Domains of Psychopathy: Evaluating the Structure of a Lexical Model ofPsychopathic Personality Disorder

Helge Andreas HoffHaukeland University Hospital and University of Bergen

Knut RypdalHaukeland University Hospital

Stephen D. HartUniversity of Bergen and Simon Fraser University

David J. CookeUniversity of Bergen and Glasgow Caledonian University

Arnstein MykletunNorwegian Institute of Public Health, Bergen, Norway, and University of New South Wales

This study examines the structure of the Comprehensive Assessment of Psychopathic Personality (CAPP)from a card sort perspective. The CAPP is a lexically based construct map of psychopathy comprising33 symptoms organized by its developers into 6 broad functional domains of personality (i.e., Attach-ment, Behavioral, Cognitive; Dominance; Emotional, Self). Groups of mental health workers andstudents were asked to sort the CAPP symptoms into the model’s 6 proposed domains. Overall, bothmental health workers and students were able to categorize the symptoms speedily and intuitivelyaccording to model. This suggests that the CAPP model’s hierarchical structure is plausible, and that thelexical nature of the model is successful in facilitating people’s ability to understand features ofpsychopathy in a way that requires limited cognitive effort. Together, these findings support the validityof the CAPP model as a lexically based concept map of psychopathy. Yet, some exceptions to the overallpattern of agreement with model were identified.

Keywords: CAPP, card sort, personality disorder, psychopathy, validation

Although there is broad consensus that psychopathy is character-ized by a syndromal structure consisting of symptoms from severalmajor areas of personality functioning (Hart & Cook, 2012), contro-versy still remains as to the key defining features of the concept(Arrigo & Shipley, 2001). Should antisocial and criminal behavior beviewed as an essential component of psychopathy, or as a possibleconsequence or sequelae of the disorder (Hare & Neumann, 2008,2010; cf. Skeem & Cooke, 2010a, 2010b)? Further, should potentiallyadaptive features like high self-assurance and the ability to remaincalm in potential dangerous situations, recover quickly from stress,and tolerate unfamiliar situations, be included in the definition ofpsychopathy, or should the concept be limited to maladaptive person-

ality traits (Patrick, Fowles, & Krueger, 2009; cf. Hare & Neumann,2008; Miller & Lynam, 2012)?

Ideally, a useful defining characteristic is both highly relevant to theconcept and helps to differentiate it from related concepts (Gerring,1999). This is the essence of content validity with respect to psycho-pathology—the extent to which the description of a disorder ade-quately represents the concept that is used by practicing mental healthprofessionals (Blashfield & Livesley, 1991). Establishing good con-tent validity is fundamental to any other type of validity: the adequacyof any measure of psychopathology is limited by—and must bejudged by—the definition of the underlying construct (Blashfield &Livesley, 1991; Middendorp, 1991; Gerring, 1999; Cooke, Hart, Lo-gan, & Michie, 2012). Concepts trumps operations; inevitably, inad-equate construct explication will lead to inadequate measures (Sireci,1998; Cooke et al., 2012).

To clarify the psychopathy concept, Cooke, Hart, Logan, andMichie (2004) developed a concept map of psychopathy named theComprehensive Assessment of Psychopathic Personality, orCAPP. The CAPP aims at capturing all major features of thedisorder as identified by various clinical descriptions in a way thatcan facilitate research on psychopathic personality disorder (PPD).It also aims to serve as a basis for understanding the associationsbetween different available diagnostic measures and for the devel-opment of new ones (Hart & Cook, 2012).

In their search for a comprehensive representation of definingfeatures, the CAPP authors first did a systematic review of theliterature. Second, they consulted subject matter experts from

Helge Andreas Hoff, Centre for Research and Education in ForensicPsychiatry, Haukeland University Hospital, and Department of Psychol-ogy, University of Bergen; Knut Rypdal, Centre for Research and Educa-tion in Forensic Psychiatry, Haukeland University Hospital; Stephen D.Hart, Department of Psychology, University of Bergen, and Department ofPsychology, Simon Fraser University; David J. Cooke, Department ofPsychology, University of Bergen, and Department of Psychology, Glas-gow Caledonian University; Arnstein Mykletun, Division of MentalHealth, Norwegian Institute of Public Health, Bergen, Norway, and Schoolof Psychiatry, University of New South Wales.

Correspondence concerning this article should be addressed to HelgeAndreas Hoff, Centre for Research and Education in Forensic Psychiatry,Haukeland University Hospital, Sandviksleitet 1, 5021 Bergen, Norway.E-mail: Helge.Hoff@helse-bergen.no

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Personality Disorders: Theory, Research, and Treatment © 2015 American Psychological Association2015, Vol. 6, No. 2, 117–128 1949-2715/15/$12.00 http://dx.doi.org/10.1037/per0000111

117

diverse theoretical backgrounds. This bottom-up or inductive sys-tematic analysis of the elements or content of the construct resultedin a list of candidate symptoms or characteristics typically definedin a mixture of lay language and technical jargon specific to aparticular theory of personality or psychotherapy. Critically, theCAPP model was developed according to the lexical hypothesis.This hypothesis proposes that because humans are a highly lin-guistic species, significant individual differences—including char-acteristics of personality and personality disorder—tend to berepresented in natural or common language as single-word de-scriptors (McCrae & Costa, 1997; Saucier & Goldberg, 2001). Inthe development of the CAPP, candidate symptoms identified viasystematic literature review and interview with subject matterexperts were deconstructed into 33 trait descriptive adjectives oradjectival phrases, each defined or explicated in terms of a furtherthree adjectives or adjectival phrases. This provides a comprehen-sive yet economical description of the disorder that has the capac-ity to be understood by both specialists and lay people (for a moredetailed description of the development of the CAPP, see Cooke etal., 2012).

The CAPP model is hierarchical. The 33 symptoms weregrouped by the CAPP developers, on a rational rather than statis-tical basis, into six basic domains of personality functioning. Thisgrouping was designed both to recognize the associations amongsymptoms but also to clarify their meaning. Symptoms that reflectintimacy or acceptance in personal relationships were grouped intoan Attachment domain. Symptoms that reflect organization andregulation of goal-directed activity were grouped into a Behavioraldomain. Symptoms that reflect organization and regulation ofthought processes were grouped into a Cognitive domain. Symp-toms that reflect agency or power in interpersonal relationshipwere grouped into a Dominance domain. Symptoms that reflectaffective experience and expression were grouped into an Emo-tional domain. Finally, symptoms that reflect self-evaluation weregrouped into a Self domain. Of course, the developers made noclaim as to the originality of the domains identified in the CAPP.These six domains may appear familiar to those who study per-

sonality or personality disorder, as they resemble expanded ver-sions of the Five Factor Model of personality (e.g., John &Srivastava, 1999), especially one version known as the HEXACOmodel (Lee & Ashton, 2004). The Attachment domain of theCAPP shows some resemblance to Agreeableness in the HEXACOmodel; the Behavioral domain, to Conscientiousness; the Cogni-tive domain, to Openness to Experience; the Dominance domain,to E[X]traversion; the Emotional domain, to Emotional Stability;and the Self domain, to Honesty-Humility. The full CAPP modelis presented in Figure 1.

