1. Female Psychopathic Offenders: Personality Disorder and Offence Types
Dr Annette McKeown
Highly Specialist Forensic Psychologist
Tees Esk & Wear Valleys NHS Foundation Trust

2. Aims & Objectives
Inform understanding of female psychopathic offenders.
Present research findings on a prison-based study exploring psychopathy in female prisoners in a specialist personality disorder service.
Compare psychopathy profiles to general female population and males in specialist personality disorder settings.
Consider practical implications of findings to guide treatment provision.
Will present offence types, personality disorder profiles and existing comparisons.

3. Psychopathy Literature I
In 1916, Marion Smith described in notes of Elmer Ernest Southard.
In 1939, David Henderson used terminology including “hypersexual” and “emotional instability”.
Emotional instability, promiscuity and suicidal behaviour referred to (Batchelor, 1954; Fremming, 1947; Greenacre, 1945).
Cleckley (1941) Mask of Sanity and female Case Studies Roberta & Anna (1941/1988)
The lead psychiatrist at the first Psychopathic Department in Boston State Hospital (Southard, 1916). Ms Smith was accused by her grandmother of attempting to control her property and it was also suggested she was a “nymphomaniac” (as cited in Lunbeck, 2006, p. 49). In hospital, Ms Smith was described as a “model patient”, “well mannered” with no presenting psychotic symptoms (as cited in Lunbeck, 2006, p. 49). It was noted, however, that she was sexually promiscuous, impulsive and irresponsible in her decision-making. Ms Smith was assessed as having a psychopathic personality (Southard, 1916). This was one of the early case studies highlighting psychopathy in women and themes of impulsivity, conning behaviour and promiscuity predominated the case.

4. Psychopathy Literature II
Roberta's mother said "She has such sweet feelings,", "but they don't amount to much. She's not hard or heartless, but she's all on the surface."
Females described as “hypersexual” and “emotionally unstable” (Cleckley, 1941)
In the 40s, test development began…
Hare (1991) developed PCL-R
In 2004, Comprehensive Assessment of Psychopathic Personality (CAPP) introduced
Cleckley (1941) more than 60 years ago. In his classic and seminal book, The Mask of Sanity, Cleckley described the condition
of psychopathy as a constellation of interpersonal, affective,
and behavioral characteristics. With regard to interpersonal characteristics, Cleckley believed that psychopaths were intelligent, egocentric, glib, superficially
charming, verbally facile, and manipulative. Emotionally, Cleckley described psychopaths as individuals who displayed short-lived emotions and as individuals
who lacked important human characteristics such as empathy and remorse. Behaviorally, Cleckley believed that psychopathic individuals were irresponsible,
prone to seek novelty and excitation, and likely to engage in moral transgressions, antisocial acts, or both.
Of Cleckley’s 15 clinical case studies, only two - Roberta and Anna - were female. It is worth noting that both Anna and Roberta were characterised by relatively minor forensic histories (e.g., fraud and theft). Therefore, the views Cleckley presented on female psychopathy generally reflected women without a history of violence. With this caveat in mind, Cleckley identified some similarities in his conceptualisation of psychopathy in male and female psychopathic individuals. He identified that a lack of emotional depth tended to typify both male and female psychopathic individuals.
The comprehensive assessment of psychopathic personality 
–Comprehensive Assessment of Psychopathic Personality 
•a hierarchical model, based on theory 
–six domains, 33 symptoms, each with trait descriptors and illustrative indicators 
•self and interpersonal pathologies prioritised 
–a personality-based model, no requirement for antisocial behaviour 
•semi-structured interview and staff rating form 

5. Psychopathy Literature III
Cleckley (1941) and Karpman (1941, 1948) originally introduced the distinction between “primary psychopaths” and “secondary psychopaths”.
Hicks et al. (2010) applied model to distinguish between primary psychopaths and secondary psychopaths in female offenders.
Associations between Factor 1, Factor 2 and BPD (Blonigen, Sullivan, Hicks, & Patrick, 2012; Coid, 1993; Kruepke, 2015; Sprague et al., 2012).
Cleckley (1941) and Karpman (1941) viewed primary psychopathy as biologically and genetically driven as opposed to secondary psychopathy which was more acquired and influenced by environmental and learning experiences. This distinction was also largely based on the difference between individuals’ capacity for depth of emotion, anxiety, empathy and desire for a meaningful relationship with others, traits. Primary psychopaths were theorized to particularly struggle with the emotional functioning skills due to biologically driven affective deficits.
Hicks et al. (2010) found primary psychopaths were characterised by generalised criminality with few presenting mental health problems, whereas secondary psychopaths were described as more impulsive in nature with criminality occurring from a young age. Heightened levels of substance use, mental health difficulties, post-traumatic stress symptoms, suicidal behaviour and violent behaviour were noted to characterise the secondary psychopath (Hicks et al., 2010). It was noted that secondary psychopathy appeared to be more consistent with emotional instability characteristics of personality disorder (e.g., Hicks, Markon, Patrick, Krueger, & Newman, 2004; Hicks et al., 2010).

