Examination of psychopathy in female homicide offenders — Confirmatory factor analysis of the PCL-R

International Journal of Law and Psychiatry 33 (2010) 177–183

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International Journal of Law and Psychiatry

Examination of psychopathy in female homicide offenders — Confirmatory factor analysis of the PCL-R Ghitta Weizmann-Henelius a,⁎, Hanna Putkonen a, Matti Grönroos b, Nina Lindberg c, Markku Eronen a, Helinä Häkkänen-Nyholm d,e a

Vanha Vaasa Hospital, Vaasa, Finland University of Turku, Faculty of Social Sciences, Turku, Finland Helsinki University Central Hospital, Helsinki, Finland d National Bureau of Investigation, Forensic Laboratory, Vantaa, Finland e University of Helsinki, Department of Psychology, Helsinki, Finland b c

a r t i c l e Keywords: Female Psychopathy Homicide Factor analysis

i n f o

a b s t r a c t The construct of psychopathy is essential in explaining criminal behavior, but unfortunately the empirical research on psychopathy in women has been inconsistent. In this study the underlying structure of psychopathy in women was examined by testing the two-factor model by Hare (2003) and the three-factor solution by Cooke and Michie (2001) using confirmatory factor analysis. We replicated the study by Warren et al. (2003) using a nationwide sample of 97 female homicide offenders in order to facilitate the comparison of results. The prevalence of psychopathy in the present study was 9.3% with a cut-off of ≥ 30 and 21.6% with a cut-off of ≥ 25. The best fit for the data out of the tested models was the three-factor model with six testlets. The two-factor model proved to be too simple a model for the female homicide data. The findings regarding comorbidity of psychopathy with personality disorders show that the concept of psychopathy includes diagnostic criteria of several personality disorders, but further research is needed to establish a possible superordinate dimension. Further research on the PCL-R and putative gender differences in the expression of psychopathy in women and men as well as on the putative impact of cultural differences on the instrument is clearly needed. © 2010 Published by Elsevier Ltd.

1. Introduction Psychopathy is an essential construct in explaining criminal behavior and has been linked to violent criminality in both males and females (Hare, 2003). The most widely used operational definition of psychopathy has been the Hare Psychopathy Checklist—Revised (Hare, 1991, 2003). The checklist is a clinical construct rating scale, designed for the assessment of psychopathy in forensic populations, which measures interpersonal and affective traits, as well as chronically unstable, antisocial, and socially deviant behavior (Hare, 1991; Hare et al., 1990). It was originally developed for male offender samples in North America (Hare, 1991) and since then has been subjected to intensive research. In order to raise the understanding of the core features of psychopathy, several studies have examined the discriminating value of the individual items in the PCL-R (Bolt, Hare, Vitale, & Newman, 2004; Cooke & Michie, 1997, 2001; Cooke, Michie, Hart, & Hare, 1999), and the factor structure of the instrument (Cooke & Michie, 2001; Hare, 1991, ⁎ Corresponding author. Vanha Vaasa Hospital, PO Box 13, 65381 Vaasa, Finland. Tel.: + 358 6 323 0135; fax: + 358 6 356 7047. E-mail address: ghitta.weizmann-henlius@vvs.fi (G. Weizmann-Henelius). 0160-2527/$ – see front matter © 2010 Published by Elsevier Ltd. doi:10.1016/j.ijlp.2010.03.008

2003; Hare et al., 1990; Harpur, Hakstian, & Hare, 1988; Harpur, Hare, & Hakstian, 1989; Hobson & Shine, 1998; McDermott et al., 2000; Templeman & Wong, 1994; Vitacco, Rogers, Neumann, Harrison, & Vincent, 2005; Windle & Dumenci, 1999). Research findings on male populations have given support for an overall superordinate factor of psychopathy as well as the two specific factors, the Interpersonal/ Affective and the Social Deviance factor (Hare, 2003). Bolt et al. (2004) however provided an item response analysis and suggested an original two factor and additional four facet solution for the instrument. Consequently, in their model, both factors were further separated into two facets, the Interpersonal and Affective facets, and the Lifestyle and Antisocial facets. However, this partitioning has been questioned on both theoretical and empirical grounds because it emphasizes indices of socially deviant and antisocial behavior (Cooke & Michie, 2001). Cooke and Michie (2001) have instead proposed a three-factor model of psychopathy based on their research using Item Response Theory (IRT) analyses. The three-factor model measures the superordinate factor of psychopathy, which is underpinned by three factors: the Arrogant and Deceitful Interpersonal Style, the Deficient Affective Experience and the Impulsive and Irresponsible Behavioral Style. The three-factor model is thought to capture basic tendencies of psychopathy rather than its behavioral manifestations.