The CAPP as a concept map of psychopathy has been evaluatedempirically in several ways. According to the lexical hypothesis,identification of corresponding concepts for a phenotypic person-ality attribute across languages adds weight to the importance ofthe attribute in a cross-cultural sense (Saucier & Goldberg, 2001).Translations of the original CAPP model into more than 15 lan-guages, several from different language families than the originalEnglish (e.g., Finnish, Hungarian, Persian, Russian, Thai), indicatethat it is possible to find similar networks of trait descriptiveadjectives representing psychopathy across translations. This pro-vides some support for the CAPP as a lexically based model ofpsychopathy (Cooke et al., 2012; see also Saucier & Goldberg,2001).

Because the CAPP symptoms are in common language it ispossible to evaluate how well the CAPP model captures theprototype of psychopathy among both lay people and mentalhealth professionals. Prototypicality, studies are used to capturewhat subject matter experts or others perceive as core features ofa concept, and which features they perceive as peripheral or evenoutside of the concept. The prototypicality approach has a longpedigree in the validation of psychiatric disorders, including psy-chopathy (Horowitz, Post, French, Wallis, & Siegelman, 1981;Livesley, 1987; Livesley, Reiffer, Sheldon, & West, 1987; Rogers,Salekin, Sewell, & Cruise, 2000; Samuel & Widiger, 2004).

In several CAPP prototypicality studies across different lan-guage versions and different cultures, mental health professionalsand lay people have rated the prototypicality of the 33 CAPP

Figure 1. Comprehensive Assessment of Psychopathic Personality. From “Explicating the Construct ofPsychopathy: Development and Validation of a Conceptual Model, the Comprehensive Assessment of Psycho-pathic Personality (CAPP),” by D. J. Cooke, S. D. Hart, C. Logan, and C. Michie, 2012, The InternationalJournal of Forensic Mental Health, 11, p. 246. Copyright 2012 by the Routledge, Taylor & Francis.

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118 HOFF, RYPDAL, HART, COOKE, AND MYKLETUN

symptoms as well as 9 foil symptoms (i.e., symptoms thought to berelevant to personality disorder but irrelevant to or even incom-patible with PPD). Across these studies there is a high degree ofconsistency with regard to which symptoms were rated as highlytypical of psychopathy (i.e., a vast majority), and which were not.Symptoms from the Attachment, Dominance, and Self domains(e.g., Unempathic, Manipulative, Self-centered) were generallyperceived as more prototypical of psychopathy than were symptomfrom the Cognitive and Behavioral domains. The symptoms Un-stable self-concept, Lacks Concentration, and Lacks pleasure werecommonly identified as not prototypical of the disorder (Clercx,Johnstone, Cooke, & de Ruiter, 2011; Flórez et al., 2014; Heinzen,Fittkau, Kreis, & Huchzermeier, 2011; Hoff, Rypdal, Mykletun, &Cooke, 2012; Kreis, Cooke, Michie, Hoff, & Logan, 2012; Shariat,personal communication, August 26, 2012; Sörman et al., 2014).

Confirmatory Factor Analyses (CFA) of prototypicality ratingsmade in English and Norwegian offered some support for theproposed structure of the CAPP (Hoff et al., 2012; Kreis et al.,2012). These CFA results indicated that the Attachment and Be-havioral domain were underpinned by unidimensional constructs,whereas the remaining domains achieved good fit after removal ofa few problematic symptoms (e.g., Lacks planfulness from theCognitive domain; Antagonistic from the Dominance domain;Lacks pleasure from the Emotional domain; Unstable self-conceptfrom the Self Domain). Together these findings suggest that theCAPP provides a concept map that is relatively stable across thestudied cultures (Cooke et al., 2012).

Current Study

The aim of the current study was to evaluate the validity of theCAPP as a lexically based concept map of psychopathy by inves-tigating the extent to which people with varying degrees of famil-iarity with psychopathic patients (i.e., undergraduate students vs.mental health workers) categorized the 33 CAPP symptoms intothe six domains proposed by the model’s developers. To do this,we used a card sort task. Card sort tasks are used to study howpeople make sense of the world around them by organizing infor-mation based on learning, experience, or preference (Coxon, 1999;cf. Rosch & Mervis, 1975). Card sort research is used in a widerange of scientific disciplines, including psychiatry and clinicalpsychology (e.g., Block, 1961; Iwamasa, Larrabee, & Merritt,2000; Davidson, Obonsawin, Seils, & Patience, 2003; Fowler &Lilienfeld, 2007; Shedler & Westen, 2007).

As discussed above, research using CFA of prototypicalityratings has provided some support for the validity of CAPP do-mains. But a card sort task provides a different and perhaps evenmore direct evaluation of people’s understanding of these domainsthan does CFA. It is possible that the domain structure could be agood conceptual model but not a good statistical model, or viceversa. Consider, for example, symptoms of psychosis. It makesgood conceptual sense to classify various hallucinatory experi-ences and disturbances in sense of reality into a symptom domainof “perceptual disturbances” as distinct from disturbances inthought content that may be grouped into a symptom domain of“delusions”—perception as a psychological function is distinctfrom thought. But factor analyses of psychotic symptoms typicallyfind that perceptual disturbances and delusions both load on asuperordinate factor sometimes referred to as “positive psychotic symp-

toms” as they commonly co-occur across patients. Also, card sort maybe preferable to CFA in some respects because it is less statisti-cally sophisticated and thus does not require assumptions regard-ing distributions of ratings and so forth.

In this study, we used a closed card sort, one in which thecategories (in this case, the CAPP domains) are specified a prioriby the researchers rather than generated by the participants them-selves. We examined the accuracy with which groups of lay peopleand mental health workers classified symptoms into their “correct”domains (i.e., as specified in the CAPP model), as well the speedwith which they classified symptoms. Next, we analyzed thecontent of group discussions concerning the classification of se-lected symptoms. We examined whether or not the groups rea-soned about the classification of symptoms or made the decisionswithout reasoning (i.e., intuitively). We predicted that if the lexicalbasis of the CAPP symptoms and the Norwegian translation isstrong, then lay people and mental health professionals alikeshould be able to categorize the symptoms into domains speedilyand intuitively. If the structure of the CAPP model is also plausi-ble, then both groups should be able to sort the symptoms into thedomains according to model.

