity genotype, but not to elevations on the overarching psychopathy construct as modeled by the general factor. Thus, it seems that the

5-HTTLPR/rs25531 haplotype is specifically associated with psychopathic core personality traits rather than the overarching psychopathy construct.

When interpreting these results it has to be noted that the association between serotonergic genes and psychopathy is putatively moderated by environmental factors like traumatic childhood experiences or socio-economic status (Buckholtz & Meyer-Lindenberg,

2008; Montag & Reuter, 2014; Sadeh et al., 2010; Sadeh et al., 2013). Given the small number of studies and the heterogeneity with respect to sampling strategies and conceptualization of psychopathy, more replication studies are needed and results should be interpreted cautiously.

The present study has some limitations. First, the available data for the external validation of the latent classes was limited. Hence, further conclusive differentiation between the

80 clusters based on relevant aspects such as behavioral inhibition, anxiety, or fearlessness was not feasible (for a link between anxiety and 5-HTTLPR see Plieger et al., 2014 and Lesch et al., 1996). Furthermore, single candidate genes or haplotypes only account for a small portion of variance in the phenotypic manifestation of disorders such as psychopathy (Gunter et al.,

2010). Overall, gene studies require large samples and outcomes should be interpreted cautiously (Geller, Wilhelm, Wacker, Hamm, & Hildebrandt, 2017). In addition, although we included gene loci that have previously been associated with antisocial and psychopathic behavior, it is very likely that other genotypes or haplotypes influence such traits. This is not limited to the serotonin system, but may also include other neurotransmitters like dopamine as well as hormones like oxytocin, cortisol, and testosterone (Dadds, Moul, Cauchi, Dobson-

Stone, Hawes, Brennan, & Ebstein, 2014; Glenn, 2009; Yildirim & Derksen, 2012; Yildirim

& Derksen, 2015).

In conclusion, the present study sought to corroborate the notion that psychopathy is associated with variation in the MAOA and SLC6A4 genes. Based on person- and variable- centered approaches we could not only show that the manifestation of interpersonal deficits is linked to the 5-HTTLPR/rs25531 haplotype across the sample, but also that individuals characterized by strong psychopathic core personality traits are disproportionally frequently carriers of the low-activity haplotype. To our knowledge, genetic correlates of psychopathic traits have not been examined in relation to subtypes yet, which is why our results should be regarded as preliminary and need to be evaluated in different samples (e.g., in female samples) and with additional gene loci.

Study 2: Supplementary Material

Table 15

Allele, Genotype, and Haplotype Frequencies for the MAOA uVNTR, 5HTTLPR, and rs25531

Allele frequencies Relative frequency (total count) 5HTTLPR (n = 305) 14 repeat (S) .42 (258) 16 repeats (L) .57 (349) 15 repeats .00 (1) 18 repeats .00 (2) rs25531 (n = 302) G .08 (50) A .92 (554) MAOA (n = 307) 3 repeats .33 (100) 3 repeats +18bp (3a) .00 (1) 4 repeats .65 (200) 5 repeats .02 (6) Haplotype frequencies 5-HTTLPR/rs25531

High (LA/LA) .24 (73) Intermediate

SA/LA .42 (128) SA/LG .08 (24) LG/LG .01 (2) LA/LG .07 (22) Low (SA /SA) .18 (53)

Table 16

Model Fit for the LPA (N = 343)

No. of Latent No. of Free Log- Adjusted BIC LRT p 1 - Entropy Classes Parameters Likelihood BIC 1 8 -2913.02 5872.74 5847.36 - - 2 13 -2581.09 5238.08 5196.84 .00 .92 3 18 -2527.05 5159.19 5102.09 .01 .86 4 23 -2475.43 5085.14 5012.17 .00 .90 5 28 -2445.72 5054.89 4966.07 .07 .89 6 33 -2422.47 5037.59 4932.91 .37 .89 7 38 -2404.95 5031.74 4911.20 .42 .90 8 43 -2389.95 503.91 4894.51 .25 .90 9 48 -2376.11 5032.43 488.16 .40 .90 Note. BIC = Bayesian Information Criterion; LRT = Lo-Mendell-Rubin Adjusted Likelihood Ratio Test.

Table 17

Frequencies of the MAOA uVNTR Genotype and 5-HTTLPR Haplotype by Cluster

C1 C2 C3 C4 Total (n = 130) (n = 94) (n = 35) (n = 42) MAOA uVNTR

(n = 301) 45 26 14 15 100 Low (n = 100) (34.62%) (27.66%) (4.00%) (35.71%) (33.22%) 85 68 21 27 201 High (n = 201) (65.38%) (72.34%) (6.00%) (64.29%) (66.78%) C1 C2 C3 C4 Total (n = 130) (n = 92) (n = 36) (n = 44) 5-HTTLPR/rs25531

(n = 302) 13 20 13 7 53 Low (1.00%) (21.74%) (36.11%) (15.91%) (17.55%) 79 52 19 26 176 Intermediate (6.77%) (56.52%) (52.78%) (59.09%) (58.28%) 38 20 4 11 73 High (29.23%) (21.74%) (11.11%) (25.00%) (24.17%) Note. C1 = Cluster 1, C2 = Cluster 2, C3 = Cluster 3, C4 = Cluster 4. MAOA uVNTR low-activity: 2-repeat alleles, high-activity: 3-repeat and 3.5-repeat alleles. 5-HTTLPR low: S/S haplotypes, intermediate: S/LA, S/LG, LG/LG, LA/LG haplotypes, high: LA/ LA haplotypes.

