Criminal Behaviour and Mental Health21: 279–294 (2011)Published online 5 April 2011 in Wiley Online Library

Psychopathy and lifetimeexperiences of depression

(wileyonlinelibrary.com) DOI: 10.1002/cbm.812

JOCHEM WILLEMSEN, STIJN VANHEULE AND PAUL VERHAEGHE,Department of Psychoanalysis and Clinical Consulting, Ghent University,Ghent, Belgium

ABSTRACTBackground Previous studies have investigated an association between psychopathyand depression as part of the broader study of co‐morbidity between psychopathy andAxis I psychopathology or as part of validity tests for psychopathy. These study methodshave, however, been limited, for example, by exclusive use of questionnaires, orcategorical measures of depression, and by low base rates of psychopathology.Aims Our aims were to extend previous research on psychopathy and depression and totest the hypothesis that total Psychopathy Checklist – Revised (PCL‐R) scores, and thefour facets of interpersonal, affective, lifestyle and anti‐social behaviour, would benegatively associated with depressive symptom scores.Methods Dimensional measures of psychopathy and lifetime major depression werederived from structured interviews (the PCL‐R and the Structured Clinical Interviewfor Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised)with adult male prisoners. The emotional experience of depression was also studiedthrough analysis of the narratives used by the men to describe their depressivesymptoms.Results The PCL‐R scores, and in particular the interpersonal, affective and lifestylefacets of the PCL‐R, were inversely associated with depression scores.Conclusion Our findings suggest that psychopathy does influence the way depression isexperienced. Copyright © 2011 John Wiley & Sons, Ltd.

Introduction

Mood disorders are among the most common psychological disorders in thegeneral population (Kessler et al., 2007). Studies that make a direct comparisonbetween prison and community samples have found a higher prevalence of majordepression among prisoners, even after taking into account sex, race, age andeducation (Bland et al., 1998; Butler et al., 2006). Nevertheless, it has beenasserted that people with psychopathy are almost devoid of depressive symptoms

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280 Willemsen et al.

(Lovelace and Gannon, 1999; Stinson et al., 2005) and that perhaps psychopathyand depression are mutually exclusive. Indeed, a grandiose and dominantinterpersonal style and lack of guilt or remorse, supposedly characteristic ofpsychopathy, seem incompatible with depression. Cleckley (1976, p. 348), in TheMask of Sanity, made no direct statements about this, but there are indications thathe considered the two concepts to be mutually exclusive. He described, forexample, how ‘even in the situations of squalor and misery into which herepeatedly works himself, when confined in jails […] he does not show anythingthat could be called woe or despair or serious sorrow. He becomes vexed andrebellious and frets in lively and constant impatience when confined, but he doesnot grieve as others grieve’. There is only one individual (Joe) who describedbecoming very depressed at times when ruminating over the magnitude of hisfailure, but his sincerity about this is questionable because he behaved cheerfully inthe hospital ward and talked with a certain pride about his escapades.

For studies with adult men, we searched for references in theWeb of Science, inPubMed and in the manual of the Psychopathy Checklist – Revised (PCL‐R; Hare,2003) that measured psychopathy with the PCL‐R, or its screening version (PCL‐SV), and depression. Such studies take one of two approaches: either examining thisassociation as part of a broader study on co‐morbidity between psychopathy andAxis I psychopathology or studies that consider depression as an external validitycriterion for psychopathy. Within the first group of studies, we found seven studiesthat tested for a statistical association between psychopathy and a diagnosis of majordepressive disorder in terms of Diagnostic and Statistical Manual of MentalDisorders (DSM) or International Classification of Diseases classifications(Stalenheim and von Knorring, 1996; Rutherford et al., 1997; Blackburn andCoid, 1998; Rasmussen et al., 1999; Blackburn et al., 2003; Assadi et al., 2006;Pham et al., 2007). Six of them did not find any significant association; onlyStalenheim and von Knorring (1996) found that forensic psychiatric patientswith acategorical diagnosis of depression had lower PCL‐R scores. Within the secondstudy group, we found five studies that used questionnaires to measure depression asa dimensional variable as a test of external validity of psychopathy (Andersen et al.,1999; Hare, 2003; Stinson et al., 2005; Hicks and Patrick, 2006; Douglas et al.,2007). Based on PCL‐R scores, Andersen et al. (1999) found no significantdifferences in depression between groups. The correlation coefficients found in theother four studies are summarised in Table 1.

