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Commentary: A Psychodynamic Model of Psychopathy, Using Gullhaugen et al. (2021) as a Reference

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Abstract

Recently in Psychoanalytic Psychology, Gullhaugen et al. (2021) proposed a Dynamic Model of Psychopathy (DMP) to better understand psychopathic traits. Several issues with the authors' methodology, including the use of the Psychopathy Checklist: Screening Version (PCL: SV) as an independent measure and a small sample size (N = 16) relative to their conceptual approach and the number of statistical analyses conducted, limit the conclusions that can be drawn from their data. Additionally, the authors discuss their findings as if the data from this study with all males could apply to women. In this article, we use the methodological issues presented in the Gullhaugen study to discuss problems with the broader psychopathy literature. We also provide a psychodynamic model of psychopathy consistent with theory and empirical data.
Archives of Assessment Psychology, Vol. 11, No. 1, (113-126) © 2021 American Board of Assessment
Printed in U.S.A. All rights reserved Psychology
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Commentary: A Psychodynamic Model of Psychopathy,
Using Gullhaugen et al. (2021) as a Reference
Carl B. Gacono, Ph.D. and Jason M. Smith, Psy.D.
Abstract
Recently in Psychoanalytic Psychology, Gullhaugen et al. (2021)
proposed a Dynamic Model of Psychopathy (DMP) to better
understand psychopathic traits. Several issues with the authors
methodology, including the use of the Psychopathy Checklist:
Screening Version (PCL: SV) as an independent measure and a
small sample size (N = 16) relative to their conceptual approach
and the number of statistical analyses conducted, limit the
conclusions that can be drawn from their data. Additionally, the
authors discuss their findings as if the data from this study with all
males could apply to women. In this article, we use the
methodological issues presented in the Gullhaugen study to discuss
problems with the broader psychopathy literature. We also provide
a psychodynamic model of psychopathy consistent with theory and
empirical data.
Introduction
Assessing the current psychopathy literature makes one realize that a plethora of largely
unchallenged biases, unsound methodology, and faulty conclusions predominate the landscape
(Cunliffe et al., 2021; Gacono, 2016; Smith et al., 2021). These poorly designed studies become
part of meta-analytic ones, which add conflicting findings to an already confusing literature
(Cunliffe et al., 2012; Gacono, 2019; Smith, Gacono, Fontan, et al., 2018, 2020). Taken together,
disparate findings—artifacts of poor researchcreate “apparent controversies,” which lead to
“pseudo-debates,” and add to the “armchair quality” of the Psychopathy Checklist–Revised
(PCL-R; Hare, 2003) literature (Gacono, 2016, 2019, 2021; Hare, 1998). This pattern provides
another level of difficulty for practicing clinicians while, at the same time, providing ample data
for those who are critical of psychological assessment (Fowler et al., 2009; Lilienfeld, 1994,
2018; Wood et al., 2000, 2001, 2003, 2010). Poorly designed studies, which fail to account for
internal validity issues, erode the science of psychology and obfuscate findings related to their
translation to theory and practice.
Eventually, these findings find their way into the courtroom in the form of incompetent
and unethical clinical practices and the creation of apparent controversies that add to the
devaluation of applied work (Gacono, 2019). These “straw person” controversies, laden with
logical fallacy and bias (Cunliffe et al., 2021), provide fuel to critics that attack psychology, not
only as a “soft” science but also as having little to offer on substantive issues. These trends make
psychologists look unprofessional and even ridiculous (Gacono, 2021).
This pervasiveness of methodological errors makes it imperative that readers be able to
identify them when they occur. A thorough evaluation of a study’s design must be conducted
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prior to accepting its findings and conclusions for every study reviewed. This is especially
critical for meta-analytic studies that hide the internal validity issues of individual studies within
a group of studies where the flawed designs are glossed over with the glitter of statistical analysis
(Gacono, 2019). As we have done for two Rorschach meta-analyses (Mihura et al., 2013; Wood
et al., 2010), individual studies must be examined related to potential internal validity issues
(Cunliffe et al., 2012; Smith, Gacono, Fontan, et al., 2018, 2020). The journal review process is
also impacted by a partial understanding of the issues and misinformation created by these
studies.