5.3 Study 3

Construct Validity of the German Version of the Hare Psychopathy Checklist-Revised

Pia Hollerbach a

Elmar Habermeyer a

Joachim Nitschke b

Zara Sünkel b

Andreas Mokros c

a Department of Forensic Psychiatry, University Hospital of Psychiatry Zurich, Zurich, Switzerland b Forensic-Psychiatric Hospital, Ansbach District Hospital, Ansbach, Germany c Department of Psychology, FernUniversität in Hagen (University of Hagen), Hagen, Germany.

This manuscript has been submitted to European Journal of Psychological Assessment.

Abstract

The Hare Psychopathy Checklist-Revised (PCL-R) is among the most well-established instruments for the assessment of psychopathy. The PCL-R is a 20-item observer rating instrument based on file review and a semi-structured interview. In the scope of the German adaptation of the PCL-R its factor structure, construct validity, and association with socially desirable responding were investigated in a sample of male criminal offenders (N = 118).

A nested hierarchical parcel model with four first-order and two second-order factors yielded excellent model fit. Convergent and discriminant validity were assessed based on correlational analyses, a multitrait-multimethod (MTMM) matrix, and a canonical correlation analysis

(CCA) including measures of psychopathy, Antisocial Personality Disorder (ASPD), the Big

Five, alexithymia, impulsivity, and socially desirable responding. The MTMM matrix as well as substantial associations with self-reported psychopathic traits and observer ratings of

ASPD indicated convergent validity. The CCA revealed that deceitful and callous features were linked to emotional stability, whereas social deviance was negatively associated with agreeableness, conscientiousness, and impulse control. The PCL-R total score was negatively correlated to impression management. The current findings indicate that the German adaptation of the PCL-R is a valid measure for the assessment of psychopathic features.

Key words: PCL-R; MTMM; Antisocial personality disorder; SRP; Big Five

1. Introduction

The concept of the psychopathic personality dates back more than 200 years. Philippe

Pinel (1809) and later Kurt Schneider (1950) described individuals with a distorted perception of emotions and a lack of empathy. With his landmark monograph “The mask of sanity”,

Hervey M. Cleckley (1976) paved the way for the modern conceptualization of psychopathy, which has been further developed by Robert Hare and colleagues. According to Hare (2003), a prototypical psychopath is emotionally shallow, manipulative and deceitful, irresponsible and impulsive, and shows disregard for social norms. Psychopathic traits are predictive of general and violent offending and recidivism, which is why the assessment of psychopathy has proven to be crucial in the criminal justice system (Hare, 2003).

The Psychopathy Checklist-Revised (PCL-R; Hare, 2003) is among the most frequently used instruments for the assessment of psychopathic features (Singh et al., 2014). It covers psychopathic core personality traits in terms of affective deficits and interpersonal manipulation as well as social deviance in terms of an unstable lifestyle and antisocial behavior. Until now, no licensed and published German version of the PCL-R was available.

Mokros et al. (2017) published the first comprehensive German translation of the PCL-R manual and provided normative data for German-speaking countries. Based on that data we investigated the factor structure as well as the convergent and discriminant validity of the

German PCL-R, and its potential susceptibility to bias caused by socially desirable responding.

2. Materials and Methods 2.1 Participants

The sample comprised 84 male inmates and 34 male forensic-psychiatric inpatients from five different correctional/forensic-psychiatric institutions in Germany. The participants’ average age was 38 years (SD = 1.96, range 21-72 years). There was no pre-selection 86 regarding the severity of psychopathic traits so that the final sample (N = 118) almost covered the whole spectrum of PCL-R scores (M = 22.76, SD = 7.14, range 3.2 - 37.9).

2.2 Instruments

The PCL-R (Hare, 2003) consists of 20 items, which are rated on a three-point ordinal scale. Information is drawn from a semi-structured interview (optional) and from available reports such as patient records or judicial verdicts (compulsory). The PCL-R encompasses four first-order factors, or facets (Interpersonal, Affective, Lifestyle, and Antisocial), which can be merged to two second-order factors, one of them measuring core psychopathic personality traits (i.e., Interpersonal/Affective) and the second factor combining an unstable lifestyle and antisocial behavior (i.e., Lifestyle/Antisocial). Sum scores can be obtained for facets, factors, and in total.

In addition, psychopathy was assessed with the Self-Report Psychopathy Scale (SRP;

Paulhus et al., 2016; German translation by Mokros et al., 2016). The SRP consists of 64 items that can be assigned to four scales (Interpersonal, Affective, Lifestyle, and Antisocial).

It shows acceptable to good internal consistency and is conceptually similar to the PCL-R

(Bärwaldt et al., 2016; Mokros et al., 2017).

Symptoms of the Antisocial Personality Disorder (ASPD) were assessed with the

Structured Clinical Interview for DSM-IV, Part II (SCID-II; First et al., 1997; German translation by Fydrich et al., 1997), an observer-rating instrument. The semi-structured interview consists of 29 items which cover antisocial behavior in childhood, adolescence, and adulthood, and are coded on a three-point scale.