Based on these results, it seems that psychopathy and a diagnosis of depressiveillness are not mutually exclusive but rather independent constructs.

Both approaches, however, have drawbacks. Categorical diagnoses of majordepression have the advantage of being specific but may miss clinically relevantsubthreshold depression and reduce recordable variability among respondents insymptom range and severity. Some of the studies just mentioned may have failedto find an association between psychopathy and depression because of the lossof statistical power associated with dichotomising a variable, which is truly

Copyright © 2011 John Wiley & Sons, Ltd 21: 279–294 (2011)DOI: 10.1002/cbm

Table 1: Correlation coefficients between psychopathy and depression in previous studies on maleoffenders

Study Samplesize

Instrument PCL‐Rtotal

Interpersonal/affective

Lifestyle/anti‐social

Douglas et al.(2007)

218 PAI – depression 0.01 0.05 0.0485 PAI – depression −0.02 −0.10 0.15

Hare (2003) 247 BDI −0.14 −0.12 −0.09Hicks and Patrick(2006)

112 BDI and PANASPA

0.04 −0.22* 0.23*

Stinson et al.(2005)

68 BDI‐II 0.19** 0.08 0.22

Note: BDI = Beck Depression Inventory; PAI – depression = Personality Assessment Inventory –Depression Scale; PANAS PA=Positive and Negative Affect Schedule – Positive Affect Scale;PCL‐R=Psychopathy Checklist – Revised.*p≤ 0.05.**p≤ 0.01.

Psychopathy and lifetime experiences of depression 281

continuous (Cohen et al., 2002). Moreover, some studies had to contend with lowbase rates of categorical diagnoses of depression and/or psychopathy, also reducingpower. In two studies, base rates of major depression below 10%made it impossibleto do any statistical analysis at all (e.g. Hart and Hare, 1989; Hildebrand and deRuiter, 2004).

An alternative approach would lie in dimensional measures of depression,although they may lack specificity. Depression questionnaires generally measuremaladaptive function instead of specific depressive symptoms, being saturated withitems sensitive tomild distress (Clark andWatson, 1991; Coyne, 1994).High scoresmay indicate not only depressive symptoms but also general distress withoutdepression, physical symptoms of amedical condition or side effects of medication orillicit drugs; interpretation of such scale scores is not straightforward. This problemhas been observed in student populations (Coyne, 1994), community samples(Horwitz, 2007), alcoholics (Hagan and Schauer, 1985) and physically sick people(Fisher et al., 2007). Such concerns are relevant to the study of depression amongoffenders as, for example, research on the impact of prison environment shows thatlack of activity and mental stimulation can lead to stress, anger and frustration(Nurse et al., 2003); likewise, decisions on parole and family matters have beenshown to provoke strong emotional fluctuations (Yang et al., 2009), as has prisoncrowding (Lawrence and Andrews, 2004) and strict confinement (Blatier, 2000).Insomnia and weight gain or loss in prisoners are not only caused by depression butalso often have other explanations (Shaw et al., 1985; Elgar and Sekera, 2009).

Thus, as questionnaires do not function well in terms of differentiating betweendepressive‐like complaints and symptoms of major depressive disorder rather thandemonstrating that depression and psychopathy are independent constructs, thevalidation studies just described may demonstrate that general distress and

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282 Willemsen et al.

psychopathy are independent constructs. This would fit with the proposition byCleckley (1976, p. 348) that the psychopath can become ‘vexed and rebellious andfrets in lively and constant impatience when confined’, but such studies are not veryinformative with regard to the question of psychopathy and depression.

In addition to issues around depression measures, use of the PCL‐R varies.Factor‐analytical studies on the PCL‐R indicate that the traditional two‐factormodel can be broken down into three (Cooke and Michie, 2001) or four facets(Hare, 2003). Studies of psychopathy–depression relationships to date, however,have used only total scores or the two‐factor model. Where tested, more negativeassociations have been found between the interpersonal/affective traits of psy-chopathy and depression. Neurobiological research suggests that both impulsive/aggressive features of psychopathy and suicidal aggression are characterised bysimilar changes in the brain serotonergic system (Goldman and Ducci, 2007).