6. Psychopathy & Personality Disorder Literature I
Borderline personality disorder (BPD) characteristics associated with secondary psychopathy (Skeem, Johansson, Andershed, Kerr, & Louden, 2007; Falkenbach et al., 2017).
It has been considered whether psychopathy in women is a manifestation of BPD (Sprague et al., 2012).
Combination of Factor 1 and Factor 2 components of psychopathy explained suicidal ideation, self-harm and suicide attempts to a greater degree in women as opposed to men.
It is also interesting that in a pooled sample predominated by male offenders (78.7%), there were no significant associations found between BPD and psychopathy; this highlights potential differences between female and male psychopathic offenders. In men, Factor 2 explained suicidal behaviours regardless of Factor 1 (Verona et al., 2012).

7. Psychopathy and Offence Types I
Victims of violent women are more likely to be those known to them (e.g., Stewart, Gabora, Allegri, & Slavin-Stewart, 2014).
Violent women who perpetrated aggression towards strangers and acquaintances, found to be more highly psychopathic (Weizmann-Henelius et al., 2003).
Vitale et al. (2002) also found significant positive links between PCL-R scores and the number of violent offences committed by female offenders

8. Psychopathy and Offence Types II
In contrast, there are findings indicating little association between psychopathy levels and severe acts of violence (e.g. Adshead, 2016).
Warren et al. (2005) found that females with a murder conviction scored significantly lower on the PCL-R compared to women without a murder conviction.
Links between minor offences and psychopathy levels mirror the findings of Coid et al. (2009a), whose pooled results of male and female offenders found that psychopathy was associated only with theft as an offence type.
In contrast, women with an index offence for property convictions or minor offences scored significantly higher than women without an index offence of this type (Warrant et al., 2005)

9. Psychopathy and Offence Types III
Klein Tuente, De Vogel and Stam (2014) examined a sample of 221 female forensic patients.
Lowered PCL-R score of 23 was applied (FAM; De Vogel et al., 2012).
Found psychopathic women were younger at the age of their first conviction and more criminally versatile than non-psychopathic women.
Findings indicated psychopathic women committed a fatal index offence less often than non-psychopathic females, and their victims were more often strangers.
Important to note latter research sample forensic hospital patients, as opposed to women in prison
Findings that female forensic patients present with differing offence characteristics than women in prison (Coid, Kahtan, Gault, & Jarman, 2000; Karsten, De Vogel, & Lancel, 2015).
In contrast, women with an index offence for property convictions or minor offences scored significantly higher than women without an index offence of this type (Warrant et al., 2005)

10. Current Study

11. Current Study I
Notable lack of research in specialist forensic settings in the UK exploring the prevalence of psychopathy.
Lack of knowledge about the patterns of psychopathy, personality disorder and offending patterns in such populations.
Current study will provide descriptive statistics on women assessed for the highest tier service within the OPD pathway for women in custody.
No existing research with this population and this study will provide preliminary findings of a unique, high-risk, personality-disordered offender population.

12. Current Study II Population:
All women assessed by the service between 2006 and 2015 (N = 45) were invited to participate in the research study.
Overall 30 women (66%) consented to engage in the broader research project.
Of this sample, twenty eight women were assessed using PCL-R and were included in the current study.
Offence Types:
93% incarcerated for violent offence (n = 26)
7% incarcerated for sexual offences (n = 2)
The STOP intervention is recommended to run over a 12-month period and includes assertiveness training, understanding anger and increasing understanding of empathy. undertaken by a charity in Leeds.

13. Current Study III Sentence Length
39.3% mandatory life sentence (n = 11)
46.4% indeterminate life sentence (n = 13)
14.3% fixed determinate sentence (n = 4).
Measures:
Demographic Information
Psychopathy Checklist - Revised (Hare, 2003)
International Personality Disorder Examination (IPDE; Loranger, 1999)
The STOP intervention is recommended to run over a 12-month period and includes assertiveness training, understanding anger and increasing understanding of empathy. undertaken by a charity in Leeds.

14. Current Study IV Psychopathy (PCL-R Scores)
Mean PCL-R score current sample (SD = 5.52)
Significantly higher than general sample of UK prisoners (Coid et al., 2009a)
Conversely significantly lower than sample of male offenders DSPD pilot (Kirkpatrick et al., 2010)
Large effect sizes
32.1% in the PCL-R 25 and above category (n = 9)
42.9% of women scored within the PCL-R category (n = 12)
25% in the PCL-R below 18 category (n = 7)
The STOP intervention is recommended to run over a 12-month period and includes assertiveness training, understanding anger and increasing understanding of empathy. undertaken by a charity in Leeds.