Impulsivity was measured through self-report with a shortened version of the UPPS questionnaire with 45 items (Whiteside & Lynam, 2001; German translation by Keye, Wil-

87 helm & Oberauer, 2009). The acronym reflects the four subscales Urgency, Lack of Premedi- tation, Lack of Perseverance, and Sensation Seeking. All items are rated on a five-point scale.

The Toronto Alexithymia Scale (TAS-26; Taylor et al., 1985; German translation by

Kupfer et al., 2001) is a self-report measure to assess impairment in perception, processing, and comprehension of emotions in the self and others. It has 26 items that load on the four scales Difficulty Identifying Feelings, Difficulty Describing Feelings to Others, Externally

Orientated Style of Thinking, and Reduced Daydreaming. The Reduced Daydreaming scale is negatively correlated to the other scales and is therefore not recommended for use (Kupfer,

Brosig, & Brähler, 2000). Due to discordant findings with respect to the factor structure and the internal consistency of the TAS subscales, we only included the total score in the analyses

(Gignac, Palmer, & Stough, 2007).

The NEO Five-Factor Inventory (NEO-FFI; Costa & McCrae, 1985; German translation by Borkenau & Ostendorf, 2008) was used to assess the expression of the five personality dimensions of Neuroticism, Extraversion, Openness, Agreeableness, and Conscientious- ness through self-report. Each of the dimensions is based on a subscale with 12 items that are answered on a five-point rating scale.

Socially desirable responding was assessed through self-report with the Balanced Di- rectory of Desirable Responding (BIDR; Paulhus, 1984; German 20-item version by Musch et al., 2002). It comprises the two subscales of Self-Deceptive Enhancement and Impression

Management. Each of the subscales has 10 items, which are rated on a 7-point rating scale.

2.3 Statistical Analyses

Factor analyses. Confirmatory factor analysis (CFA) was conducted with Mplus for

Mac, Version 7.4 (Muthén & Muthén, 2015). Based on previous research (Hare & Neumann,

2008), a nested hierarchical parcel model with the four facets loading on two higher-order

88 factors (Interpersonal/Affective and Lifestyle/Antisocial) was estimated. Variances of the two factors were fixed to 1 in order to have all loadings estimated freely and still enable model identification. Model fit was assessed with two absolute fit indices and an incremental fit index. For the former we used the χ² test of model fit and the Root Mean Square Error of

Approximation (RMSEA; Steiger, 1990), and for the latter the Comparative Fit Index (CFI;

Bentler, 1990). Good model fit was indicated by RMSEA values ≤.08, and CFI values ≥.90

(Kline, 2005).

Convergent validity. To examine the relationship between the PCL-R and the SRP 4, their total scores were correlated. In addition, their facet scores were correlated and entered into a multitrait-multimethod matrix (MTMM; Campbell & Fiske, 1959). The MTMM matrix consisted of four traits (Interpersonal, Affective, Lifestyle, Antisocial) within two method blocks, namely observer rating (PCL-R) and self-report (SRP 4). The monotrait-monomethod correlations of 1 between the same traits measured with the same methods in the reliability diagonal were replaced with reliability coefficients (internal consistency: Cronbach’s α). The- se values were expected to be significantly different from 0 and should be the highest in the matrix. Correlations between the same traits measured with different methods (monotrait- heteromethod) were supposed to be lower than the reliability coefficients but still substantial

(validity diagonals). They were followed by the set of smaller correlations between different traits measured with the same method (heterotrait-monomethod). Correlations between different traits measured with different methods were expected to have the lowest values (heterotrait-heteromethod). Ideally, convergent validity could be assumed if the values of the correlation coefficients decreased in the described order.

Sawilowsky (2002) described a distribution-free test which helps to determine whether the null hypothesis (i.e., values are unordered and no relationship between the two measures can be assumed) can be rejected in favor of the alternative hypothesis (i.e., values

89 follow a decreasing trend, thus a relationship between the two measures can be assumed).

The number of inversions (in terms of violations of the decreasing trend) was counted and a permutation test was conducted in order to obtain inversion-related p values. Additionally, facet, factor, and total scores of the PCL-R were correlated with the ASPD symptom count.

Discriminant validity. In the first step, the facet, factor, and total scores of the PCL-

R were correlated with the TAS-26 total score, and the scale scores of the NEO-FFI and

UPPS. In the second step, a canonical correlation analysis (CCA) was conducted. A CCA serves to discover associations between two sets of variables by creating linear combinations of variables (canonical variates) that maximally correlate with each other, which was described as a “double-barreled principal component analysis” by Tatsuoka (1971, p. 183). Set

1 included the two PCL-R factors, and set 2 was composed of the TAS-26 total score, and the

NEO-FFI and UPPS scales. Finally, a variance maximizing (Varimax) rotation was conducted in order to facilitate the interpretation of the canonical loadings, which can be interpreted like factor loadings. In addition, a redundancy index that indicates the amount of variance in set 1 explained by the variables in set 2 (and vice versa) was calculated based on the canonical loadings (Stewart & Love, 1968). The redundancy coefficients were corrected for shrinkage according to Wherry (1931), as described by Thompson (1990).