Method

Participants

Two samples were recruited. The first sample comprised 110undergraduate students in psychology and nursing attending insti-tutions in southern Norway. They ranged in age from 19 to 51years (Mdn � 23 years). Most (92%) were female and almost all(97%) had Norwegian as their first language. Although we re-cruited this sample to get participants inexperienced in deliveringservices to personality disordered clients in health care settings,just over half (53%) reported some experience with this group(Mdn � 2 months, range 1 month to 26 years).

The second sample was recruited to get participants with a highlevel of experience in day-to-day interaction with personalitydisordered and most likely psychopathic clients. This sample com-prised 102 psychiatrists, psychologists, and nursing staff fromacute and forensic psychiatric wards in southern Norway. Themajority were nursing staff. They ranged in age from 20 to 62(Mdn � 41). About half the sample was female (45%) and most(89%) had Norwegian as their first language. In this sample almostall (94%) reported having worked with personality disorderedpatients for more than a year (Mdn � 8 years, range 1 month to 11years).

The participants were approached and recruited by a localcontact at the institutions where they studied or worked. Potentialparticipants attended an information session where they wereadvised of the nature of the study. No payment or other credit wasoffered. All those who attended consented to participate; therewere no refusals. All study procedures were reviewed by theRegional Ethics committee and deemed not to require approval.

Procedure

After filling out a brief demographic questionnaire, participantscompleted the card sort task in groups. There were a total of 48groups, 26 of students and 22 of health care workers, ranging in

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119DOMAINS OF PSYCHOPATHY

size from 3 to 6 participants. A researcher presented each groupwith six large (15 � 21 cm) laminated cards placed on a table. Onthe cards were printed the names of each CAPP domains and aone-sentence definition of the domain, taken from the NorwegianCAPP manual. (Because we were concerned that some participantsperhaps were unfamiliar with the terms Cognitive and Emotional,we decided to use the equivalent Norwegian terms for Thinkingand Feeling, respectively.) The researcher arranged the domaincards in a circle around the table, in the same way for all groups.The researcher then gave the Groups 33 smaller (10 � 15 cm)cards on which were printed the CAPP symptoms and definitions.The symptom cards were presented to groups one at a time, inrandom order (i.e., after the researcher shuffled the deck). Afterpresenting a symptom card, the researcher asked the group todiscuss it and sort it into the domain in which it belonged best.(The researcher did not tell groups how to reach this decision.) A3-min time limit was imposed on the sort for each symptom tolimit the overall time demand on participants (3 mins � 33symptoms � 99 mins). For each symptom, the researcher notedinto which domain it was sorted and the time it took to sort thesymptom. A voice recording was made of each group discussion.

Analyses

To examine accuracy, we calculated the mean proportion ofcorrect classifications (i.e., correct according to the CAPP model)for all symptoms, as well as individual symptoms within eachdomain. We also compared the proportion of correct classificationsacross the two samples.

To examine speed, we calculated the mean time taken to classifyall symptoms, as well as individual symptoms within each domain.We also compared the time taken to classify symptoms across thetwo samples and the time taken when symptoms were classifiedcorrectly versus classified incorrectly.

Finally, to examine the content of group discussions, we tran-scribed and coded the digital voice recordings using QSR Inter-national’s NVivo 10 software (QSR International, 2012). To keepthe number of group discussions to a manageable number, wedecided to focus only on the eight symptoms most often classifiedcorrectly and the eight symptoms most often classified incorrectly.Two independent raters coded whether the group discussions be-fore the sorting of these symptoms contained any reasoning forclassifications versus those that contained only statements of pref-erence.

Results

Accuracy of Classification

With only one exception, all groups sorted at least one symptomcorrectly within each domain (see Table 1). There was, however,considerable variation between domains in to what extent allsymptoms were sorted correct within domain. More than half ofthe groups sorted all symptoms correct within the Emotionaldomain, and about a third got all correct for the Self domain. Allsymptoms sorted correct was less common in the other domains(see Table 1).

Table 2 presents the frequency with which symptoms wereclassified into the six domains by the students and mental healthworkers. As is clear from inspection of the table, most groupssorted most symptoms correctly, that is, in a manner consistentwith the CAPP model. The number of correct classifications for allsymptoms by all groups was 1,119 of a total of 1,584. Theproportion of correct classifications for all symptoms across the 48groups ranged from .45 to .88, with a mean of .71 [SE � .11]. Thisis clearly many more than would be expected by chance alone. Oneway to estimate chance agreement is to assume that each symptomcould be classified into one of six domains with equal probability,and thus on average 5.50 of 33 symptoms, or .17, of the total,would be classified correctly by each group simply on the basis ofchance. Another way to estimate chance agreement, given thevarying number of symptoms per domain in the CAPP model andthe possibility that groups preferred to classify symptoms intosome domains more than others, is from the marginal distributionsof the observed and expected classifications symptoms with do-mains and the frequency of classifications to domains. Accordingto this approach, an average of 5.63 out of 33 symptoms, or .17 ofthe total, would be classified correctly by each group simply on thebasis of chance.

The overall mean proportion of correct classifications for the 26student groups was slightly but not significantly lower than that forthe 22 mental health worker groups, .69 [SE � .02] versus .73[SE � .01], respectively, t(39.26) � 1.66, p � .105, eta squared �.05 (equal variances not assumed).

Turning next to the correct classification of symptoms withindomains, there was some variability across domains. For the foursymptoms in the Attachment domain, the proportion of correctclassification by each of the 48 groups ranged from .00 to 1.00,with a mean of .64 [SE � .03]. For the six symptoms in the

Table 1Number of Groups Sorting at Least One Card and All Cards Correct Within Domain

CAPP domain

Students(n � 26 groups)

Mental health workers(n � 22 groups)

At least one cardsorted correctwithin domain

All cards sortedcorrect within

domain

At least one cardsorted correctwithin domain

All cards sortedcorrect within

domain

Total 26 0 22 0Attachment 25 3 22 2Behavioural 26 2 22 3Cognitive 26 4 22 2Dominance 26 0 22 1Emotional 26 15 22 10Self 26 5 22 7

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120 HOFF, RYPDAL, HART, COOKE, AND MYKLETUN

Behavioral domain, the proportion of correct classification rangedfrom .17 to 1.00, with a mean of .74 [SE � .02]. For the fivesymptoms in the Cognitive domain, the proportion of correctclassification ranged from .20 to 1.00, with a mean of .62 [SE �.03]. For the six symptoms in the Dominance domain, the propor-tion of correct classification ranged from .17 to 1.00, with a meanof .50 [SE � .03]. For the five symptoms in the Emotion domain,the proportion of correct classification ranged from .40 to 1.00,with a mean of .88 [SE � .02]. Finally, for the seven symptoms inthe Self domain, the proportion of correct classification rangedfrom .57 to 1.00, with a mean of .84 [SE � .02]. Overall, theproportion of correct classifications within domains for the studentgroups was similar to that for the mental health worker groups. AMANOVA comparing the proportions for the six domains for thetwo samples yielded nonsignificant results, Wilks � � .811, F(6,41) � 1.59, p � .174, partial eta squared � .19. Post hoc univar-iate analyses indicated that the only significant difference betweensamples was with respect to the proportion of correct classifica-tions in the Self domain, .80 [SE � .03] for student groups versus.88 [SE � .02] for mental health worker groups, t(44.61) � 2.59,p � .013, eta squared � .12 (equal variances not assumed).