15. Current Study V
The mean PCL-R score for women in this sample was (SD = 5.52). One-sample t-tests indicated the total score in the Primrose sample was significantly higher (M = 20.68, SD = 5.52; t (27) = 11.86, p < .001; d = 1.71, 95% CI [10.34, 14.31]) than the general sample of UK female prisoners (M = 8.3, SD = 8.6) (Coid et al., 2009a). Conversely, one-sample t-tests found the total score was significantly lower (M = 20.68, SD =5.52, t (27) = -7.30, p < .001; d = -1.47, 95% CI [-9.69, -5.59]) than the sample of male offenders from the DPSD pilot (M = 28.30, SD = 4.80) (Kirkpatrick et al., 2010). Large effect sizes were found for differences between the Primrose sample and the general UK female sample (d = 1.71) and the DSPD male offenders (d = -1.47). One-sample t-tests indicated no significant difference between the Primrose sample and Hare’s (2003) female US sample (M = 19, SD = 7.5, t (27) = 1.61, p = .12, d = .25, 95% CI [-.43, 3.57]). The difference between the Primrose sample and Hare’s (2003) sample indicated a small effect size (d = .25).

16. Current Study VI
In this sample, of the seven women who scored below 18 on the PCL-R, the women tended to be incarcerated for murder (n = 2), arson (n = 2) or threats to kill (n = 2) (see Figure 2). The offence of arson was most often found in this category in comparison to other categories. Of women scoring below 18 on the PCL-R, 71.4% of their victims were strangers (n = 5) and 28.6% were intimates/family (n = 2).

17. Current Study VII
Of the moderate PCL-R group (score 18-24), 100% were convicted for violent offences (see Figure 3). This included 25% convicted of murder (n = 3), 17% convicted of child cruelty (n = 2) and 8% convicted of violent sexual offences against an adult (n = 1). In this sample, an index offence of child cruelty only occurred in this category of PCL-R scorers. Women convicted of non-fatal violence were most often found in the category (n = 9) as opposed to the categories of below 18 (n = 5) or above 25 (n = 3). The category of non-fatal violence included offences of wounding, robbery, actual bodily harm, and threats to kill.

18. Current Study VIII
Forty-four percent of the sample who scored 25 or more on the PCL-R were incarcerated for murder (n = 4) (see Figure 4). For these women, 50% of victims were strangers (n = 2) and 50% were intimates or family members (n = 2). Furthermore, 66.7% of women scoring over 25 on the PCL-R were incarcerated for the offence of either murder or manslaughter (n = 6), in comparison to 25% of those scoring (n = 3), and 28.6% of those scoring less than 18 (n = 2). Women in PCL-R category 25+ convicted of either manslaughter or murder tended to kill a victim known to them (66.7%; n = 4).

19. Current Study IX Psychopathy (PCL-R Scores) & Offence Type
Fisher’s Exact Tests were performed to examine the relationship between the three PCL-R categories (i) PCL-R score below 18, (ii) PCL-R score 18-24; (iii) PCL-R score 25 + and offence type.
The offence types were categorised as: (i) sexual/child cruelty; (ii) murder/manslaughter; (iii) non-fatal violence and (iv) arson.
There were no significant associations found between the PCL-R categories and offence types, X2 (6, N = 27) = 9.21, p = .10, V = .43.
Cramer’s V effect size moderate.
It must be noted that the standardized effect size constitutes a relatively strong effect size (Rea & Parker, 1992).

20. Current Study X Psychopathy, Personality Disorder & Offence Type
The most prevalent personality disorder diagnosis in the sample :
BPD (85.1%) (n = 23)
Antisocial personality disorder (ASPD) (51.8%) (n = 14),
Narcissistic personality disorder (NPD) (11.1%) (n = 3)
Paranoid personality disorder (PPD) (3.7%) (n = 1)
Obsessive-compulsive personality disorder (OCPD) (3.7%) (n = 1),
Histrionic personality disorder (HPD) (3.7%) (n=1)
Avoidant personality disorder (APD) (3.5%) (n = 1).
Fisher’s Exact Tests were also performed to examine the relationship between PCL-R categories and personality disorder.
Women in this study sample did not meet criteria for any other personality disorder other than those presented.

21. Current Study XI
Previously employed PCL-R categories were retained and due to the high prevalence of BPD, categories were devised to distinguish those (i) with a diagnosis of BPD and (ii) those without a BPD diagnosis.
Significant associations were found between women with a diagnosis of BPD in the different PCL-R categories X2 (2, N = 27) = 6.36, p = .01, V = .50.
Findings indicated that 100% of those in the 18 – 24 category were diagnosed with BPD as opposed to 50% of those in the below 18 PCL-R category.
Women in this study sample did not meet criteria for any other personality disorder other than those presented.