Socially desirable responding. The BIDR scores of the study were compared to those of a reference sample from the general population (Musch et al., 2002) by calculating effect sizes. In addition, the BIDR scales were correlated with the PCL-R facet, factor and total scores.

3. Results 3.1 Confirmatory Factor Analysis

The estimation of a hierarchical nested parcel model with four facets and two factors revealed excellent fit (χ²[1] = .19, p = .660, RMSEA = .00, CFI = 1.00). All facets showed 90 substantial loadings on the respective factors, and the two factors were highly correlated (see

Figure 6).

Figure 6. Nested parcel model of the PCL-R with four facets and two factors (N = 118). Factor 1 = psychopathic core personality traits. Factor 2 = deviant lifestyle. 95% CI in square brackets.

3.2 Convergent Validity

The total scores of the PCL-R and the SRP were substantially correlated (r = .50, p <

.001, two-tailed). The number of ASPD symptoms was strongly associated with the PCL-R total score, the lifestyle facet, and the factor covering a deviant lifestyle (see Table 18).

Table 18

Correlation Between ASPD Symptom Count and PCL-R Facets, Factors, and Total Score

(N = 118)

PCL-R INT AFF LIF ANT Factor 1 Factor 2 Total SCID-II ASPD .20* .44** .63** .48** .39** .63** .61** Note. p < .05, ** p < .001 (two-tailed). ASPD = Antisocial Personality Disorder. INT = Interpersonal. AFF = Affective. LIF = Lifestyle. ANT = Antisocial. Factor 1 = psychopathic core personality traits. Factor 2 = social deviance. Total = total score. PCL-R = Psychopathy Checklist-Revised (Hare, 2003; German version by Mokros et al., 2017). SCID-II = Structured Clinical Interview for DSM-IV, Part II (First et al., 1997; German version by Fydrich et al., 1997).

The MTMM matrix of the PCL-R facets and SRP subscales is presented in Table 19.

According to the permutation test, construct validity could be assumed at the .05 level if no more than 14 inversions were observed (Sawilowsky, 2002). There were 12 inversions (p =

.02), thus the null hypothesis (no substantial relation between the traits as measured by the

PCL-R and the SRP) could be rejected in favor of the alternative hypothesis (both instruments measure the same traits).

Table 19

Multitrait Multimethod Matrix

Interview (PCL-R) Self-Report (SRP 4) Traits INT AFF LIF ANT INT AFF LIF ANT Interview (PCL-R) INT (.69) AFF .39 (.73) LIF .22 .35 (.70) ANT .17 .34 .56 (.62) Self-Report (SRP 4) INT .10 .16 .21 .35 (.78) AFF -.02 .37 .44 .29 .58 (.64) LIF .07 .25 .53 .47 .54 .59 (.74) ANT .03 .15 .44 .59 .51 .42 .53 (.71) Note. N = 106 to 118 (due to deletion of cases with missing values). Reliability estimates (Cronbachs α) in brackets (monotrait-monomethod). Validity coefficients in italics (monotrait-heteromethod). Correlations between different traits measured with the same method in bold (heterotrait-monomethod). All others: correlations between different traits measured with different methods (heterotrait-heteromethod). PCL-R = Psychopathy Checklist-Revised (Hare, 2003; German version by Mokros et al., 2017). SRP 4 = Self-Report Psychopathy Scale 4 (Paulhus et al., 2016; German translation by Mokros et al., 2016).

3.3 Discriminant Validity

The correlation analysis revealed that the psychopathic core personality traits (i.e.,

PCL-R Factor 1) were negatively associated with the NEO-FFI scales Neuroticism and Ex- traversion. Social deviance (i.e., PCL-R Factor 2), in contrast, was negatively linked to the

NEO-FFI scales of Agreeableness and Conscientiousness scales, and positively correlated with alexithymia (TAS-26), and impulsivity (UPPS; see Table 20).

Table 20

Correlations Between PCL-R and TAS-26, NEO-FFI, and UPPS

INT AFF LIF ANT F1 F2 Total Alexithymia (TAS-26; N = 116) Total score -.22* .04 .17 .23* -.11 .23* .09 Big Five (NEO-FFI; N = 115) Neuroticism -.26** -.26** .02 .00 -.32*** .01 -.17 Extraversion -.12 -.19* .01 .00 -.19* .01 -.09 Openness .10 -.09 -.11 -.15 .01 -.14 -.09 Agreeableness -.14 -.14 -.27 -.31*** -.17 -.33*** -.32*** Conscientiousness .27** .01 -.29** -.29 .17 -.33*** -.11 Impulsivity (UPPS) Total score (n = 117) -.06 .09 .52** .45** .02 .55** .36** Urgency (n = 117) -.13 -.03 .35*** .48*** -.10 .47*** .25** Lack of Premeditation (n = 117) .03 .14 .32*** .24** .10 .31*** .26** Lack of Perseverance (n = 111) -.06 -.07 .35*** .27** -.08 .35*** .17 Sensation Seeking (n = 117) .07 .14 .33*** .14 .12 .26** .24** Note. * p < .05, ** p < .01, *** p < .001 (two-tailed). AFF = affective. LIF = lifestyle. ANT = antisocial. F1 = psychopathic core personality traits. F2 = deviant lifestyle. Total = total score. TAS-26 = Toronto Alexithymia Scale (Taylor et al., 1985; German translation by Kupfer et al., 2001). NEO-FFI = NEO Five-Factor Inventory (Costa & McCrae, 1985; German translation by Borkenau & Ostendorf, 2008). UPPS = Urgency, Lack of Pre- meditation, Lack of Perseverance, Sensation Seeking (Whiteside & Lynam, 2001; German translation by Keye et al., 2009).