In this article, we use the Gullhaugen et al. (2021) study titled The Theoretical Validation
of the Dynamic Model of Psychopathy (DMP): Toward a Reformulation of the Construct,
Assessment, and Treatment of Psychopathic Traits as a starting point for offering guidelines for
reviewing psychopathy studies (see also Gacono 2016, 2021; Gacono & Gacono, 2006; Gacono
et al., 2001). We also provide a theoretical and empirically derived psychodynamic model for
understanding psychopathic men and women (Smith et al., 2021).
Caveats for Understanding the Study of Psychopathy
Psychopathy can be conceptualized both dimensionally (composed of traits) and
categorically (taxon; PCL-R 30; Gacono & Gacono, 2006; Gacono et al., 2001). Discussions
that create an either–or (dimensional or categorical) construct are based on a logical fallacya
false dichotomy (Cunliffe et al., 2021). All things (categories) are dimensional as all things are
made up of traits. However, they also require a sufficient quantity of these traits to reach a
threshold in order to be classified as the object. Apples and oranges are round but differ in
texture, type of skin, and so on. Paranoid disorders and compulsive disorders share an attention
to detail. However, the person diagnosed as paranoid does so to avoid attack, while the person
diagnosed as compulsive does so to avoid making mistakes. Substitute apples for cherries, and
you have a different pie. The eitheror is an arbitrarily established forced choice that falls short
of sound logic.
Proponents of the either–or stance frequently use methodologies inadequate for forming
conclusions about psychopathy as a category. They lower the threshold for psychopathy (below
a PCL-R score of 30) and use an inappropriate measure for creating a psychopathy group.
Subsequently, they recreate subtypes (categories) from the new very heterogeneous grouping
(that may run the entire range of PCL-R scores), labeling them as psychopathic. They begin with
a false dichotomy (either–or) in which they say a PCL-R category for psychopathy does not exist
(PCL-R 30; a comparatively homogeneous grouping) and then create their own categories
(subtypes from a heterogeneous grouping labeling them all as types of psychopathy).
In reality, the psychopathy category created by the PCL-R cutoff of greater-than-or-
equal-to 30 creates an ideal threshold that balances sensitivity (the ability of a diagnostic
modality to identify all patients with the disease correctly) and specificity (the extent to which a
diagnostic test is specific for a particular condition, trait, and so on) within the context of the
instrument’s SEM (Hare, 1991, 2003). Regardless of gender, those within this range are
consistently more behaviorally problematic (validity) than those that score below 25. Also,
subtypes do exist within the high range, as they do for most disorders (e.g., consider the many
variants of schizophrenia).
The eitheror argument frequently leads to creating psychopathic groups containing few,
if any, psychopaths. Confusion increases when categorical inferences (psychopathy; PCL-R
30) are made from studies utilizing dimensional research designs (e.g., correlations of behavior
Commentary: A Psychodynamic Model of Psychopathy, Using Gullhaugen et al. (2021) as a Reference
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with total PCL-R scores, and absence of a psychopathic group of scores greater than 30). The
resultant discrepant findings are the result of internal validity problems rather than representative
of true differences or similarities (a form of Type I error). What might seem obvious—for a
study to make inferences about psychopathy, it must have psychopaths in itis ignored in many
studies.
One research procedure that may create samples without psychopaths involves using the
Psychopathy Checklist: Screening Version (PCL: SV) to create a psychopathic group, rather than
using the PCL-R (Gacono & Gacono, 2006; Hare, 2003). Not a substitute for the PCL-R, the
PCL: SV is for screening purposes only (Gacono et al., 2001). As noted in the PCL: SV manual,
“The Hare PCL: SV was not designed to replace the Hare PCL-R but to offer an efficient tool to
screen for the possible presence of psychopathy” (Hart et al., 1995, p. IX). Unlike the PCL: SV,
the PCL-R allows for a categorical designation of psychopathy (PCL-R ≥ 30). Although the
PCL: SV is appropriate for examining relative differences within a given sample, it cannot be
used to make inferences about psychopaths (or a model for psychopathy) when used incorrectly
as the independent measure for forming a psychopathic group.