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The construct of psychopathy has increasingly been applied to women (Berardino, Meloy, Sherman, & Jacobs, 2005; Cooney, Kadden, & Litt, 1990; Forouzan & Cooke, 2005; Forth, Brown, Hart, & Hare, 1996; Forth, Kisslinger, Brown, & Harris, 1993; Hare, 2003; Nicholls, Ogloff, Brink, & Spidel, 2005; Rutherford, Cacciola, Alterman, & McKay, 1996; Strand & Belfrage, 2005; Warren et al., 2003; Weizmann-Henelius, Viemerö, & Eronen, 2003; Verona & Vitale, 2006). A majority of the studies with female offender samples as well as psychiatric and community samples reveal a lower prevalence rate of psychopathy and a lower PCL-R score in females than in male offenders (Cale & Lilienfeld, 2002; Grann, 2000; Jackson, Rogers, Neuman, & Lanmbert, 2002; Loucks & Zamble, 2000; Nicholls et al., 2005; Rutherford, Cacciola, Alterman, McKay, & Cook, 1999; Rutherford et al., 1996; Salekin, Rogers, & Sewell, 1997; Salekin, Rogers, Ustad, & Sewell, 1998; Tien, Lamb, Bond, Gillstrom, & Paris, 1993, May; Warren et al., 2003; Vitale & Newman, 2001; Vitale, Smith, Brinkley, & Newman, 2002; Zagon & Jackson, 1994). Hare (2003) reported that approximately 15% of male offenders and 8% of female offenders score 30 or above on the PCL-R. Vitale, Smith, Brinkley, and Newman (2002) reported that base rates with female offender samples usually range from 9% to 23% but fall between 15% and 30% in men. Thus, there is no agreement on the diagnostic cut-off score for psychopathy in women and the cut-off score used has varied across studies (Nicholls et al., 2005). Cut-off scores of 25 to 28 or more have been proposed in European studies (Cooke & Michie, 1999; Cooke, Michie, Hart, & Clark, 2005a,b). Furthermore, gender differences have also been observed regarding prevalence symptomatology as well as in comorbidity of psychopathy with other disorders (Cale & Lilienfeld, 2002; Grann, 2000; Hamburger, Lilienfeld, & Hogben, 1996; Salekin et al., 1997). Altogether this research has opened a discussion regarding the question of psychopathy being expressed differently in women than in men, leading to the question as to whether the measure of psychopathy should be modified for women (Forouzan & Cooke, 2005; Nicholls & Petrila, 2005; Vitale et al., 2002). Research indicates that the factor structure and item loadings on the PCL-R seem to differ between women and men, but research on factor structure of the PCL-R in women has been sparse. Salekin et al. (1997) found support for the two-factor model using exploratory factor analysis on female offenders, but the individual PCL-R items loaded on different factors as compared to the original two-factor solution. The researchers suggested that the factor structure used to conceptualize psychopathy in men may not be applicable to women. More recent studies seem to support the three-factor solution among females (Jackson et al., 2002; Skeem, Mulvey, & Grisso, 2003; Warren et al., 2003) and indicate that psychopathy might be expressed differently in females than in males (Cale & Lilienfeld, 2002; Forouzan & Cooke, 2005). Skeem et al. (2003) found, however, a similar factor structure of the Screening Version of the PCL-R in female and male civil psychiatric patients, whereas Strand and Belfrage (2005) found that scores divided into three factors instead of two as in a male sample. Jackson et al. (2002) tested the factor solutions by Hare (1991), Salekin et al. (1997) as well as Cooke and Michie (2001) using confirmatory factor analysis on a sample of 119 female inmates. They found that the three-factor model with six testlets proved to be the best fit for their data. Warren et al. (2003) examined Hare's two-factor solution with eight and ten testlets as well as with raw items, and Cooke's three-factor models with six and ten testlets as well as with raw items using the confirmatory factor analysis on a sample of 138 females incarcerated at a maximum-security prison. They found that the three-factor model with six testles out of all the solutions represented the best fit for the data, although it did not indicate a significant improvement over the two-factor model. The aim of the present study was to investigate the underlying structure of the concept of psychopathy in women. The two-factor model by Hare (2003) and the three-factor solution by Cooke and Michie (2001) were tested using confirmatory factor analysis. The study by Warren et al. (2003) was replicated in order to facilitate the