Our aim was to extend previous research on psychopathy and depression inthree ways:

1. by discriminating general distress from specific symptoms of depression;2. by testing for a relationship between psychopathy and depression only when

one of the two primary symptoms (depressed mood or anhedonia) have beenpresent for at least two weeks; and

3. by testing for a relationship between psychopathy and depression only whenthe depressive symptoms cannot be entirely attributed to medication, illicitdrugs, alcohol, physical illness or injury.

Our first hypothesis was that total PCL‐R scores would be negativelyassociated with specific depressive symptom scores, as measured through astructured clinical interview, but not a categorical diagnosis of major depressivedisorder nor general distress scores, as measured by a questionnaire for depression.Our second hypothesis substituted the interpersonal, affective, lifestyle and anti‐social facets of the PCL‐R separately for the total PCL‐R score.

Finally, we examined the narrative descriptions of depression. In line withCleckley, we expected that participants with high PCL‐R scores would experiencenegative emotionality (e.g. vexation, frustration, boredom) rather than sadness.Weexpected that all participants would use negative emotional words but that words inthe anger range (e.g. angry, threaten, annoyed) would appear more frequently thanthose in the anxiety (e.g. worried, fearful, nervous) or sadness (e.g. crying, grief, sad)ranges when high PCL‐R scorers spoke about depression.

Method

Participants

Prison‐based psychologists selected 655 detainees from all sentenced prisoners intwo prisons in Flanders (Bruges and Oudenaarde) according to file data on the

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Psychopathy and lifetime experiences of depression 283

following criteria: competency in the Dutch language sufficient for interview andquestionnaire completion, absence of psychotic symptoms and having beendeclared fully responsible for their actions in respect of the index offence. The 655detainees were invited by mail to participate in this study; 140 responded to themail, with a final total of 89 men included after giving written informed consent(13.6% response rate). The 51 respondents who could not be included did not differfrom the 89 participants with respect to age, racial/ethnic origin and index offence.

The instruments

The PCL‐R (Hare, 2003). Ratings were based on information gathered from asemistructured clinical interview by one of us (J.W.), who had received training inadministering and scoring the PCL‐R, and from a review of the participant’s file.Inter‐rater reliability was checked by comparing the ratings with PCL‐R ratingsmade by clinical psychologists working in the prisons. In that way, we obtainedindependent PCL‐R ratings for just over 2/5 of the participants. Inter‐raterreliability as determined by the intraclass correlation coefficient (absoluteagreement) for a single rating, by using a two‐way random effects model, was0.79 for the interpersonal/affective factor, 0.76 for the lifestyle/anti‐social factor and0.82 for the PCL‐R total score. Cronbach’s alpha as an index of internal consistencywas good for the interpersonal facet (0.82), the affective facet (0.77), the lifestylefacet (0.78), the anti‐social facet (0.69) and the total PCL‐R scale (0.83).

The Structured Clinical Interview for Depression was drawn from the StructuredClinical Interview for DSM‐III‐R Axis 1 Disorders (SCID‐I). The interviews andsymptom ratings were performed by one of us (J.W.), after training in administeringand scoring the SCID‐I. The presence of each symptom occurring during thelifetime was scored on a 3‐point Likert scale of 0 (absent), 1 (uncertain) and 2(present). In each of the selected items, participants were asked whether they hadexperienced a specific depressive symptom for 2weeks or longer. Where aparticipant had no lifetime experience of either depressedmood or anhedonia, thenno further questions were asked about depressive symptoms (in accordance withSCID‐I procedure). To rule out substance‐induced depression, symptoms werecoded as ‘0’ (absent) if they were attributed by the interviewer entirely tomedication, drugs, alcohol, physical illness or injury. Recordings of the SCID‐Iinterview were independently rated by a post‐graduate psychology student for 39participants (44%). Inter‐rater reliability of the individual symptoms as determinedby the kappa coefficient ranged from 0.59 for the symptom ‘behaviour that isagitated or slowed down’ to 0.83 for the symptom ‘considerable loss or gain ofweight’. The intraclass correlation coefficient (absolute agreement) was 0.89 for thedepression severity scale.