Incorrect classifications apparently were not the result ofrandom error, but in fact reflected problems with a relativelysmall subgroup of symptoms. Six symptoms were sorted inac-curately by a majority of groups in both samples, together, theyaccounted for 216 of 465 incorrect classifications, or more than46% of all the errors. The first of these symptoms, Unempathic,falls in the Attachment domain according to the CAPP devel-opers, but it was frequently “lost” or misclassified to the Emo-tional domain. Unreliable falls in the Behavioral domain in theCAPP model, but was often lost to the Attachment domain.Inflexible falls in the Cognitive domain of the CAPP, but wasoften lost to the Behavioral domain. Antagonistic and Insincerefall in the Dominance domain of the CAPP, but both were lostmost often to the Behavioral domain. Finally, Self-justifyingfalls in the Self domain of the CAPP, but was most often lost tothe Cognitive domain.

We conducted univariate analyses to test differences betweensamples in the proportion of correct classifications. There weresignificant differences (p � .05) for only 5 of 33 symptoms. Inmost cases these differences were relatively unimportant becauseoverall the symptom was either correctly classified by the majority

Table 2Frequency With Which Symptoms Were Classified into Domains

CAPP Symptoms

Students(n � 26 groups)

Mental health workers(n � 22 groups)

A B C D E S A B C D E S

A1 Detached 21 1 4 20 2A2 Uncommitted 25 1 21 1A3 Unempathic 5 1 1 19 3 2 16 1A4 Uncaring 15 2 1 7 1 12 1 1 7 1B1 Lacks perseverance 23 1 1 1 22B2 Unreliable 17 6 2 1 11 10 1B3 Reckless 24 2 19 1 2B4 Restless 24 2 17 5B5 Disruptive 17 1 7 1 1 17 3 1B6 Aggressive 20 3 3 13 9C1 Suspicious 3 22 1 5 1 12 4C2 Lacks concentration 10 15 1 3 19C3 Intolerant 1 22 2 1 1 1 15 5C4 Inflexible 3 10 7 4 2 1 9 9 2 1C5 Lacks planfulness 5 14 7 5 14 3D1 Antagonistic 7 10 4 1 4 4 5 4 8 1D2 Domineering 1 23 2 4 18D3 Deceitful 2 7 17 10 1 9 1 1D4 Manipulative 1 1 1 23 2 20D5 Insincere 8 14 2 2 8 8 3 1 2D6 Garrulous 2 17 5 1 1 5 1 14 2E1 Lacks anxiety 5 21 1 19 2E2 Lacks pleasure 1 25 22E3 Lacks emotional depth 1 25 22E4 Lacks emotional stability 1 2 23 2 6 14E5 Lacks remorse 4 22 1 1 19 1S1 Self-centered 1 1 24 22S2 Self-aggrandizing 1 1 4 1 19 3 19S3 Sense of uniqueness 1 25 22S4 Sense of entitlement 1 5 20 22S5 Sense of invulnerability 1 1 24 1 21S6 Self-justifying 2 1 14 2 7 2 4 5 1 1 9S7 Unstable self-concept 26 1 21

Note. CAPP � Comprehensive Assessment of Psychopathic Personality (Cooke et al., 2004). Domains: A � Attachment, B � Behavioural, C �Cognitive, D � Dominance, E � Emotional, S � Self. Numbers with underline indicate correct classifications (i.e., classifications consistent with the CAPPmodel). Numbers appear in boldface when �50% of student or mental health worker groups classified a symptom into a single domain.

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121DOMAINS OF PSYCHOPATHY

of both groups or incorrectly classified by the majority of bothgroups. One symptom for which there was a significant difference,Garrulous, was incorrectly classified by the majority of studentgroups and correctly classified by the majority of mental healthworker groups. Garrulous falls in the Dominance domain of theCAPP, but in the majority of student groups and a minority ofmental health worker groups, it was lost to the Behavioral domain.

Speed of Classification

Overall, the card sort task was completed quickly comparedwith our expectations. Because of the imposed 3-min time limit forsorting each card, the maximum time groups could take to sort all33 symptoms was 1 hour and 39 minutes. The students usedbetween 7 and 37 minutes, spending on average only 21 minutesand 15 seconds (SD � 8 minutes and 49 seconds). Similarly, themental health worker groups used between 11 and 41 minutes,spending on average only 21 minutes and 56 seconds (SD � 7minutes and 19 seconds).

Next, we analyzed the mean time (in seconds) taken to classifysymptoms. These findings are presented in Table 3. Several pat-terns are evident in the table. First, looking at the combinedsamples, there was some variability in the average time taken toclassify symptoms from domains (as specified in the CAPP model,rather than by the groups who completed the card sort). A repeatedmeasures MANOVA comparing the mean classification speed forsymptoms within the six domains yielded statistically significantresults for within-groups effects, F(5, 235) � 13.18, p � .001(sphericity assumed). Post hoc contrasts compared each the mean

time to classify symptoms within domains to the grand mean. Themean time to classify symptoms in the Attachment and Behav-ioral domains did not differ significantly from the grand mean.But the mean time to classify symptoms in the Self and Emo-tional domains was significantly less than the overall mean, andthe mean time to classify symptoms in the Dominance andCognitive domains was significantly greater than the overallmean, all p � .007.

Second, comparing the classification speed for correct versusincorrect decisions, it is apparent that correct classifications weremade much more quickly than incorrect classifications—typically,almost twice as long.

Third, comparing the classification speed for students versusmental health workers, students tended to classify symptomsslightly faster than did mental health workers overall. However,this differences was not statistically significant, t(45.99) �0.98, p � .333 (equal variances not assumed), d � 0.29. Thesame pattern held true when looking at time for correct classi-fications, t(45.94) � 0.77, p � .444 (equal variances notassumed), d � 0.22, and time for incorrect classifications,t(44.32) � 1.79, p � .080 (equal variances not assumed), d �0.52.

The differences between domains in classification speedclosely paralleled those in classification accuracy. Also, correctclassifications took less time than incorrect classificationswithin domains. To evaluate the extent to which this held truefor individual symptoms, we plotted mean classification timeby the percentage of incorrect classifications across groups. Thebivariate scatter plot (see Figure 2) revealed a strong associa-tion; the correlation was r � .87, p � .001.