A similar issue exists when using self-report measures of psychopathy (Lilienfeld &
Andrews, 1996; Lilienfeld & Widows, 2005). These instruments suggest that individual traits
(dimensional: inherent in any one of several disorders and non-disorders) are individually
psychopathic (category). In reality, a designation of psychopath is appropriate only when a
sufficient number of individual traits are present. It is the aggregate of traits, rather than an
individual trait, that determines the presence of a psychopath (Cleckley, 1941). With some
exceptions, self-report measures assess traits or dimensions, as opposed to categories (presence
of a psychopath), and correlate most strongly with Factor 2 of the PCL-R rather than with core
Factor I traits. Additionally, mislabeling traits such as self-centeredness, impulsivity, impaired
empathy, and irresponsibility as inherently psychopathic, returns psychology to the pre-1900s
pejorative trend of including all personality disorders under the rubric of psychopathy or the
antiquated term “sociopathy.” Even established self-report measures, such as the MMPI-2 or
PAI, are never appropriate for establishing psychopathic groups (Hare, 1991, 2003; Smith et al.,
2020b). Some self-reports, additionally, lack the necessary validation within appropriate
antisocial and psychopathic populations (e.g., attempting to validate an instrument to assess
psychopathy within a college population where no psychopath exists).
A related concern involves lowering PCL-R cutoff scores to form a psychopathic group
(a common practice in female offender studies; Cunliffe et al., 2016; Gacono & Gacono, 2006;
Smith et al., 2021). Researchers frequently do this because their samples do not contain enough
actual psychopaths (PCL-R ≥ 30). While this procedure could be part of an acceptable research
design, authors must refrain from making inferences about psychopaths (category) when they
have few, if any, psychopaths in their sample. When lowered PCL-R cutoff scores are used to
establish groups, the best that can be inferred is relative differences between high and low
scorers within that sample1.
The need to form psychopathic groups using a threshold of PCL-R ≥ 30 can be illustrated
using simple math. The PCL-R is a 20-item, 40-possible-point scale, in which individual items
1 In studying female psychopathy, we have found that at least eight PCL-R items need modifications to accurately
capture psychopathy in women (Cunliffe et al., 2021). While these differences could account for slightly lower mean
scores for female offenders, lowering the cutoff scores for creating a psychopathic group is not warranted.
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can be scored 0, 1, or 2, or omitted. When comparing an individual with a score of 37 (out of 40
possible points) to one with a score of 20, the high scorer has fewer ways to arrive at the total
score (i.e., they might receive 17 prototypic item scores of 2) than the number of possible
combinations that could occur to obtain a 20-point score (Balsis et al., 2017). The 20-point score
may be achieved without a single prototypic score of 2 (Gacono, 2021).
These mathematical estimates do not include how the statistical relationships among
items and overlapping criteria within specific item clusters (those items that cluster or contain
overlapping criterion points; see Gacono, 2000, 2005, 2021; Gacono & Hutton, 1994) further
reduce the number of possible combinations to arrive at a PCL-R total score of 34. For example,
if one receives a score of 2 on Item 3, Need for Stimulation/Proneness to Boredom, they will
receive a 1 or 2 (never a 0) for Item 14 (Impulsivity) and Item 15 (Irresponsibility). These
individual items form clusters that not only correlate, but also have overlapping criteria for
scoring (information used to score the item; Gacono, 2000, 2016; Gacono & Hutton, 1994).
Consequently, the number of combinations for scoring patterns increases significantly at a score
of 20 when compared to the 34 score. Those that score equal or greater than 30, despite their
differences, form a more homogeneous group with an acceptable probability that psychopathy is
present. That probability of the PCL-R identifying a psychopath deceases rapidly as you move
down the scale (particularly when you get below 27). Therefore, the actual number of
combinations may be less (about 20% of combinations when studying clinical diagnoses; Paap et
al., 2020).