TheDepression Anxiety Stress Scale (DASS‐21; Lovibond and Lovibond, 1995) isa questionnaire for assessing current symptoms of depression. It has three scales,namely depression, anxiety and stress, confirmed by factor analytical studies in

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284 Willemsen et al.

clinical and non‐clinical samples (de Beurs et al., 2001; Norton, 2007). The scaleshave good construct validity (Henry and Crawford, 2005; Norton, 2007). Thedepression scale consists of seven items: dysphoria, hopelessness, devaluation of life,self‐deprecation, lack of interest/involvement, anhedonia and inertia. Respondentsare asked to indicate how much each item applies to them on a 4‐point Likert scale(from 0, did not apply to me at all, to 3, applied to me very much or most of thetime). The score is the double of the sum of the item ratings, resulting in aminimumof 0 and a maximum of 42. The DASS‐21 was introduced after the research hadstarted, so just 66 of the 89 participants completed it; it was performed immediatelyafter the SCID‐I interview. Cronbach’s alpha as an index of internal consistencywas 0.88.

The 2001 Linguistic Inquiry and Word Count (LIWC2001; Pennebaker et al.,2001; Tausczik and Pennebaker, 2010) is a content analysis system that maps abroad range of psychological and basic linguistic characteristics, developed toanalyse texts on a word‐by‐word basis. The LIWC was translated into Dutch andvalidated in a Dutch population (Zijlstra et al., 2004; Zijlstra et al., 2005). Itconsists of 66 thematic categories, from which we selected the general category‘negative emotion words’ and its subcategories ‘anxiety or fear’, ‘anger’ and‘sadness or depression’. The 25 participants who presented at least two lifetimesymptoms of depression (including depressed mood and/or anhedonia) wereselected for narrative analysis. The recordings of their SCID‐I interview fordepression were transcribed by an individual who was blind to the psychopathyscore of the participants and were subsequently coded to indicate whetherinterviewer or participant was speaking. These transcripts were analysed with theLIWC dictionary by means of PROTAN, a computer programme developed forlexical content analyses (Hogenraad, 2007). For each category, weightedfrequency scores (i.e. the total number of words used from each category,balanced against the total number of words used during the interview) werecalculated for both interviewer and participant separately. The weightedfrequency scores for the participants indicate the degree of concern or pre‐occupation with a theme. The mean total number of words used by theparticipants to describe their depressive episode was 1130 [standard deviation(SD) = 928, range 182–3529].

Statistical analysis

To test the first hypothesis, we first used independent samples t‐tests to examinedifferences in PCL‐R total scores as a function of the presence or absence of alifetime diagnosis of depression. Second, we calculated Pearson correlationcoefficients between PCL‐R total scores and the DASS‐21 Depression Scale.Finally, we used independent samples t‐tests to examine differences in PCL‐Rtotal scores as a function of presence or absence of individual symptoms ofdepression and Pearson correlations to examine the association between PCL‐R

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Psychopathy and lifetime experiences of depression 285

total scores and depression severity. To test the second hypothesis, these testswere repeated for the four facets of the PCL‐R. To test the third hypothesis, wecomputed Pearson correlations between PCL‐R scores and the languagevariables.

Results

Twenty‐five participants (28%) were convicted of attempted or actual homicide,23 (26%) for other violent crimes, 34 (38%) for contact sexual crimes and 7 forother crimes (drugs, fraud, burglary); 76 (85%) were white European, 11 (12%)were North African, and 2 were of other ethnic origin. Their mean age at thetime of the interview was 39.4 years (SD=12.0, range 20–73 years). The samplesfrom each prison did not differ in racial/ethnic origin or age but did differsignificantly in index offence (χ²(2) = 8.35, p< 0.05). In the Bruges prisonsample, half of the convictions had been for sexual crimes, but just over half inthe Oudenaarde prison had homicide convictions.

The mean PCL‐R total score was 22.9 (SD=8.5, range 1–36); 30 (34%) of theparticipants in the sample scored below 20, whereas 26 (29%) scored equal to orabove the threshold of 30.

Thirty‐six participants (40%) had experienced at least one 2‐week periodduring which one or both of the primary symptoms of depression were present;their ‘depression severity’ rating was calculated by summing all the symptomspresent during this period (i.e. coded as ‘2’). Their mean score was 4.6 (SD= 2.03,range 1–9); the distribution was normal. Seventeen men (19%) had a lifetimecategorical diagnosis of major depression.