Group Discussions of Classification

Two independent raters coded the group discussions for theeight symptoms most often classified correctly (Uncommitted,Lacks perseverance, Lacks pleasure, Lacks emotional depth,Self-centered, Sense of uniqueness, Sense of invulnerability,and Unstable self-concept) and the eight symptoms most oftenclassified incorrectly (Unempathic, Unreliable, Inflexible, An-tagonistic, Deceitful, Insincere, Garrulous, and Self-justifying).The raters were able to code a total of 723 group discussions.(For two groups, all group discussions could not be transcribedor analyzed due to technical problems with the recordings, andthe same was true for a small number of other group discussionsfor individual symptoms.) The coding was a simple dichoto-mous judgment regarding whether any reasoning was present(no vs. yes). The raters agreed on the coding for 616 of 723group discussions, corresponding to an overall agreement rateof 85% and Cohen’s � of .68 [95% CI .62, .73]. For thepurposes of analysis, we considered the group discussion tocontain reasoning if at least one of the raters coded it as present.

To illustrate the nature of the group discussions, Table 4presents verbatim quotes from selected group discussions forthe 8 symptoms most often classified incorrectly. For each ofthese symptoms, we present discussions with and without rea-soning. These quotes support the view that the absence ofreasoning was associated with intuitive classification.

Overall, 43% of the group discussions for all symptomscontained reasoning. Reasoning was present in 59% of the

Table 3Mean Time (in Seconds) Taken to Classify Symptoms WithinCAPP Domains

SampleCAPP domain

All Correct Incorrect

M SE M SE M SE

Combined (n � 48)Total 40 2 31 2 58 3Attachment 39 3 33 4 46 5Behavioral 38 3 31 3 51 5Cognitive 47 3 38 3 60 6Dominance 52 3 33 3 69 5Emotional 33 3 30 3 63 10Self 28 2 22 2 64 7

Students (n � 26)Total 38 3 30 3 53 4Attachment 35 4 31 6 42 7Behavioural 36 4 30 4 44 6Cognitive 47 4 39 5 57 7Dominance 50 4 30 3 65 6Emotional 27 4 26 4 52 12Self 31 3 24 3 61 9

Mental health workersTotal 42 3 33 3 64 5Attachment 43 5 36 6 50 9Behavioural 41 4 32 4 61 7Cognitive 47 5 36 4 63 11Dominance 55 5 38 4 72 8Emotional 40 5 36 5 73 15Self 25 4 19 3 68 12

Note. CAPP � Comprehensive Assessment of Psychopathic Personality(Cooke et al., 2004).

Thi

sdo

cum

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ghte

dby

the

Am

eric

anPs

ycho

logi

cal

Ass

ocia

tion

oron

eof

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lied

publ

ishe

rs.

Thi

sar

ticle

isin

tend

edso

lely

for

the

pers

onal

use

ofth

ein

divi

dual

user

and

isno

tto

bedi

ssem

inat

edbr

oadl

y.

122 HOFF, RYPDAL, HART, COOKE, AND MYKLETUN

group discussions for the 8 symptoms most often classifiedincorrectly, but in only 27% of the groups discussions for the 8symptoms most often classified correctly. This is consistentwith our prediction that most symptoms would be classifiedintuitively, that is, without much need for discussion or debateabout the reasons for classification.

Discussion

The findings of the present study show that people, regardless ofwhether they are mental health workers with day-to-day experience inrelating to psychopathic patients or simply laypeople (students), wereable to sort symptoms into domains as specified in the CAPP modelin a way that was reasonably accurate, as well as speedy and intuitive.

Specifically, the findings suggest that the lexical nature of themodel is successful in facilitating people’s ability to understandfeatures of a complex clinical condition in a way that requireslimited cognitive effort. Furthermore, the findings suggest that themodel’s hierarchical structure—the grouping of symptoms intodomains of personality function—is plausible or makes sense topeople. Together, these findings support the validity of the CAPPmodel as a lexical concept map of psychopathy.

Exceptions/Qualifications

There were, however, some exceptions to the general pattern offindings discussed above. First, the accuracy with which symp-toms were classified into domains was nowhere near perfect.Second, the ease (accuracy, speed, and effort) with which symp-toms were classified varied to some degree across domains.Groups appeared to have difficulty correctly classifying some

symptoms from the Dominance and second in the Cognitive do-mains, which they quite frequently misclassified to the Behavioraldomain. Third, the ease of classification was not the same forsymptoms within a given domain. Most of the classification errors,for example, were attributable to a relatively small number ofsymptoms. Fourth, there were some differences, albeit small forthe most part, with respect to the ease with which students andmental health workers classified symptoms.

One possible explanation for at least some of these exceptions isthat the CAPP domains were not very well defined or very wellspecified—that is, the developers grouped symptoms into domainsin ways that don’t make good “common sense.” (That is, thedomains are difficult to understand.) A second possible explana-tion is that the CAPP domains made good sense to people, but thatpeople had difficulty understanding the definitions of some symp-toms or their associations with the construct of psychopathy. (Thatis, some symptoms are difficult to understand.) A third possibleexplanation is that some symptoms and domains are not clearly oreasily distinguishable from each other. (That is, the domains andsymptoms are complex.) For example, it could be that a particularsymptom straddles two domains, or that some domains naturallyoverlap to some extent, or that the CAPP developers grouped thesymptoms in the wrong domains. We now discuss which expla-nations seem most likely in light of the available evidence.

That the domains generally do not make sense or are difficult tounderstand is not plausible. First because the overall rate of correctclassification and the rate of correct classification of symptomswith domains were much higher than would be expected bychance. Furthermore, people in general tend to think and storeinformation in basic level categories (i.e., symptom-level) rather

Figure 2. Mean time to sort card versus proportion of cards sorted according to the CAPP concept map. Resultsfrom 48 groups, each sorting 33 cards in six groups. Symptom names are provided in Table 1. Each dot/labelrepresents the mean time to sort card and the proportion of cards sorted according to the CAPP concept mapacross 48 groups.

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ocia

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publ

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Thi

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tend

edso

lely

for

the

pers

onal

use

ofth

ein

divi

dual

user

and

isno

tto

bedi

ssem

inat

edbr

oadl

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123DOMAINS OF PSYCHOPATHY

Tab

le4

Sele

ctiv

eQ

uote

sF

rom

Gro

upD

iscu

ssio

nsW

ith

Reg

ard

toIn

corr

ectl

ySo

rted

Sym

ptom

s

Dis

cuss

ions

with

out

reas

onin

gD

iscu

ssio

nsw

ithre

ason

ing

A3

Une

mpa

thic

•E

mot

ions

..

.ye

s.