comparison of results. Furthermore, we wanted to examine the comorbidity of psychopathy with personality disorders. Our goal was to contribute to the understanding of the manifestation of psychopathy in female offenders. 2. Method 2.1. Sample The present study was register-based and nationwide. Information concerning homicides and the offenders was obtained from the Finnish National Authority for Medico-legal Affairs (NAMA), which organizes the forensic psychiatric examinations in Finland. According to Finnish law, courts decide whether a forensic psychiatric examination is needed. An examination is commonly administered as a part of the homicide investigation procedure. The NAMA arranges the forensic psychiatric examinations, which are inpatient evaluations lasting six weeks on average. The evaluations are extensive, consisting of data collection from various sources: review of medical, criminal, and military records; interviews by a multi-professional team, psychiatric evaluation, psychological assessment, physical evaluation and observation by hospital staff. The final forensic psychiatric report includes an opinion of the level of criminal responsibility, a putative psychiatric diagnosis, and an assessment as to whether the offender fulfils criteria for involuntary psychiatric care. Forensic examination reports of all female offenders prosecuted for a homicide between 1993 and 2005 and subjected to a forensic psychiatric examination, were collected from the NAMA's archives. Criminal reports of these homicides were collected from the Finnish police computerized Criminal Index File. During the years 1993–2005, 148 women were prosecuted for homicide in Finland (Statistics Finland, 2006). Of these women, 97 (65.5%) had undergone a forensic psychiatric evaluation and been convicted by the court. The excluded women had either not been evaluated, or not been convicted of homicide in court or had died by 2006 when the data collection for the present study started. Four women were excluded due to incomplete records. Of the 97 convicted female homicide offenders, 72 (74.2%) had been convicted of murder and 25 (25.8%) of manslaughter. There were, in total, 117 victims: 10 offenders had two victims each, and three single offenders had three, five and seven victims, respectively; the rest had one victim each. Thirteen offenders had committed their crime in company with another offender. The mean age of the offenders was 36.3 years (SD = 10.2, range 17–60 years) at the time of offence. Of the offenders, 41 (42.3%) had a criminal history and 30 (30.9%) offenders had a history of violent criminality specifically. Of the offenders, 62 (64.6%) had been declared fully responsible for their crime in the forensic psychiatric evaluation, whereas 23 (24.0%) were found to have diminished responsibility and 11 (11.5%) had been regarded not legally responsible for their act, due to psychosis. 3. Measure Psychopathy Checklist—Revised (PCL-R; Hare, 1991, 2003) is a 20item rating scale for the assessment of psychopathy in male prison and forensic populations. The ratings are based on a semi-structured interview and a review of collateral information. The items are rated on a three-point scale according to the degree to which the personality and behavior matches the item description. The total score amounts to 40. In addition to the usual diagnostic cut-off score of 30, recommended by Hare (1991, 2003), the cut-off score of 25 was applied as it often is in European studies (Cooke, 1998; Grann, Långström, Tengström, & Stålenheim, 1998). The forensic evaluation reports of the 97 female offenders were reviewed and the PCL-R was retrospectively rated by trained raters. Previous studies have shown that file-only PCL-R ratings