The mean score on the DASS‐21 was 15.6 (SD=11.6, range 0–42).Table 2 presents the mean PCL‐R scores as a function of lifetime depression.

Prisoners with a lifetime diagnosis of major depressive disorder had a significantlylower PCL‐R total and facet 1, 2 and 3 scores compared with those without sucha diagnosis. Furthermore, we found that detainees who had ever experienced a2‐week period of depressed mood (A1) and/or anhedonia (A2) had a lowerPCL‐R total and facet 1 score compared with those who had never experiencedsuch an episode.

Next, we focussed on the subsample of 36 men who reported experiencing a2‐week period of depressed mood (A1) and/or anhedonia (A2). Table 3 presentsthe mean PCL‐R scores as a function of specific depressive symptoms. We foundthat the mean PCL‐R total score was significantly lower in those prisoners whoreported depressed mood (A1), weight gain/loss (A3) and worthlessness (A8)than those who did not. In terms of the four facets of psychopathy, the meanfacet 1 and 2 scores were generally lower in men who reported depressivesymptoms, but this difference was significant only for weight gain/loss (A3) andworthlessness (A8). The mean facet 2 score was also significantly lower in menwho reported depressed mood (A1). The mean facet 3 score was significantly

Copyright © 2011 John Wiley & Sons, Ltd 21: 279–294 (2011)DOI: 10.1002/cbm

Table

2:Independ

entsamples

t‐testresultsforPsycho

pathyChecklist–Revised

scores

asafunction

ofdiagno

sisof

major

depressive

disorder

andprim

ary

symptom

sof

depression

inthetotalsample(n

=89)

Depression

Presence

nPC

L‐Rtotal

Facet1,

interpersonal

Facet2,

affective

Facet3,

lifestyle

Facet4,

anti‐social

Mean(SD)

Mean(SD)

Mean(SD)

Mean(SD)

Mean(SD)

Major

depressive

disorder

No

7224.5

(7.41)

4.7(2.65)

6.0(2.15)

6.8(2.84)

5.1(2.84)

Yes

1716.1

(9.69)

1.6(2.45)

3.2(2.27)

5.1(3.08)

5.1(3.50)

t(87)=

3.95**

t(87)=

4.29**

t(87)=

4.76**

t(87)=

2.22*

t(87)=

0.00

A1and/or

A2present

No

5324.7

(7.31)

4.7(2.72)

5.8(2.29)

6.9(2.80)

5.2(2.73)

Yes

3620.4

(9.56)

3.2(2.86)

4.9(2.53)

5.9(3.10)

5.0(3.28)

t(87)=

2.38*

t(87)=

2.51*

t(87)=

1.84

t(87)=

1.52

t(87)=

0.44

Note:PC

L‐R=Psycho

pathyChecklist–Revised;SD

=standard

deviation.

*p≤0.05.

**p≤0.01.

286 Willemsen et al.

Copyright © 2011 John Wiley & Sons, Ltd 21: 279–294 (2011)DOI: 10.1002/cbm

Psychopathy and lifetime experiences of depression 287

lower in men reporting depressed mood (A1), weight loss/gain (A3) orworthlessness (A7). For facet 4, we found no significant differences betweendetainees who did and did not report symptoms of depression.

Table 4 displays the Pearson correlation coefficients for psychopathy anddepression severity, again in the subsample of 36 participants who had everexperienced a 2‐week period of depressed mood and/or anhedonia. PCL‐R totalscores were inversely associated with depression severity. For the four facets ofpsychopathy, this negative association was strongest for facet 2 but was alsopresent with facet 1 and facet 3. Facet 4 was not significantly associated withlifetime depression severity.

Table 4 shows that there are no correlations between psychopathy and theDASS‐21 Depression Scale.

The Pearson correlations between the language variables and the threecontrol variables (age, depression severity and interviewer word use) are shownin Table 5. Because of the small sample size (n= 25), effect sizes were consideredwith correlation coefficients of 0.10, 0.30 and 0.50 corresponding to small,medium and large effects, respectively. Age had a large positive effect on thefrequency of ‘anxiety’ words. Interviewer word use had a medium effect on thefrequency of ‘anxiety’, ‘anger’ and ‘sadness’ words. These effects were taken intoaccount when calculating the correlations between the language variables andPCL‐R scores.