As indicated by the respective factor loadings, the first canonical function reflected the social deviance factor, and the second canonical function captured psychopathic core personality traits. Since the association between two sets of variables is susceptible to overes- timation, the coefficient was corrected as suggested by Cohen and Nee (1984). Accordingly, the corrected set correlation (Cohen, 1982) between the two sets was R2= .50. Psychopathic core personality traits (PCL-R Factor 1) showed a negative association with the Neuroticism scale, whereas social deviance (PCL-R Factor 2) was most clearly negatively linked to the

Agreeableness and Conscientiousness scales of the NEO-FFI, and to the Urgency, Lack of

Perseverance, and Lack of Premeditation scales of the UPPS (see Table 21). The largest dif-

94 ferences between the two canonical functions could be observed for the Conscientiousness,

Urgency, and Lack of Perseverance scales. Regarding the redundancy coefficients, 28% of the variance in set 1 (i.e., the PCL-R factors) could be explained by the variables in set 2, whereas the PCL-R factors in set 1 accounted for 11% of the variance in set 2.

Table 21

Canonical Loadings of PCL-R Factors, TAS-26 Total Score, NEO-FFI Personality Dimen- sions, and UPPS Subscales (N = 109)

Canonical function I II Set 1: PCL-R factors Factor 1 .27 .96 Factor 2 .99 .14 Set 2: Alexithymia, Big Five, impulsivity TAS-24 .35 -.24 Big Five Neuroticism .02 -.57 Extraversion .06 -.41 Openness -.24 .08 Agreeableness -.56 -.21 Conscientiousness -.52 .43 UPPS Urgency .81 -.38 Lack of Premeditation .50 .06 Lack of Perseverance .58 -.32 Sensation Seeking .45 .17

Canonical correlation coefficient .64 .55

Note. I: Bartlett’s V(11) = 54.11 (p < .001), II: Bartlett’s V(9) = 36.44 (p < .001). The CCA matrix was varimax rotated in order to facilitate interpretation. Factor 1 = psychopathic core personality traits. Factor 2 = deviant lifestyle. TAS-26 = Toronto Alexithymia Scale (Taylor et al., 1985; German translation by Kupfer et al., 2001). NEO-FFI = NEO Five-Factor Inventory (Costa & McCrae, 1985; German translation by Borkenau & Ostendorf, 2008). UPPS = Urgency, Lack of Premeditation. Lack of Perseverance, Sensation Seeking (Whiteside & Lynam, 2001; German translation by Keye et al.,2009).

3.4 Socially Desirable Responding

The offender sample had higher scores on both the Self-Deceptive Enhancement scale

(d = .38, 95%-KI = [.09; .67]) and the Impression Management scale (d = .36, 95%-KI = [.07;

.65]) of the BIDR compared to a sample from the general population (N = 75; Musch et al.,

2002, Study 2). The Self-Deceptive Enhancement scale was not correlated with the PCL-R total score (r = .04, n. s.), whereas the Impression Management scale was negatively associated with the PCL-R total score (r = -.31, p < .001).

4. Discussion

The aim of the current study was to assess factor structure, construct validity, and potential response bias for the German adaptation of the PCL-R in a correctional/forensic- psychiatric sample. A nested hierarchical CFA parcel model according to the customary

PCL-R structure with four first-order factors (facets) and two-higher-order factors (Factor 1 and Factor 2) reflected the empirical data well. Correlational analyses between the PCL-R and self-report measures of psychopathy, personality, alexithymia, and impulsivity were supportive of the convergent and discriminant validity. In addition, the PCL-R score was negatively associated with impression management, but not with self-deception.

Regarding convergent validity, the strong associations between ASPD symptom count and the social deviance factor of the PCL-R, in particular, are not surprising given previous research on the overlap between impulsivity, antisocial behavior, and ASPD (Hare, 2003). In addition, the correlation between the total scores of the PCL-R and the SRP instruments and the outcome of the MTMM matrix, indicate substantial overlap in terms of measuring the same construct.

On a related note, a detailed examination of the MTMM matrix revealed that a considerable number of inversions were due to comparatively low validity coefficients of the

96 interpersonal and affective facets. This discrepancy between the ratings obtained by self- report vs. external assessment might be explained by the lack of insight and introspection that is typically observable in psychopathic individuals (Haviland et al., 2004). Even after correct- ing for attenuation, the validity coefficients for the psychopathic core personality traits (.14 and .54 for Interpersonal and Affective, respectively) remained much lower than the validity coefficients for the social deviance component (.74 and .89 for Lifestyle and Antisocial, respectively; cf., Table 18). Possibly, Lilienfeld and Fowler (2006) are right that highly psychopathic individuals may be unaware of their “semantic aphasia” as described by Cleckley

(1976, p. 383). Consequently, attempts at asking them to describe traits considered as core features of psychopathy (i.e., deceitfulness and being affectionless) could be forlorn. Instead, it might be worthwhile to develop other methods of assessment (e.g., indirect ones like the

Implicit Association Test) that would tap into the inner concepts of highly psychopathic individuals without having to rely on self-report.