..

defi

nite

lyem

otio

ns(s

tude

ntgr

oup)

•I

belie

vea

psyc

hopa

this

able

toun

ders

tand

man

yth

ings

,bu

the

does

n’t

feel

(M.H

.W.

grou

p)•

Em

otio

ns.

..

doyo

uag

ree?

..

.em

otio

ns.

..

orat

tach

men

t.

..

Isa

ym

ore

emot

ions

..

.em

otio

nsth

en(S

tude

ntgr

oup)

•Y

ouca

n’t

put

your

self

into

othe

rpe

ople

’sun

ders

tand

ing—

how

they

’re

doin

g-

beca

use

you

don’

tfe

elan

ythi

nglik

eit

your

self

(Stu

dent

grou

p)•

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otio

ns.

..

Ibe

lieve

so(M

.H.W

.gr

oup)

B2

Unr

elia

ble

•A

ttach

men

tto

othe

rs.

..

not

trus

twor

thy

..

.at

tach

men

t.

..

yes

(Stu

dent

grou

p)•

Atta

chm

ent?

..

.ye

s.

..

yes

(Stu

dent

grou

p).

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ota

bit

the

feel

ing

it’s

atta

chm

ent

..

.ye

s,be

caus

e.

..

..

..

yes,

let’

spu

tit

onat

tach

men

t(M

.H.W

.gr

oup)

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ttach

men

t.

..

my

firs

tth

ough

tto

o.

..

yes

..

.at

tach

men

t(M

.H.W

.gr

oup)

•A

ttach

men

t.

..

atta

chm

ent,

not

bein

gre

liabl

e(S

tude

ntgr

oup)

•M

ost

likel

yat

tach

men

t.

..

yes,

or.

..

..

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ould

we

gofo

rat

tach

men

t?.

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let’

s.

..

yes

(Stu

dent

grou

p)

•T

here

isa

reas

onw

hyon

eis

unre

liabl

e,on

eha

sa

sens

eof

com

mitm

ent

toot

hers

,or

rath

erla

ckth

ereo

f.

..

you

dono

tac

hiev

eat

tach

men

tif

you’

reun

relia

ble

..

.if

you

don’

tfe

elan

yat

tach

men

tto

othe

rsth

enth

ere’

sno

reas

onto

stic

kto

agre

emen

ts,

itdo

esn’

tm

ean

anyt

hing

,bu

tit’

sbe

havi

orto

o.

..

it’s

your

beha

vior

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isun

relia

ble

..

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know

..

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ffic

ult

this

one

(M.H

.W.

grou

p)•

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ink

it’s

diff

icul

tto

becl

ose

and

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ched

toot

hers

ifyo

u’re

not

trus

twor

thy

and

resp

onsi

ble

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uca

n’t

atta

chto

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rsif

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C3

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Thi

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goei

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havi

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cogn

itive

styl

e,bu

tbe

havi

oris

mor

ean

effe

ctof

your

cogn

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styl

e,so

then

we’

reba

ckto

caus

ality

agai

n(M

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oup)

D1

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agon

istic

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omin

ance

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s.

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chm

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(stu

dent

grou

p)•

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sto

bea

bit

like

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ddo

min

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-bet

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ould

say

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havi

or(M

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ould

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cess

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upto

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som

ethi

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you

coul

dbe

host

ilew

ithou

tw

antin

gso

met

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from

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does

n’t

have

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esse

din

beha

vior

eith

er,

but

usua

llyis

(Stu

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It’s

defi

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sdo

neon

purp

ose

then

it’s

dom

inan

ce.

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ina

way

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too

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sm

ore

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rolle

d,do

neon

purp

ose

(Stu

dent

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omin

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rhap

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vior

(Stu

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inI

thin

kit’

sso

met

hing

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do,

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lie,

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wan

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achi

eve

som

ethi

ng,

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conc

rete

beha

vior

,an

actio

n.

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beha

vior

then

(M.H

.W.

grou

p)•

Beh

avio

r.

..

beha

vior

..

.ha

sto

be.

..

mos

tlybe

havi

or.

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(M.H

.W.

grou

p)•

Dom

inan

ce.

..

dom

inan

ceor

beha

vior

..

.a

bit

onat

tach

men

tto

o.

..

dom

inan

ceor

atta

chm

ent

..

.w

hat

doyo

uth

ink?

..

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vote

for

atta

chm

ent

..

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s,A

gree

(Stu

dent

grou

p)

•T

obe

dece

itful

isan

expr

essi

onof

beha

vior

and

thin

king

..

.bu

tit

isal

sodo

min

ance

inth

ese

nse

that

you

cont

rol

othe

rs.

..

dom

inan

ce.

..

beha

vior

wou

ldbe

my

seco

ndal

tern

ativ

e(S

tude

ntgr

oup)

D5

Insi

ncer

e•

Dom

inan

ce.

..

or.

..

..

.do

min

ance

..

.or

beha

vior

perh

aps

..

.be

havi

or(S

tude

ntgr

oup)

•It

’sdi

ffic

ult

..

.su

perf

icia

lan

dsl

ick

isbe

havi

or.

..

yes

(Stu

dent

grou

p)•

Supe

rfic

ial,

imm

edia

tely

thou

ght

emot

ions

..

.it‘

sbe

havi

orin

ther

eto

o.

..

supe

rfic

ial

slic

kbe

havi

or.

..

beha

vior

(M.H

.W.

grou

p)

•H

avin

gan

evas

ive

beha

vior

..

.be

ing

supe

rfic

ial,

slic

kan

dev

asiv

eis

beha

vior

..

.bu

tyo

uca

n’t

rela

teto

othe

rs,

then

it’s

atta

chm

ent,

the

way

you

atta

chto

othe

rsor

not

isbe

havi

or.

..

Isa

ybe

havi

or.

..

(M.H

.W.

grou

p)•

Dom

inan

ceor

beha

vior

..

.co

uld

gose

vera

lpl

aces

..

.it

refl

ects

beha

vior

,bu

tco

uld

beus

edto

dom

inat

e.

..

coul

dbe

used

for

othe

rth

ings

asw

ell

..

.I

say

beha

vior

(M.H

.Wgr

oup)

Thi

sdo

cum

ent

isco

pyri

ghte

dby

the

Am

eric

anPs

ycho

logi

cal

Ass

ocia

tion

oron

eof

itsal

lied

publ

ishe

rs.

Thi

sar

ticle

isin

tend

edso

lely

for

the

pers

onal

use

ofth

ein

divi

dual

user

and

isno

tto

bedi

ssem

inat

edbr

oadl

y.