For our third hypothesis, we found that the PCL‐R total and facet scores hadno relationship with the use of negative emotion words generally whenparticipants spoke about their depression, except for a small negative effect of theinterpersonal facet. In accordance with our prediction, PCL‐R total scores wereinversely associated with use of sadness words. More specifically, high scores onthe affective and lifestyle facets were associated with low scores on frequency ofsadness words. Contrary to our third hypothesis, there were no significantrelationships between PCL‐R total scores and use of ‘anxiety’ words or ‘anger’words. The lifestyle facet had a weak positive relationship with the frequency of‘anxiety’ words, and the anti‐social facet has a weak negative relationship withfrequency of ‘anger’ words.

Discussion

Our first hypothesis was sustained in that we found that PCL‐R total scores wereassociated with ‘specific depression’ in terms of a history of a minimum 2‐weekperiod of depressed mood and/or anhedonia and that lower PCL‐R scores wereassociated with scores indicating more severe depression. At the level of theinterpersonal, affective and lifestyle facets of the PCL‐R, we found a similarpattern of findings, supporting our second hypothesis. These findings makeconceptual sense, because the presence of depression is difficult to reconcile with

Copyright © 2011 John Wiley & Sons, Ltd 21: 279–294 (2011)DOI: 10.1002/cbm

Table3:

Independ

entsamples

t‐testresultsforP

sychopathy

Checklist–Revised

scores

asafunction

ofsymptom

sof

depression

inasubsam

plewithlifetim

eexperience

ofdepressive

symptom

A1and/or

A2(n

=36)

Depression

Presence

nPC

L‐R

total

Facet1,

interpersonal

Facet2,

affective

Facet3,

lifestyle

Facet4,

anti‐social

Mean(SD)

Mean(SD)

Mean(SD)

Mean(SD)

Mean(SD)

A1,

depressedmood

No

1325.7

(5.67)

3.9(2.40)

6.1(2.02)

7.6(1.56)

6.2(2.45)

Yes

2317.4

(10.11)

2.8(3.06)

4.2(2.57)

4.9(3.35)

4.2(3.52)

t(34)=

3.15**

t(34)=

1.16

t(34)=

2.30*

t(33.2)=

3.28**

t(31.9)=

2.03

A2,

anhedonia

No

623.2

(5.98)

5.0(2.83)

5.8(1.83)

6.0(3.03)

4.8(3.82)

Yes

3019.8

(10.12)

2.8(2.77)

4.7(2.63)

5.9(3.16)

5.0(3.24)

t(34)=

0.77

t(34)=

1.75

t(34)=

1.03

t(34)=

0.09

t(34)=

−0.10

A3,

weightloss/gain

No

1924.8

(7.51)

4.5(2.63)

6.2(1.89)

7.3(2.79)

5.0(3.19)

Yes

1715.5

(9.38)

1.8(2.44)

3.4(2.40)

4.3(2.67)

5.0(3.48)

t(34)=

3.31**

t(34)=

3.19**

t(34)=

3.83**

t(34)=

3.30**

t(34)=

0.00

A4,

insomnia

No

1518.7

(8.33)

3.1(2.47)

5.1(2.25)

5.1(3.22)

3.8(3.20)

Yes

2121.6

(10.39)

3.2(3.16)

4.7(2.76)

6.5(2.94)

5.8(3.16)

t(34)=

−0.87

t(34)=

−0.11

t(34)=

0.41

t(34)=

−1.37

t(34)=

−1.82

288 Willemsen et al.

Copyright © 2011 John Wiley & Sons, Ltd 21: 279–294 (2011)DOI: 10.1002/cbm

A5agitation

No

2621.8

(8.38)

3.5(2.77)

5.2(2.22)

6.3(2.97)

5.2(3.34)

Yes

1016.9

(11.91)

2.3(3.02)

4.1(3.21)

4.9(3.36)

4.4(3.25)

t(34)=

1.38

t(34)=

1.17

t(34)=

1.12

t(34)=

1.18

t(34)=

0.60

A6,

energy

No

2222.4

(8.85)

3.5(2.61)

5.4(2.44)

6.5(2.77)

5.1(3.30)

Yes

1417.3

(10.15)

2.7(3.24)

4.0(2.51)

4.9(3.43)