Clearly, the methods used for creating a psychopathy group have direct bearing on the
types of inferences that can be made; moreover, these methods are critical to the evaluation of
the study’s generalizability. Results across studies can be appropriately compared only when
psychopathy has been defined by a consistent PCL-R score of 30 or above (measurement error
notwithstanding) and other relevant confounds are controlled. Internal validity issues can
frequently explain divergent study findings, including uncontrolled confounds (gender).
Additionally, statistical approaches that use simple correlational methods to compare dependent
variables with individual, rather than group PCL-R total scores (dimensional application) fail to
capture true between-group differences.
When evaluating research findings that present conclusions about psychopathy, the
reviewer must always examine the mean, standard deviation, frequencies, and ranges of PCL-R
scores for the sample. This data should be required for a study to be given publication
consideration. Within an acceptable methodology, this data will allow for a determination of
whether the study contained enough psychopathic subjects (PCL-R 30) to justify the
conclusions. For inferences to be made regarding psychopathy (category), the PCL-R, or the
Psychopathy Checklist: Youth Version (PCL: YV; Forth et al., 2003, 2016) must be used as the
independent measure, and there must be enough of ≥ 30 scorers in the samples analyzed.
In summary, when examining an article that purports to study psychopaths or
psychopathy as a group, the reader should assess the following (Gacono, 2013, 2021; Gacono &
Gacono, 2006; Gacono et al., 2001):
1. Was the full PCL-R or PCL: YV used as the independent measure for creating the
psychopathy group? The PCL: SV or self-report psychopathy measures (e.g., PPI-R)
should not have been used to make this designation.
2. Was a cutoff of PCL-R 30 used to establish the threshold for psychopathy? Lower
cutoffs are not appropriate for this designation. They can influence both the validity of
findings and the study’s generalizability.
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3. Were the appropriate statistics used? The reviewer should be particularly cautious of
studies that use a “dimensional methodology” and then make inferences about
psychopathy as a distinct group, an all too frequent occurrence.
4. Were gender and age accounted for in participant selection? Psychopathy manifests
differently depending on these issues.
5. Was the PCL-R training of the researchers discussed? The training should: (a) involve
an accepted method as outlined in the manual; (b) require supervised ratings beyond
any basic training; and (c) never be based solely on a group workshop or certification
process. The interrater reliability for a significant number of ratings should also be
presented. I have reviewed the protocols of several established researchers to discover
that they were not scoring the PCL-R correctly.
Logic suggests that it is always preferable to thoroughly examine a study’s potential
fallacies and internal validity issues (conceptual framework, e.g., authors conclude psychopaths
are X in a study containing no psychopaths) prior to challenging the resultant data (content) and
conclusions. When one begins by challenging the content, one acknowledges, by inference, that
the conceptual framework has merit.
Let us now turn toward an examination of the Gullhaugen et al. (2021) article using these
criteria.
Criterion 1: Was the PCL-R used to create a psychopathy group? No. While the authors
do not overstate their position, “The DMP must be validated across populations and statistically
compared with the PCL-R. There is a need for a reformulation of the concept, assessment and
treatment of psychopathic traits” (Gullhaugen et al., 2021, p. 8, it must be noted that there is no
way of evaluating how many psychopaths were in this study, as they used the PCL: SV rather
than the PCL-R. A total of 11 male offenders scored 18 or higher on the PCL-R. While it is
likely that no more than half (5 or 6) would have scored at or above the PCL-R cutoff of 30,
there could be as few as none (range was 18–23). Further, the researchers expanded the data set
to include those scoring 13 or higher (N = 16; range = 13–23).
Criterion 2: Was the correct PCL-R cutoff used? No, the PCL-R was not administered.
On the PCL: SV, a cutoff of 18 or greater triggers further assessment for psychopathy. It does
not indicate psychopathy (N = 11, subjects scored greater than 17). The reviewer has no way of
knowing if there was even one PCL-R score equal to or above 30 in the sample.