124 HOFF, RYPDAL, HART, COOKE, AND MYKLETUN

than higher level or superordinate categories (i.e., domains) (Rosch& Mervis, 1975; Rosch, Mervis, Gray, Johnson, & Boyesbraem,1976). A brief explanation may be warranted. People tend to beable to identify significantly more attributes for basic-level cate-gories (e.g., hammer, chair, car) than for superordinate categories(e.g., tool, furniture, vehicle). People also tend to use basic-levelnames (e.g., table, bird) more frequently to identify objects thansuperordinate- (e.g., furniture, animal). Consequently, one wouldexpect the students to have more difficulty classifying symptomsinto domains than did the mental health workers due to the rela-tively limited training and experience of the former compared tothe latter. This was not the case—the rate of accuracy and the timespent on the card sort was similar across samples.

The second explanation, that people had difficulty understand-ing the definitions of some symptoms or their associations with theconstruct of psychopathy, is plausible. Yet, with regard to the latterthere is no clear association between incorrect classification ratefor individual symptoms and prototypicality ratings in earlierstudies (Flórez et al., 2014; Heinzen et al., 2011; Hoff et al., 2012;Kreis et al., 2012). In other words, none of the “problematic”symptoms in the current study has been identified as among theleast central symptoms to the construct of psychopathy, that isperhaps at the border or outside of the psychopathy construct(typically Lacks pleasure, Lacks concentration, and Unstable self-concept). Furthermore, even though groups spent more time on theinaccurately sorted symptoms, which suggest that more cognitiveeffort was needed, there is nothing in the group discussions toindicate that this was attributable to a lack of understanding of thebasic definition of the symptoms. This suggests a possible problemwith understanding the association of symptoms with the domain.There is some evidence from the group discussions to suggest thatthis may apply to Garrulous, but also that it was a problem forstudents only, who in contrast to mental health workers perceivedthe symptom primarily as behavioral (being talkative) withoutacknowledging its functional link to dominance. We speculatewhether this could be attributable to the relative lack of experienceamong students from work with psychopathic patients, who per-haps more noticeably than others are garrulous as a means todominate interactions. However, Garrulous was also early identi-fied by the translators as difficult to translate into Norwegian witha clear denotation or connotation toward dominance (Hoff et al.,2014). In the above mentioned Norwegian prototypicality study(Hoff et al., 2012), fit for the dominance domain was also im-proved when removing Garrulous from the CFA, which was notthe case in the equivalent prototypicality study in English (Kreis etal., 2012). Together this suggests that there is a possible transla-tional issue that needs to be resolved before one could draw anyfirm conclusions regarding the status of the garrulous in the model,at least based on Norwegian CAPP data.

The third possible explanation for the exceptions to theoverall patterns of accuracy—that some symptoms and domainsare not clearly or easily distinguishable from each other, or thatthe CAPP developers were wrong in their grouping of a fewsymptoms—is plausible. Many groups experience at least somedifficulties differentiating especially the dominance domainfrom the behavioral domain. Based on the group discussions itseems likely that this happened because many, although recog-nizing that the function of the symptoms could be dominancestill “added more weight” to their (overt) behavioral aspectsT

able

4(c

onti

nued

)

Dis

cuss

ions

with

out

reas

onin

gD

iscu

ssio

nsw

ithre

ason

ing

D6

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rulo

us•

Beh

avio

r,ye

s?.

..

Ith

ink

beha

vior

too

..

.be

havi

or(s

tude

ntgr

oup)

•B

ehav

ior

..

.do

min

ance

perh

aps

..

.be

havi

or.

..

let’

sgo

for

beha

vior

(Stu

dent

grou

p)•

Beh

avio

r?.

..

bein

ggl

ibin

the

way

you

spea

k,th

at’s

aw

ayof

beha

ving

..

.ye

s(S

tude

ntgr

oup)

•D

omin

ance

..

.pr

eten

tious

isbe

havi

orac

tual

ly.

..

beha

vior

(M.H

.W.

grou

p8)

•I

imm

edia

tely

thou

ght

beha

vior

,bu

tI’

mno

tsu

re,

coul

dbe

dom

inan

cebe

caus

eyo

uca

nse

eit

asm

anip

ulat

ion

(M.H

.W.

grou

p)•

It’s

unde

rbe

havi

or,

ane

edto

talk

all

the

time

(Stu

dent

grou

p)•

It’s

am

anip

ulat

ing

and

dom

inat

ing

beha

vior

..

.it’

sab

out

getti

ngin

cont

rol,

but

whe

ther

itis

beha

vior

ordo

min

ance

..

..

..

.it’

sok

topu

tit

ondo

min

ance

..

.be

caus

eit

isa

way

ofge

tting

cont

rol

over

othe

rsin

inte

ract

ions

,th

at’s

wha

tit

is(M

.H.W

.gr

oup)

S6Se

lfju

stif

ying

•Se

lf?

Self

orth

inki

ng.

..

thin

king

,co

uld

bebo

th.

..

thin

king

(Stu

dent

grou

p12

)•

Self

perh

aps

..

.w

hy?

..

.a

way

toju

stif

yon

esac

tions

..

.I

thin

kit’

sa

cogn

itive

tool

,an

effe

ctiv

est

rate

gy(S

tude

ntgr

oup)

•I

belie

veth

inki

ng.

..

real

lyno

tsu

re.

..

coul

dbe

beha

vior

..

.m

inim

izin

g.

..

thin

king

?.

..

shou

ldw

eso

rtit

toth

inki

ng?

..

.ye

s(S

tude

ntgr

oup

25)

•If

you

perc

eive

your

self

abi

tsp

ecia

lth

enyo

um

inim

ize

your

own

faul

ts,

refu

seto

acce

ptcr

itiqu

e,it’

sa

bit

syno

nym

ous

toin

tole

rant

(Stu

dent

grou

p)•

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?.

..

coul

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125DOMAINS OF PSYCHOPATHY

(i.e., Antagonistic, Deceitful, Insincere, Garrulous). In both thementioned prototypicality studies, only Antagonistic had to beremoved from the CFA to achieve good fit in the dominancedomain (in addition to Garrulous in the Norwegian study only).Together this suggests that perhaps Antagonistic is at the borderof the domain or even more strongly associated with symptomsin other domains (e.g., Suspicious, Intolerant, Aggressive, Dis-ruptive). That some symptoms link to two domains seems (also)a plausible explanation in regard to Self-justifying, which de-spite the fact that the symptom included the term “self” wascategorized to the cognitive domain instead of to the proposedSelf domain by many groups (especially students). This isperhaps not that surprising as Self-justifying and especially itsdefining adjectives Minimizing, Denying, and Blaming implycognitive mechanisms used to avoid accepting responsibility forown actions (protecting Self).