4.6(3.36)

t(34)=

1.58

t(34)=

0.80

t(34)=

1.67

t(34)=

1.52

t(34)=

0.44

A7,

worthlessness

No

2224.2

(7.70)

4.0(2.68)

5.9(2.16)

7.1(2.51)

5.9(2.89)

Yes

1414.4

(9.29)

2.0(2.80)

3.2(2.22)

4.0(3.07)

3.9(3.63)

t(34)=

3.47**

t(34)=

2.10*

t(34)=

3.61**

t(34)=

3.29**

t(34)=

1.66

A8,

concentration

No

2121.2

(9.53)

3.6(2.79)

5.4(2.40)

5.7(3.17)

4.8(3.40)

Yes

1519.3

(9.83)

2.7(2.97)

4.1(2.58)

6.1(3.09)

5.2(3.21)

t(34)=

0.59

t(34)=

0.94

t(34)=

1.63

t(34)=

−0.39

t(34)=

−0.29

A9,

suicide

No

1420.1

(9.63)

3.6(2.82)

5.2(2.29)

5.1(3.15)

4.6(3.53)

Yes

2220.6

(9.74)

2.9(2.91)

4.6(2.70)

6.4(3.02)

5.2(3.18)

t(34)=

−0.17

t(34)=

0.75

t(34)=

0.66

t(34)=

−1.28

t(34)=

−0.48

Note:PC

L‐R=Psycho

pathyChecklist–Revised;SD

=standard

deviation.

*p≤0.05.

**p≤0.01.

Psychopathy and lifetime experiences of depression 289

Copyright © 2011 John Wiley & Sons, Ltd 21: 279–294 (2011)DOI: 10.1002/cbm

Table 4: Pearson correlations between psychopathy and depression severity as measured with theStructured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, ThirdEdition, Revised Axis 1 Disorders and the Depression Anxiety Stress Scale

n PCL‐R total Facet 1 Facet 2 Facet 3 Facet 4

SCID‐I depression severity 36 −0.50** −0.44* −0.61** −0.40* −0.13DASS‐21 Depression Scale 66 −0.03 −0.07 −0.09 −0.01 0.01

Note: SCID‐I =Structured Clinical Interview for DSM‐III‐RAxis 1 Disorders; DASS 21=DepressionAnxiety Stress Scale.*p≤ 0.05.**p≤ 0.01.

Table 5: Correlations between the language variables, age, depression severity, interviewer worduse and Psychopathy Checklist – Revised scores

Language variables

Negative emotion Anxiety Anger Sadness

Control variablesAge 0.08 0.50* −0.05 0.04Depression severity −0.02 0.04 0.01 0.01Interviewer word use −0.05 0.34 0.44* −0.49*

PsychopathyControlling for… None Age and interviewer Interviewer InterviewerPCL‐R total −0.06 0.07 −0.07 −0.19Facet 1 −0.10 −0.06 0.04 −0.01Facet 2 −0.04 0.06 0.01 −0.25Facet 3 0.04 0.19 −0.02 −0.18Facet 4 −0.06 0.04 −0.19 −0.08

Note: PCL‐R=Psychopathy Checklist – Revised.*p≤ 0.05.

290 Willemsen et al.

psychopathic traits, and contribute to the growing evidence that psychopathy –as defined by the PCL‐R – is a heterogeneous concept (Smith et al., 2009;Skeem and Cooke, 2010). In this line of reasoning, previous researchers haveencouraged the use of the factors/facets of the PCL‐R instead of the total scoresfor making predictions with respect to negative emotionality (Hicks and Patrick,2006). The strong negative correlations that we found between theinterpersonal, affective and lifestyle facets and the severity of depression suggestthat these facets, rather than the anti‐social facet, are relevant for makingpredictions on depression in detainees (e.g. risk for suicide).

Our results are partly consistent with the studies cited previously (i.e.Stalenheim and von Knorring, 1996; Hare, 2003; Hicks and Patrick, 2006; Phamet al., 2007), although we found stronger inverse associations between psychopathy

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Psychopathy and lifetime experiences of depression 291

and depression. In our opinion, there are several possible reasons for this. First, wehave already outlined the problems that characterise studies in which eitherdepression or psychopathy, or both, are dichotomised. In fact, we found no evidencethat dichotomising depression would make it impossible to demonstrate an inverserelationship between psychopathy and depression. We have no explanation of thedifference from previous studies; just one other found this result (Stalenheim andvon Knorring, 1996).