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have good reliability for research purposes (Alterman, Cacciola, & Rutherford, 1993; Grann et al., 1998; Wong, 1988). 4. Procedure Information on the offender's personality disorder was collected from the forensic evaluation reports. Diagnoses made during the forensic evaluations were based on DSM-III-R (American Psychiatric Association, 1987) criteria until 1996. Since then ICD-10 (World Health Organization, 1992) has been used along with DSM-IV (American Psychiatric Association, 1994). The overall quality and reliability of Finnish forensic psychiatric evaluations are considered highly reliable both by courts and scientists (Eronen, Repo, Vartiainen, & Tiihonen, 2000). The present female sample was a part of a national sample including both genders. To evaluate inter-rater agreement of the PCL-R ratings in the entire research project, twenty reports were randomly chosen and the PCL-R was rated by nine trained forensic psychiatrists and psychologists after having attended workshops and undergone several training sessions. The raters were kept blind to the ratings regarding the offence, clinical and life course data, but the forensic evaluation report contains a short description of the crime. The interrater agreement was assessed using Intraclass correlation ICC(2,1). The ICC was .89 for the PCL-R total score; .72 for factor 1 and .92 for factor 2 scores. All correlations were significant (p b .001). The internal consistency, as measured by Cronbach's alpha, was, in the two-factor model, .89 for all items, .86 for factor 1 and .79 for factor 2, and .84 for facet 1, .83 for facet 2 , .87 for facet 3, and .64 for facet 4. Supervisory ethical authorities approved the study and additional permission was granted by the Ministry of Interior, the National Authority for Medico-legal Affairs and the Legal Register Centre. 5. Data analysis The SPSS 16.0 statistical software package was used in all analyses. Inter-rater agreement was assessed using Intraclass correlation ICC(2,1). Correlations between PCL-R scores and the dichotomous personality disorder diagnoses were assessed by the Point Biserial Correlation. Receiver Operating Characteristic (ROC) curve analysis was performed to determine the cut-off value of the PCL-R score providing the best values of sensitivity and specificity. The presence of a history of criminality were used to define psychopathy. The test accuracy, estimated by Youden's index, was calculated by equation: sensitivity + specificity − 1 (Bewick, Cheek, & Ball, 2004). The area (AUC) under the ROC-curve with a confidence interval (95% Cl) was calculated. LISREL 8.71 software (Jöreskog & Sörbom, 2004) was used to conduct confirmatory maximum likelihood factor analysis (CFA). The fit of the Hare two-factor and the three-factor solution by Cooke and Michie (2001) was determined using the confirmatory maximum likelihood factor analysis. We used multiple fit indices to evaluate the various models. We included the absolute fit (χ2), the comparative fit index (CFI), the adjusted goodness-of-fit index (AGFI), the goodnessof-fit index (GFI) and the root mean square error of approximation (RMSEA) as well as the chi-square goodness-of-fit statistic. The CFI measures the fit of the model relative to the null model and is less affected by study group size. The values of CFI, AGFI and GFI range from 0 (poor fit) to 1 (good fit). CFI values of greater than .90, AGFI values greater than or equal to .80, and GFI values greater than or equal to .85 indicate good fit. RMSEA accounts for model parsimony and values less than .08 indicate an acceptable fit. 6. Results

scores in the sample was 16.83 (SD = 9.71; range 0–34). The mean score for factor 1 was 7.71 (SD = 4.50; range 0–16) and 7.52 (SD = 5.08; range 0–18) for factor 2. Nine (9.3%) offenders scored ≥ 30 and 21 (21.6%) offenders ≥25.

6.1. Confirmatory factor analysis We examined the underlying structure of the concept of psychopathy in women as measured by the PCL-R by testing the two-factor model with eight testlets by Hare (2003) and the threefactor model with the original six testlets and with ten testlets by Cooke and Michie (2001). In addition, both models were tested with raw items. Item 19, Revocation of Conditional Release was omitted from the two-factor model to get a correlation matrix that could be analyzed with LISREL. Fit indices for each model are presented in Table 1. Out of all models, the Cooke three-factor model with six testlets proved to be the best fit for the data (χ2(6) = 10.26, p = .114, CFI = .991, GFI = .966, AGFI = .880, RMSEA = .086). All testlets loaded significantly on their respective factor (p b .05) with the factor loadings ranging from .73 to .99 (Fig. 1). Correlations between factors were high, particularly between factor 2, the Deficient Affective Experience and factor 3, the Impulsive and Irresponsible Behavioral Style. Only this model provided a good fit for the data. The lack of adequate goodness of fit of the three-factor model with ten testlets seems to be due primarily to testlet six, but to some extent also on testlets eight and ten (Fig. 2). If testlets six and eight are left out of the model, the model shows a better fit for the data. This probe indicates that the model with six testlets is a more accurate model. The twofactor model with eight testlets did not meet the fit criteria as well as the three-factor model with six testlets (Fig. 3). A further examination of the two-factor model showed that the poor fit of this model was due to factor 1. If this factor comprises testlets four and eight, either testlet one or three should be left out of the factor. Only then will the model show an adequate goodness of fit. The testlets one and three of the two-factor model loaded on factor 1 in the three-factor model and the two-factor testlets four and eight on factor 2 in the three-factor model. All models with raw items had a very poor fit.