Perhaps the strongest evidence that the CAPP developersincorrectly constructed domains would be if a majority of bothmental health workers and students categorized a symptom intothe “wrong” domain. This was the case only for two symptoms,Unempathic and Unreliable. The group discussions suggestedthat participants, when sorting Unempathic almost exclusivelyto the Emotional instead of to the Attachment domain, had arationale consistent with the views of Schneider (1923) andBlair (2008; both cited in Domes, Hollerbach, Vohs, Mokros, &Habermeyer, 2013), who argued for an emotional basis (feelingcompassion) behind the lack of empathy in psychopathy. Withregard to Unreliable, the group discussions indicated that manygroups acknowledged the symptom could have been sorted tothe Behavioral domain (as proposed by the model), yet sorted itto the Attachment domain. It is perhaps noteworthy that in theliterature on psychopathy, unreliability typically has been con-ceptualized as irresponsible behavior, but it is important to notethat such behavior almost always occur in the context of or arerelevant to interpersonal relationships (e.g., failure to upholdspousal, parental, employment, financial, legal, or other obli-gations and commitments to others). For example, the PCL-Rmanual highlights the relational aspects of unreliability in thedefinition of Irresponsibility (Item 15): “an individual whohabitually fails to fulfill or honor obligations and commitmentsto others” (Hare, 2003, p. 43). Thus, although CFA of proto-typicality ratings have indicated that Unreliable is statisticallyrelated to the other symptoms in the proposed Behavioral do-main (Hoff et al., 2012; Kreis et al., 2012), the symptom seemsto have strong conceptual relations to symptoms in the attach-ment domain. As one of the participants in the present studyremarked, “If you don’t feel attachment to others then there isno reason to stick to agreements, it doesn’t mean anything, butit is behavior too.” This issue warrants further investigation.

Methodological Issues

In the current study a group-based, closed card sort was chosen.The closed variant with predetermined categories resembles astatistical CFA and thus made a comparison with findings fromCAPP studies that have used CFA possible. We also believe aclosed card sort provided the most direct test of the CAPP authorsgrouping of symptoms. If participants were instructed to definenumber of categories and their labels, this would be called an open

sort. Such a task would perhaps be an even stronger test of themodel. It could also produce other possible ways to categorize thesymptoms. An open version was tested in a pilot, but was rejectedbecause sorting symptoms without specifying domains in advancetook much more time than the closed sort.

A group setting was chosen because we wanted to know moreabout people’s rationale for grouping any symptoms (systemati-cally) differently than specified in the CAPP model. Client-relatedwork within mental health and prison settings also typically goeson in group or team settings where a common understanding of thelanguage used to describe patients is vital. Yet, relying on groupsinstead of individuals may have affected the results. For instancewe, by instructing groups to come to a joint (consensus) decision,by imposing a time-limit and registering time spent on each card,may have contributed to conformity pressures like false consensusbias and bandwagon effects. Perhaps more importantly from aqualitative perspective, we did not get as much information as wehoped for concerning the reasons people had for disagreeing withmodel when they did. In fact, more often than not it was impos-sible to understand why or how groups came to a decision, whichwas rather unexpected. Accordingly, our analyses of group dis-cussions must be interpreted with caution. Future CAPP card sortcould consider using a design that combines cards sorts performedindividually (to increase sample size), followed by focus groups(to extract more qualitative information).

Furthermore, we could not determine whether participants sortedsymptoms based on how they perceived words were conceptuallyrelated to domains versus similarities among words at a superficiallinguistic level. For instance, several symptoms in the Self domaincontain the word “self,” and all symptoms in the Emotional domainstart with the word “lacks.” But if participants had sorted symptomsbased on superficial linguistic cues, Self-justifying should have beensorted consistently to the Self domain. It was not. Instead, many(most) groups sorted it to the Cognitive domain. Furthermore, severalsymptoms that did not begin with the word “lacks” were sorted bygroups to the Emotional domain. Although these findings are reas-suring and suggest participants sorted words conceptually, future cardsort studies could be designed to more directly encourage conceptual-based sorting. For instance, participants could also be asked to rank-order the symptoms within each domain based on their perceivedrelevance to psychopathy.

The samples used in the current study differed with respect toseveral demographic characteristics. The student sample containedmore young people and more females than did the sample of mentalhealth workers. Furthermore, the latter group was more heterogeneousin terms of age and educational level. Participants were recruitedwithout concern for these demographic characteristics. In addition,groups within each sample were formed unsystematically, and thesorting reflected group rather than individual decisions. Thus, wewere unable to investigate the influence of demographics character-istics on sorting, either at the group or individual level.

The current study was based on the Norwegian translation of theCAPP. To rule out the possibility of specific translational orcultural effects future research should investigate whether themodel replicates in cards sorts in the original English version aswell as more diverse languages and cultures. This is importantbecause according to the lexical hypothesis, if an attribute have acorresponding concept in virtually any language, “such an attribute

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126 HOFF, RYPDAL, HART, COOKE, AND MYKLETUN

would have a major claim to importance in a pancultural sense”(Saucier & Goldberg, 2001, p. 849).

Finally, it might be argued that it is a mistake to trust a lexicalmodel to tell us anything meaningful (i.e., valid, truth-like) aboutthe nature of a complex mental disorder like psychopathy. Thegeneral concern actually comprises at least two specific concerns.One is that linguistic terms are inherently fuzzy. It is difficult todefine them precisely and consensually (Block, 1995). For in-stance, consider Aggressive, which is used frequently in English.Synonyms include assertive, hostile, and violent. In the CAPP,Aggressive is defined as threatening, violent, and bullying (i.e., inthe sense of being brutal rather than forceful). The fact thatparticipants in this study were able to categorize the symptomsspeedily, fairly consistently, and accurately suggests that the lex-ical approach used to develop the CAPP did not result in adverselyor unduly fuzzy symptom definitions. (This is further supported bythe fact that previous research found prototypicality ratings ofCAPP symptoms in different languages are consistent both withinand between studies; e.g., Hoff et al., 2014.)

A second concern is that the lexical approach used to develop theCAPP may result in a limited or restricted lexicon (e.g., Block, 1995).For example, it may be that the process of breaking complex symptomconstructs, such as narcissistic, into common language adjectivesresults in the loss of important denotative or connotative meaning, atleast with respect to clinical practice. The findings from this study,however, support the view that what is included in the CAPP modelis meaningful to Norwegians, and therefore can be used to commu-nicate about psychopathy in a way that is understandable to patients,their family, staff, and the general public.

To conclude, the findings of the current study add weight to thevalidity of the CAPP as a concept map and suggest that the lexicalnature of the model is successful in facilitating people’s ability tounderstand and communicate about features of psychopathy in a waythat requires limited cognitive effort. This can be of importanceespecially in high-stake clinical settings where people need to com-municate efficiently concerning symptoms that might be of relevancewhen it comes to treatment planning and violence risk formulation.

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128 HOFF, RYPDAL, HART, COOKE, AND MYKLETUN