Criterion 3: Were the appropriate statistics used? Though there is no accepted value for
sample size, it has been suggested that less than 20 is problematic (Smith, Gacono, Fontan et al.,
2018, 2020). This study had 16 male offenders with PCL: SV 13 (n = 5; 13–17), with only 11
scoring 18 or above (possible psychopaths with PCL-R 30), compared to a control sample of
35. Eleven male offenders are too small a sample for developing a theoretical model and the N is
not adequate for conducting this number of statistical analysis.
Related to the authors dependent measures, self-report measures without lie or social
desirability scales were used to examine schemas and interpersonal/affective problems (Young
Schema QuestionnaireShort Form [YSQ- SF; Young & Brown, 1998], the Inventory of
Interpersonal Problems–Circumplex Scales [IIP- C; Soldz et al., 1995], Positive and Negative
Affect Schedule [PANAS; Watson et al., 1988]). Although it is unclear as to how they were
used, they were also used in scoring the independent measure—the PCL: SV (criterion
contamination). The authors stated “PCL: SV rating was based on clinical interview and self-
rating measures” (Gullhaugen & Nøttestad, 2012, p. 924, original emphasis noted). However,
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this is completely at odds with standardized PCL-R or PCL: SV administration. As mentioned in
the PCL: SV manual, “An interview is one of the two key data sources on which the PCL: SV is
rated, the other being charts or collateral informants” (Hart et al., 1995, p. 18).
In general, using self-report data with this population should be done with caution. As
Hare (2003) mentioned, in creating the PCL-R he chose to use a semi-structured interview with a
prior file review, as this population is notorious for lying and manipulation. However, we are not
saying one cannot use self-report measures such as the Personality Assessment Inventory (PAI;
Morey, 1991) as a dependent measure. They are not used, however, as part of the PCL-R or
PCL: SV administration procedures.
Criterion 4: Was gender considered as a possible confound? This sample involved males
only, hence, referring to him/her when describing their model is not warranted. We will discuss
importance of considering this confound in the next section.
Criterion 5: Was the PCL-R training of the researchers discussed? Interrater reliability
was provided, and it was appropriate (Cohen’s κ = 0.770–1.00, p < .000); however, there was no
mention of the qualifications of the researchers (Gullhaugen & Nøttestad, 2012, p. 922).
In addition to the above, there is no mention of having used collateral information (chart
review, interviewing third parties) when administering the PCL: SV. As stated in Gullhaugen
and Nøttestad (2012):
Clinical interview and testing took from a little more than 1 hr to approximately 5 hr,
depending on the clinical picture and how much the individual was able or willing to
reveal. After completing tests and clinical interview, questionnaires estimated to require
an effort of about 2 hr were handed out for independent work. Of importance,
interviewers had no access to previous reports of psychopathy or other study variables in
the study sample. (p. 924)
As noted in the PCL: SV manual, “The PCL: SV should not be completed in absence of
file or collateral information” (Hart et al., 1995, p. 18).
An N of 16 (11 male offenders PCL: SV 18, may or may not be psychopathic) is a very
small sample on which to base the resultant conclusions or speculations (as the authors
acknowledge, “which are not being presented due to the relatively small sample”; Gullhaugen et
al., 2021, p. 3). Not only is this N beyond making any strong conclusions, it is also not an
adequate number for the number of statistical analysis conducted. With this multiple testing
problem, one is at risk of Type I error, or finding significance where none exists by chance.
Finally, the literature review for the Gullhaugen et al. (2021) article might be compared
with the references in this commentary for determining its thoroughness and contemporariness.
A Psychodynamic Understanding of Male and Female Psychopathy
While male and female psychopaths evidence increased amounts of behavioral problems
when compared to non-psychopaths, the extant research indicates that they are not dynamically
equivalent (Cunliffe & Gacono, 2005; Forouzan & Cooke, 2005; Gacono & Meloy, 1994;
Gacono & Smith, 2021; Pauli et al., 2018; Smith et al., 2018, 2019, 2020a, 2021). In line with
David Shapiro’s (1965) personality styles, the personality functioning of the psychopathic male
is best understood as a form of pathological narcissism (malignant narcissism; Gacono & Meloy,
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1994; Kernberg, 1967, 1975, 1976; Meloy, 1988); while the psychopathic female displays a form
of malignant hysteria2 (Cunliffe et al., 2016; Forouzan & Cooke, 2005; Gacono, 2016; Gacono &
Meloy, 1994; Gacono & Smith, 2021; Smith et al., 2014, 2018).