Negative associations between the NEO-FFI and PCL-R scores underlined the discriminant validity of the PCL-R. Neuroticism and extraversion were negatively associated with psychopathic core personality traits, whereas agreeableness and conscientiousness showed negative relationships to social deviance. These results support the assumption that core psychopathy, on the one hand, is characterized by a somewhat detached interpersonal style as well as by emotional robustness, very much akin to Cleckley’s (1941/1976) description of primary psychopathy. Social deviance, on the other hand, is usually associated with a challenging and uncooperative personality, as well as with impulsive, careless behavior (Jones &

Paulhus, 2011; Lynam & Widiger, 2007). This was affirmed by the finding that the social deviance factor of the PCL-R showed substantial association to different types of impulsive behavior.

Furthermore, alexithymia was weakly correlated to the social deviance factor of the

PCL-R. This outcome mirrors previous findings of alexithymia being linked to juvenile delinquency (Zimmermann, 2006) and antisocial personality disorder (Sayar et al., 2001). Alt- hough the constructs of alexithymia and psychopathy share the notion of empathy deficits, there was no association between the TAS-26 total score and the PCL-R Affective facet, which captures emotional deficiency. This might be due to phenotypical differences between the two concepts: alexithymic individuals typically present as anxious, conforming or even boring, while psychopathic individuals are usually described as calm, dominant or even charming (Haviland et al., 2004). Other researchers even reported a negative relationship between the Affective facet of the PCL-R and measures of alexithymia (Pham et al., 2010).

The aforementioned results become more apparent when shifting to the CCA. The social deviance factor was characterized by low agreeableness and conscientiousness, and by pronounced impulsivity. Psychopathic core personality traits, however, were associated with low neuroticism exclusively. Importantly, the CCA helped to clarify the diverging associations between the two PCL-R factors. While psychopathic core personality traits were characterized by emotional robustness, social deviance was linked to urgency, and a lack of perseverance and conscientiousness. These results suggest that low neuroticism and lack of inhibition, rather than fearlessness, are the key components of psychopathy (Derefinko, 2015).

With respect to redundancy, psychopathic traits could partly be predicted from general personality traits (including impulsivity). This goes along the lines of O’Boyle, Forsyth, Banks,

Story, and White (2015), who reported that a large portion of the variance in psychopathic traits within the Dark Triad could be explained by the Big Five personality dimensions.

The negative association between psychopathy and impression management is not surprising in light of the assumption that psychopathy is associated with boldness (Lilienfeld et al., 2016). Against this backdrop it is conceivable that participants with pronounced psy-

98 chopathic features worried less about the impression they made. Similarly, meta-analytic findings point toward a weakly negative correlation between faking good and psychopathic traits assessed via self-report (Ray et al., 2013).

The current validation study was conducted with adult male participants only. Despite the higher prevalence and stronger manifestation of psychopathic traits in men, it is generally assumed that psychopathy is a construct that is applicable to both men and women (Cale &

Lilienfeld, 2002; Gray & Snowden, 2016; Salekin, Rogers, & Sewell, 1997). Neumann et al.

(2012), for instance, examined a large sample with the SRP and found strong measurement invariance across male and female participants. Accordingly, further validation studies on the

German version of the PCL-R that focus on female offenders are needed. All in all, the present investigation illustrates that the German adaptation of the PCL-R is a valid instrument for the assessment of psychopathy in male correctional/forensic samples.

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CURRICULUM VITAE

Personal Details Name Pia Sofie Hollerbach Office address University Hospital of Psychiatry, Department of Forensic Psychiatry, Zurich, Switzerland Private address Fabrikstrasse 34, 8005 Zürich E-Mail Office: [email protected] Private: [email protected] Date of birth 11/04/1989 Place of birth Karlsruhe, Germany Nationality German

Education 2015 - present PhD. Candidate in Forensic Psychology, Department of Forensic Psychiatry, University Hospital of Psychiatry Dissertation: “Psychopathic personality traits: Assessment and genetic correlates” Advisors: Prof. Dr. Dr. Andreas Maercker (main advisor) Prof. Dr. Andreas Mokros Prof. Dr. Boris Quednow 2012 - 2014 Master of Science in Psychology, specialization in Clinical and Health Psychology, University of Zurich, Switzerland Thesis: “Subtypes of schizophrenic offenders and offences” Advisors: Prof. Dr. Dr. Andreas Maercker (main advisor) Prof. Dr. Andreas Mokros 2008 - 2011 Bachelor of Science in Psychology, University of Freiburg, Germany Thesis: “Emotional and cognitive empathy in offenders” 2005 - 2008 Bismarck secondary school, Karlsruhe, Germany 1999 - 2005 Eichendorff secondary school, Ettlingen, Germany 1995 - 1999 Primary school, Langensteinbach, Germany