6.2. ROC curve ROC analysis of the PCL-R identified a score of 22 as the best cut-off value discriminating between psychopaths and non-psychopaths as defined by criminal history with a sensitivity of 78% and a specificity of 81%. The AUC was .85 (95% Cl: .77–93) and the highest value of the Youden's index was .59.

Table 1 Fit indices for confirmatory factor analysis models. χ2

CFIa

GFIb

AGFIc

RMSEAd

19

.954

.861

.736

.154

10.26

6

.991

.966

.880

.086

97

70.75

32

.965

.872

.779

.112

97

308.57

103

.914

.713

.622

.144

97

145.44

62

.942

.811

.723

.118

Model

N

Two-factor model with eight testlets Three-factor model with six testlets Three-factor model with ten testlets Two-factor model with raw items Three-factor model with raw items

97

62.24

97

a b

The PCL-R total scores were approximately normally distributed (skewness= .056, kurtosis = −.992). The mean of the total PCL-R

179

c d

df

The comparative fit index (CFI). The goodness-of-fit index (GFI). The adjusted goodness-of-fit index (AGFI). The root mean square error of approximation (RMSEA).

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Fig. 1. Path diagram for the three-factor model with six testlets.

6.3. Psychopathy and personality disorder The PCL-R total scores and the Interpersonal/Affective and Social Deviance Factor scores of the two-factor model correlated significantly

with antisocial and borderline personality disorders (Table 2). Factor 1, the Arrogant and Deceitful Interpersonal Style of the three-factor model, correlated with borderline, histrionic and narcissistic personality disorders. Factor 2, the Deficient Affective Experience, correlated

Fig. 2. Path diagram for the three-factor model with ten testlets.

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181

Fig. 3. Path diagram for the two-factor model with eight testlets.

with antisocial personality disorder and factor 3, the Impulsive and Irresponsible Behavioral Style, correlated with antisocial and borderline personality disorders. 7. Discussion The purpose of the current study was to examine the underlying construct of psychopathy in women by utilizing confirmatory factor analysis to test the fit of the two-factor model by Hare (2003) and the three-factor solution by Cooke and Michie (2001). This was done by replicating the study by Warren et al. (2003) in order to facilitate a

comparison of results. The findings of the present nationwide study indicated that the three-factor model with six testlets was the best model for the female homicide sample. In the present study, the prevalence of psychopathy among female homicide offenders was lower than in some earlier studies on women (Hare, 2003; Salekin et al., 1997; Vitale et al., 2002). For example, Warren et al. (2003) reported a prevalence rate of 17% among highsecurity female inmates. However, Jackson et al. (2002) found an even lower prevalence among female inmates convicted mostly of drugrelated crimes and thefts than in the present study. Six percent of their female inmates scored 30 or above and 22% scored 25 or above. The

Table 2 Point Biserial Correlation between PCL-R scores and the dichotomous personality disorder diagnoses (N = 97). a

Personality disorder

Total

Avoidant Dependent Obsessive-compulsive Cluster C Schizotypal Schizoid Cluster Ab Histrionic Narcissistic Borderline Antisocial Cluster B

.078 −.033 .078 .038 −.155 .100 −.039 .067 .080 .325⁎⁎ .405⁎⁎⁎ .475⁎⁎⁎

a b

Adjusted scores according to the original two-factor model. No occurrences of Paranoid PD. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.