For psychopathic males, the grandiose self-structure is self-regulating. It serves to bolster
an omnipotent sense of self while circumventing both internal and external threats to self-image
(Gacono, 1990; Kernberg, 1967, 1975, 1976; Meloy, 1988). The women lack the men’s
grandiose self-structure. They are not immune from experiencing themselves as damaged. They
“need” others (pseudo-dependency, i.e., maladaptive neediness) to bolster their self-esteem and
obtain some sense of stability with their troubling affect (pseudo-emotionality; Cunliffe &
Gacono, 2005; Forouzan & Cooke, 2005; Smith et al., 2021). We have found empirical evidence
in our Rorschach (for both men & women) and PAI (in women) data that each type also contains
the pattern of defensive operations consistent with these theoretical formulations (Gacono &
Meloy, 1994; Gacono & Smith, 2021; Smith et al., 2021).
Underneath their respective personality styles, psychopathic individuals display similar
levels of personality organization (borderline or psychotic; Gacono & Meloy, 1994; Kernberg,
1967, 1975, 1976; Smith et al., 2021) resting at a paranoid position (Gacono & Smith, 2021;
Klein, 1946; Mahler, 1975; Smith et al., 2021). When the defensive purposes of the pathological
narcissism or malignant hysteria fail to maintain a homeostasis, the psychopath’s paranoid style
becomes behaviorally evident (Gacono & Meloy, 1994). During a clinical interview with a
female psychopath, this may become evident when attention is withdrawn or when she is
ignored: She would escalate into uncontrollable giggling and, during the Rorschach slammed
one of the cards (VI) on the table in a moment to dramatic outburst … she interpreted Reid
Meloy’s withdrawal of attention … as sadistic” (Gacono & Meloy, 1994, p. 122).
Personality Organization
A structural psychodiagnostic approach with levels of personality organization provides
the best template for understanding psychopathy (Acklin, 1997; Kernberg, 1967, 1975, 1976;
Gacono & Meloy, 1994; Meloy, 1988). These levels range from the neurotic to psychotic, with
the borderline level resting between the two. Kernberg (1967, 1975, 1976, 1984) posited three
issues pertinent to borderline personality organization: 1) identity diffusion (disturbances of
affect regulation as well as the ability to accurately assess, interpret, and judge the meaning of
important interpersonal and intrapersonal events; Kernberg, 2005); 2) reliance on primitive
defenses, and 3) transient lapses in reality testing (Acklin, 1997; Kernberg, 1967, 1975, 1976,
1984).
Central to borderline level personality functioning is the use of primitive defenses
(Acklin, 1997; Kernberg 1967, 1975, 1976, 1984), with splitting functioning as the primary
defense. Primitive defenses can be contrasted with higher-level ones where repression, rather
than splitting, is the central defense. Primitive or lower order defenses concern boundaries
between self and the outer world while mature or higher order defenses structure internal
2 We do not endorse the early historically biased gender associations to hysteria. As discussed by Chodoff (1982)
and Pfohl (1991), the continued “devaluation” of the hysteria construct is primarily due to a partial understanding of
its roots. Hysterical personalities are not gender specific (Cleckley, 1941; Pfohl, 1991). Psychopathy, in either
gender, represents a severe personality aberration organized at a borderline or psychotic level for which malignant
hysteria (female) and malignant narcissism (male) best describes their psychodynamic psychopathy functioning.
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boundaries, such as between the id, ego, and superego (Laughlin, 1970). These include defenses
such as devaluation, idealization, denial, projective identification, and so forth (Cooper et al.,
1988; Lerner & Lerner, 1980).
Splitting differs from repression found in individuals organized at the neurotic level.