Research Stays and Internships 03/2016 – 05/2016 Research stay at the Center of Behavior Genetics, Abo Akademi University, Turku, Finland 06/2013 – 07/2013 Research stay at the Centre for Forensic and Criminological Psychology, University of Birmingham, Birmingham, United Kindom 05/2012 – 08/2012 Research internship at the Institute for Sex Research and Foren- sic Psychiatry

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01/2012 – 03/2012 Research internship at the Department of Forensic Psychiatry, University Hospital of Psychiatry, Zurich, Switzerland 09/2010 – 10/2010 Clinical internship at the Hospital for Forensic Psychiatry and Psychotherapy, Center for Psychiatry, Emmendingen, Germany 09/2009 – 10/2009 Clinical internship at the Department of Psychiatry, SRH Hospi- tal Langensteinbach, Karlsbad, Germany

Student supervision/Workshops Winter semester Student supervision of master thesis (“Subtypen von Straftätern 2018/2019 auf der Grundlage psychopathischer Eigenschaften [Subtypes of offenders based on psychopathic traits“, Marcus Schmid, FernUniversität Hagen] together with Prof. Dr. Andreas Mokros 24-25/08/2016, Workshop “PCL-R/SV – Psychopathy Checklist-Revised/ 31/05 – 01/06/2018 Screening Version” together with Prof. Dr. Andreas Mokros

Employment History 01/2018 - present Executive assistant at the Department of Forensic Psychiatry, University Hospital of Psychiatry, Zurich, Switzerland 08/2014 – 12/2017 Research assistant at the Department of Forensic Psychiatry, University Hospital of Psychiatry, Zurich, Switzerland 10/2012 – 07/2014 Student assistant at the Department of Forensic Psychiatry, Uni- versity Hospital of Psychiatry, Zurich, Switzerland 05/2010 – 09/2011 Student assistant at the Department of Biological and Personality Psychology, University of Freiburg, Freiburg, Germany

Awards 10/2014 Ludwig-Meyer Award (Symposium Empirische Forschung in der Forensischen Psychiatrie, Psychologie und Psychotherapie, Vienna, Austria)

Trainings and Workshops 29/06/2016 Falcon Training: Testing Mediation and Moderation using MPlus, London, United Kindom 22-26/06/2015 Summer School: Twin Model Fitting, Centre, Institute of Psy- chiatry, Psychology and Neuroscience, King´s College, London, United Kindom

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Personal Skills Languages German (Native speaker) English (Full professional proficiency) French (Elementary proficiency)) Computer Skills MS office (Word, Excel, PowerPoint) SPSS Mplus EndNote

Publications Manuals Mokros, A., Hollerbach, P., Nitschke, J., & Habermeyer, E. (2017). Deutsche Version der Hare Psychopathy Checklist-Revised (PCL-R) von R. D. Hare: Manual [German version of the Hare Psychopathy Checklist-Revised (PCL-R) by R. D. Hare: Manual]. Göt- tingen, Germany: Hogrefe.

Articles Domes, G., Hollerbach, P., Vohs, K., Mokros, A., & Habermeyer, E. (2013). Emotional empathy and psychopathy in offenders: an experimental study. Journal of Personality Dis- orders, 27(1), 67-84. doi: 1.1521/pedi.2013.27.1.67 Hollerbach, P., Johansson, A., Ventus, D., Jern, P. , Neumann, C. S., Westberg, L., Santtila, P., Habermeyer, E., & Mokros, A. (2018). Main and interaction effects of childhood trauma and the MAOA uVNTR polymorphism on psychopathy. Psychoneuroendocrino- logy, 95, 106-112. doi: 1.1016/j.psyneuen.2018.05.022 Hollerbach, P., Mokros, A., Nitschke, J., & Habermeyer, E. (in press). Hare Psychopathy Checklist-Revised: Deutschsprachige Normierung und Hinweise zur sachgerechten Anwendung [Hare Psychopathy Checklist-Revised: German adaptation and recommendations for use]. Forensische Psychiatrie, Psychologie und Kriminologie. Mokros, A., Hollerbach, P., Vohs, K., Nitschke, J., Eher, R., & Habermeyer, E. (2013). Normative data for the Psychopathy Checklist–Revised in German-speaking countries: A meta-analysis. Criminal Justice and Behavior, 40(12), 1397-1412. doi: 1.1177/0093854813492519

Book Sections Hollerbach, P. & Mokros, A. (in press). Psychopathie [Psychopathy]. In G. Berberich, M. Zaudig, C. Benecke, H. Saß, & J. Zimmermann. Update Persönlichkeitsstörungen. Stuttgart, Germany: Schattauer. Hollerbach, P. (in press). Nature & Nurture? Haupt- und Interaktionseffekte von Kindheits- trauma und genetischer Disposition auf Psychopathie [Nature & Nurture? Main and interaction effects of childhood trauma and genetic disposition on psychopathy]. In J.L. Müller, P. Briken, M. Rösler, & R. Eher, Empirische Forschung in der forensischen Psychiatrie, Psychologie und Psychotherapie. Berlin, Germany: Medizinisch Wissenschaftliche Verlagsgesellschaft.