We have a stronger argument pertaining to the discrepancy with previousresearch using questionnaires for depression. We found that psychopathy is ne-gatively associated with severity of depression as measured through semistructuredinterviews but not associated with ‘depression’ asmeasured through a questionnaire.As argued previously, the assessment of depression by questionnaires might tap intosomething other than depression, such as general distress. For example, when oneparticipant in our study (with a PCL‐R score of 30) was asked whether he felt downor depressed during the previous month, he answered, ‘short moments, but that wasdue to noise nuisance. I am very bothered by certain sound equipment. I havenothing against music, but I get crazy by that boom‐boom house‐music. … then Ihave a hard time.’ When filling in a depression questionnaire, this detainee mightanswer affirmative while, in fact, he was talking about irritation instead ofdepression. During an interview, the interviewer can evaluate the clinical validity ofsymptoms reported by the interviewee, and explore further, with additionalquestions or observations whether the emotional presentation corresponds to thereported symptoms. This finding also fits with previous research, discussed in theIntroduction section, on the lack of specificity in questionnaires for depression incertain populations. Hare (2003, p. 104) suggested that research on anxiety andpsychopathy might benefit from ‘the assessment of anxiety with the interview andfile review methods used to score the PCL‐R’. We agree with this recommendationand make a similar suggestion for future research on depression and psychopathy.

Our analysis of the narratives used to describe symptoms of depression tended toconfirm that the way of experiencing a depressive episode is different for those whohave high PCL‐R scores. In spite of the small sample size (n= 25) and the forcedresponse format (a semistructured SCID‐I interview), we found small effects ofpsychopathic traits on emotion word usage. Men who scored highly on theaffective and lifestyle facets of psychopathy, for example, used fewer sadness words.By contrast, our third hypothesis, that other negative word use would be morefrequent in the context of psychopathy or its facets, was not sustained. This mayhave been because both the effect size and the sample were small. Nevertheless, weargue that the experience of a depressive episode is different for those with moreand those with less psychopathic traits.

Do our results suggest that psychopathy and major depression are mutuallyexclusive? Although we found a negative association between psychopathy anddepression, this would not be the correct conclusion. Even when using thestringent criteria of the DSM‐IV, we were able to detect clinically relevant

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symptoms of depression in detainees with a PCL‐R score of 30 or higher. Ourstudy, however, was the first to investigate differences in the experience of adepressive episode. Future research should further explore the differences in theexperience of depression and the factors that lead to it and also concepts ofpsychopathy other than Hare’s. From a psychodynamic point of view, it has beensuggested that psychopathy and anti‐social behaviour may each constitute adefence against underlying depression (Howard, 1981; Meloy, 2004). Further-more, research on subtypes of psychopathy has found two or more with differentaetiology, clinical presentation and outcomes (for a review, see Hervé, 2007).Certain subtypes demonstrate increased negative emotional states and highco‐morbidity with internalising disorders.

Our study had several limitations. First, both PCL‐R and SCID‐I interviewsand ratings were performed by the same person, so rater bias may have affectedthe associations we found between PCL‐R scores and depression. We seem tohave been successful in minimising this by using a structured interview forassessing depression, by providing the interviewer with special training inadministering it and by testing inter‐rater reliability with a rater blind to PCL‐Rscores. Furthermore, correlations between PCL‐R scores and language variableswere controlled for in terms of the interviewer word use.

Amore important limitation of the study is its small sample size and the fact thatthis represented such a small proportion of the population invited to participate.This did not, however, prevented us from finding effects. A third concern is thegeneralisability of our results: the mean PCL‐R total score of 22.9 in our sample ishigher than that generally found in European samples (e.g. Hare, 2003), so thesemenmay not be representative of European or evenBelgian prisoners. Themen did,however, show considerable variance on these scores.

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Address correspondence to: Jochem Willemsen, Department of Psychoanalysisand Clinical Consulting, Ghent University, Henri Dunantlaan 2, B‐9000 Ghent,Belgium. Email: Jochem.Willemsen@UGent.be

Copyright © 2011 John Wiley & Sons, Ltd 21: 279–294 (2011)DOI: 10.1002/cbm