22. Current Study XII
Results also found that 78% of women who scored 25 or above were diagnosed with BPD.
For women convicted of manslaughter or murder in this PCL-R category, the results indicated all women in this category with a diagnosis of BPD tended to kill intimates or family victims (100%).
Women in this study sample did not meet criteria for any other personality disorder other than those presented.

23. Implications for practice I
When adopting the PCL-R cut-off score of 25, psychopathy prevalence rates of 32.1% in this specialist service for female personality disordered offenders.
Indicates the importance of services for higher levels of psychopathy.
Overall, findings suggest psychopathy, as measured by the PCL-R, to be somewhat muted in female prisoners in specialist personality disorder services in comparison to men.
Use of other measures such as CAPP would be useful to explore
Rates are notably higher than those previously identified in UK general female prisoner populations (Coid et al., 2009a) and general female forensic European samples (e.g., Weizmann-Henelius et al., 2010).
PCL-R scores in this sample were significantly lower than UK male samples from comparable services (e.g., Kirpatrick et al., 2009).
Overall, findings suggest psychopathy, as measured by the PCL-R, to be somewhat muted in female prisoners in specialist personality disorder services in comparison to men.

24. Implications for Practice II
High proportion of the PCL-R score of 25 or over category (66.7%) were incarcerated for the offences of either murder or manslaughter.
It is somewhat in conflict with some findings, have suggested a lower prevalence of fatal index offences perpetrated by women with higher PCL-R scores (e.g., Klein Tuente et al., 2014).
Further research with specialist female populations required and comparisons with general female forensic population.
This prevalence of serious violence offences is consistent with findings with male psychopathic offenders (Kirkpatrick et al., 2010) and some findings with female psychopathic offenders (Weizmann et al., 2003).
Power analysis also indicated a larger study sample would have been more powerful in detecting smaller effects.
This finding suggests the potential value of exploring differences between forensic patients and female prisoners in specialist personality disorder services.

25. Implications for Practice III
The most prevalent category of PCL-R scores in this study was women scoring between 18 and 24. All women in the 18 to 24 category met the criteria for diagnosis of BPD.
The prevalence of this category, along with its association to BPD, is consistent with the views that BPD may be a manifestation of psychopathy in females (Hicks et al., 2010; Sprague et al., 2012).
This suggests the potential value of further exploring whether etiological pathways into BPD and psychopathy overlap, the nature of such overlaps, as well as potential differences.
Sprague et al. (2012) highlighted associations between BPD and PCL-R Factor 2 characteristics are somewhat unsurprising. This is given the common underlying features of impulsivity and instability characterising both constructs. The prevalence of these overlapping constructs is also consistent with the conceptualizations of secondary psychopathy (e.g., Skeem et al., 2007).
This would provide greater understanding of gendered pathways into particular personality difficulties and theoretical underpinning of the constructs. This would also enhance psychological formulation with this population and inform treatment pathways.

26. Implications for Practice IV
Potential clinical and theoretical implications warrant further exploration.
For psychopathic women with BPD, it may be that emotional regulation and interpersonal difficulties key areas of treatment and BPD evidence-base treatment.
It also may be that treatment interventions for psychopathic women with BPD may be less responsive for psychopathic women without this diagnosis.
Sprague et al. (2012) highlighted associations between BPD and PCL-R Factor 2 characteristics are somewhat unsurprising. This is given the common underlying features of impulsivity and instability characterising both constructs. The prevalence of these overlapping constructs is also consistent with the conceptualizations of secondary psychopathy (e.g., Skeem et al., 2007).
This would provide greater understanding of gendered pathways into particular personality difficulties and theoretical underpinning of the constructs. This would also enhance psychological formulation with this population and inform treatment pathways.

27. Future Research Use of different measures of psychopathy (e.g. CAPP)
Exploring different PCL-R cut-offs and categories and predictive value and whether distinguish between different types of violent female offenders.
Exploring personality and psychopathy patterns across OPD pathway for women would be of value.
Examining treatment responsivity also of great value.
Comparisons to other population and sample size considerations.
Sprague et al. (2012) highlighted associations between BPD and PCL-R Factor 2 characteristics are somewhat unsurprising. This is given the common underlying features of impulsivity and instability characterising both constructs. The prevalence of these overlapping constructs is also consistent with the conceptualizations of secondary psychopathy (e.g., Skeem et al., 2007).
This would provide greater understanding of gendered pathways into particular personality difficulties and theoretical underpinning of the constructs. This would also enhance psychological formulation with this population and inform treatment pathways.

28. Thank You Any questions? Annette.Mckeown01@hmps.gsi.gov.uk