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Hollerbach, P. S. (2015). Gibt es einen Zusammenhang zwischen Schizophrenie und Ge- walt? [Is there a relationship between schizophrenia and violence?]. In J.L. Müller, P. Briken, M. Rösler, & R. Eher, Empirische Forschung in der forensischen Psychiatrie, Psychologie und Psychotherapie. Berlin, Germany: Medizinisch Wissenschaftliche Verlagsgesellschaft.

Conferences Hollerbach, P., Johansson, A., Ventus, D., Jern, P. , Neumann, C. S., Westberg, L., Santtila, P., Habermeyer, E., & Mokros, A. (June 2018). Nature & Nurture? Main and interaction effects of childhood trauma and MAOA on psychopathy. Annual conference of the European Association of Psychology and Law, Nuremberg, Germany (Poster presentation) Hollerbach, P., Mokros, A., Nitschke, J., Sünkel, Z., Habermeyer, E. (November 2017). Construct Validity of the German Version of the Psychopathy Checklist-Revised (PCL- R). 4. Burghölzli Psychiatry Meeting, Zurich, Switzerland (Oral presentation) Hollerbach, P. (September 2017). Konstruktvalidität der deutschen Fassung der Hare Psy- chopathy Checklist-Revised (PCL-R): Konvergente und diskriminante Validität [Construct validity of the German adaptation of the Hare Psychopathy Checklist- Revised (PCL-R): Convergent and discriminant validity]. Fachgruppentagung Rechts- psychologie der Deutschen Gesellschaft für Psychologie, Jena, Germany (Oral presentation) Hollerbach, P., Johansson, A., Ventus, D., Jern, P. , Neumann, C. S., Westberg, L., Santtila, P., Habermeyer, E., & Mokros, A. (September 2017). Nature & Nurture? Haupt- und Interaktionseffekte von Kindheitstrauma und genetischer Disposition auf Psychopathie [Nature & Nurture? Main and interaction effects of childhood trauma and genetic disposition on psychopathy]. Symposium Empirische Forschung in der Forensischen Psy- chiatrie, Psychologie und Psychotherapie, Vienna, Austria (Oral presentation) Hollerbach, Santtila, P., & , Mokros, A. (November 2016). From Maltreated Children to Psychopathic Adults: The Role of the Monoamine Oxidase A Gene. 3. Burghölzli Psy- chiatry Meeting, Zurich, Switzerland (Poster presentation) Hollerbach, P., Nitschke, J., Habermeyer, E., Wilhelm, O., & Mokros, A. (September 2016). Psychopathie und interpersonelle Fähigkeiten: Genetische Moderatoreffekte [Psycho- pathy and interpersonal skills: Genetic moderating effects]. 5. Kongress der Deutschen Gesellschaft für Psychologie (SGPs). Leipzig, Germany (Oral presentation) Hollerbach, P., Santtila, P., & Mokros, A. (September 2016). Genetische Grundlagen von Psychopathy [Genetic foundations of psychopathy]. 5. Kongress der Deutschen Gesell- schaft für Psychologie (DGPs). Leipzig, Germany (Oral presentation) Hollerbach, P., Santtila, P., Mokros, A. (November 2015). Moderator effects of monoamine oxidase A on the association between childhood maltreatment and psychopathy. 2. Burghölzli Psychiatry Meeting, Zurich, Switzerland (Poster presentation) Hollerbach, P., Santtila, P. & Mokros, A. (November 2015). Genetische Aspekte der Psy- chopathie [Genetic aspects of psychopathy]. Conference of the Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde (DGPPN), Berlin, Germany (Oral presentation)

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Hollerbach, P., Santtila, P., Mokros, A. (August 2015). Genetic correlates of psychopathic traits in the general population. Annual Conference of the European Association of Psychology and Law, Nuremberg, Germany (Oral presentation) Hollerbach, P., Santtila, P., Mokros, A. (May 2015). Moderator effects of monoamine oxidase A (MAO-A) on the association between childhood maltreatment and psychopathic traits. Masterstudierenden- und Doktorandinnen-Kongress des Psychologischen Institu- tes der Universität Zürich, Zurich, Switzerland (Poster presentation) Hollerbach, P. (October 2014). Typologien schizophrener Straftäter und Straftaten [Typolo- gies of schizophrenic offenders and offences]. Symposium Empirische Forschung in der Forensischen Psychiatrie, Psychologie und Psychotherapie, Vienna, Austria (Oral presentation) Hollerbach, P. (October 2014). Typologien schizophrener Straftäter und Straftaten [Typolo- gies of schizophrenic offenders and offences]. 29. Münchner Herbsttagung der Arbeits- gemeinschaft für Methodik und Dokumentation in der Forensischen Psychiatrie, Mu- nich, Germany (Oral presentation)

Publications under Preparation/Revision Hollerbach, P., Habermeyer, E., Nitschke, J., Sünkel, Z., & Mokros, A. (2018). Construct Validity of the German Version of the Hare Psychopathy Checklist-Revised. Manuscript under revision. Hollerbach, P., Olderbak, S., Wilhelm, O., Montag, C., Jung, S., Neumann, Craig S., Ha- bermeyer, E., & Mokros, A. (2018). Associations of the MAOA uVNTR genotype and 5-HTTLPR/rs25531 haplotype with psychopathic traits. Manuscript under review.

Unpublished Work Hollerbach, P. (2014) Subtypes of schizophrenic offenders and offences (Master thesis)

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