Splitting involves the separation of oppositely toned feelings and urges toward object or self to
circumvent these feelings being experienced simultaneously. It protects against the experience of
unbearable affects such as guilt or anxiety (Cooper et al., 1988). Repression, on the other hand, is
a defense that is unconsciously motivated to remain unaware of socially unacceptable impulses.
For individuals that rely on splitting, self and others are experienced as idealized (all good) or
devalued (all bad). This part object orientation can be contrasted with higher levels of personality
organization that retain the experience of others as a balance of good and bad qualities, a view
that can be tolerated simultaneously. The consistency with which one relies on these
developmentally distinct defenses is important. Unlike those organized at the neurotic level
where more primitive defenses are absent, those at the borderline level tend to show oscillations
between mature and primitive defenses (Gacono & Meloy, 1994; Schafer, 1954).
In a recent study (Gacono & Smith, 2021), we evaluated CS Rorschach variables (as well
as supplemental scale scores3) associated with narcissism, hysteria, and paranoia as well as
Kernberg’s three components of borderline personality functioning: 1) identity diffusion, 2)
reliance on primitive defenses, and 3) transient lapses in reality testing. We statistically
compared select variables between PCL-R determined (PCL-R 30) psychopathic males (N =
44) and females (N = 115).
We found the findings supported both the characterological issues related to psychopathy
(narcissism, hysteria, paranoia; Gacono & Meloy, 1994; Gacono & Smith, 2021; Smith et al.,
2021) and the presence of a borderline level of personality functioning among psychopathic
characters (Gacono, 1990; Gacono & Meloy, 1988, 1994; Kernberg, 1967, 1975, 1976, 1984;
Meloy, 1988). The findings also provided additional support for gender differences within
psychopathy that we have discussed here (Cunliffe & Gacono, 2005; Forouzan & Cooke, 2005;
Gacono & Meloy, 1994; Pauli et al., 2018; Smith et al., 2018, 2019, 2020a, 2021).
Not only did the psychopathic men and women differ, but also the men’s grandiosity
functions effectively in warding off external and internal threats to self-image while the women’s
malignant hysteria does not. The women’s struggles with their reliance on another for bolstering
their self-image and attempting to achieve some stability in a constant state of affective
dysregulation. They require others for mirroring. This pseudo-dependency is the cornerstone of
hysteria (Chodoff, 1982; Cunliffe & Gacono, 2005; Gacono & Meloy, 1994; Smith et al., 2021)
and problematic in any psychopathic character. The psychopathic male has a greater ability to
bask in their own reflection, maintaining themselves through gazing at their own image safely
devaluing without attachment any internal or external threats to their inflated image.
Conclusion
The ability to accurately interpret the results of psychopathy studies and the awareness of
3 These supplemental scales include: 1) Rorschach Oral Dependency (ROD) scale (Masling et al., 1967); 2) Trauma
Content Index (TCI; Armstrong &. Loewenstein, 1990); 3) Gacono and Meloy (1994) Extended Aggression scores
(AgC, AgPast, AgPot, & SM); 4) Kwawer (1980) Primitive Modes of Relating (PMR) scores; 5) Cooper et al.
(1988) Rorschach Defenses Scales (RDS).
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potential confounds (e.g., gender) are essential to formulating appropriate methodological
investigations and using sound principles in guiding the assessment and treatment of these
difficult, trying, and enigmatic patients. The reader is referred to three comprehensive sources for
additional guidance: The Rorschach Assessment of Aggressive and Psychopathic Personalities
(Gacono & Meloy, 1994), The Clinical and Forensic Assessment of Psychopathy: A
Practitioner’s Guide (Gacono, 2016), and Understanding Female Offenders: Psychopathy,
Criminal Behavior, Assessment, and Treatment (Smith et al., 2021).
About the Authors
Carl B. Gacono, Ph.D., ABAP, is a principal with Maverick Psychology Training and
Consultation PLLC in North Carolina. Correspondence concerning this article should be
addressed to Carl B. Gacono, PhD, ABAP, Email: drcarl14(at)aol.com.
Jason M. Smith, Psy.D., ABPP, is a principal with Maverick Psychology Training and
Consultation PLLC in West Virginia.
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