Two-factor model

Three-factor model

Factor 1

Factor 2

Factor 1

Factor 2

Factor 3

.090 .064 .052 .116 −.130 .098 −.023 .166 .166 .243⁎⁎ .257⁎ .358⁎⁎⁎

.057 −.107 .094 −.028 −.152 .090 −.044 −.073 .006 .321⁎⁎ .451⁎⁎⁎ .477⁎⁎⁎

.055 .080 −.002 .093 −.083 .079 −.003 .201⁎ .201⁎ .298⁎⁎

.111 .045 .098 .126 −.143 .098 −.032 .097 .098 .159 .279⁎⁎ .282⁎⁎

.099 −.043 .084 .042 −.156 .115 −.029 .000 −.006 .301⁎⁎ .430⁎⁎⁎ .455⁎⁎⁎

.199 .388⁎⁎⁎

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lower base rate in our sample may be partly due to lower scores in European than in North American samples (Cooke et al., 2005a,b) and due to file-based ratings of psychopathy. Moreover, as suggested by Warren et al. (2005) the sample composites may have some bearing on the prevalence. Warren et al. found significantly lower PCL-R scores among the female maximum-security prison inmates who had been convicted of murder than among those convicted of property, sex and less severe violent crimes. As the association between PCL-R and a history of criminality has been established in many studies, we used this as state variable in the ROC analysis. The analysis showed that PCL-R scores predicted having a criminal history and indicated a lower cut-off score for women than has been proposed, based on European studies (Cooke, 1998; Cooke & Michie, 1999; Grann et al., 1998). Further research on the cut-off for women, specifically for use in Europe, is clearly needed. The confirmatory factor analysis, which was used to examine the underlying construct of psychopathy demonstrated that, out of all solutions tested, the three-factor six testlets model was the best fit for the data. Furthermore, analysis of the three-factor model with ten testlets supported the six testlets' solution as a good fit for the data, because the poor fit of the ten testlets model was due to testlets eight and ten with items indicating poor behavioral control and antisocial behavior, not included in the three-factor model. This suggests that antisocial behavior is not crucial in female psychopathy, in contrast to findings suggesting that early and versatile antisocial behavior is important signifiers of psychopathy in women (Neumann, Hare, & Newman, 2007). Examination of the two-factor model indicated that the two-factor model seems to be too simple a model. The current analyses support the findings by Warren et al. (2003) and Jackson et al. (2002). All the factor loadings in the three-factor model in the present study were substantial indicating that this model with six testlets captures the underlying dimensions of psychopathy in female homicide offenders. The number of participants in the study was on the border for using a confirmatory factor analysis. It was not meaningful to examine item models due to the small sample size, therefore, the testlet models, which decreased the number of parameters, were used in the analysis. Also, due to the small sample size no further analyses were performed to see how changes in the models or testlets would have lead to models with better fit to the data. LISREL makes it possible to use different methods of estimation, the methods used in the study gave similar results. Detailed conclusions regarding the results cannot be drawn, but the obtained differences between the goodness of fit of the models were clear and large, which justified the use of confirmatory factor analysis, particularly because factor structure of psychopathy in women has not been extensively studied. The correlations between PCL-R and personality disorders emerged differently in our study than in the study by Warren et al. (2003). The association of psychopathy with cluster B personality disorders, particularly with antisocial personality disorder was clear and in line with the results of Warren et al. (2003). The association of psychopathy with the antisocial personality disorder seems to be strong, as the affective and behavioral factors of the three-factor model correlated with antisocial personality disorder, although items indicating antisocial behavior were excluded from this model. Our results showed, however, contrary to the findings by Warren et al. (2003) no correlations with cluster A and C personality disorders, but the association between psychopathy and borderline personality disorder appeared strongly. The interpersonal factor of the threefactor model did not correlate with antisocial personality disorder, but with borderline, histrionic and narcissistic personality disorders. The robust association in the present study between psychopathy and borderline personality disorder indicates that the association between female psychopathy and the impulsive as well as unstable features of this disorder should be studied further. The differences in findings between the two studies regarding comorbidity of psychop-

athy with personality disorders may to some extent be explained by the use of dichotomous personality disorder diagnoses in the present study, whereas the total SCID-II symptom scores were used in the Warren study. Furthermore, the diagnoses in the present study were based on the ICD-10 and DSM-IV, and not on SCID-II interviews. However, the correlations between psychopathy and personality disorders show that the concept of psychopathy includes diagnostic criteria of several personality disorders, but further research is needed to establish a possible superordinate dimension (Blackburn, 2007; Blackburn & Coid, 1998; Neumann et al., 2007; Warren et al., 2003). A limitation of the present study was that the PCL-R scoring was based on file-only information and was assessed retrospectively. Scoring problems emerged in the assessments based on the forensic psychiatric evaluation reports. Although the reports were very extensive, information on promiscuous relationships and long-term goals was often lacking. Information of sexual relationships was recorded in the report only if it had been highly deviant and the information on goals is seldom relevant in a situation where the offender does not yet know the result of the forensic psychiatric evaluation nor the court decision regarding criminal responsibility. However, the strength of the study lay in the fact that the sample was nationwide and comprised all female homicide offenders who had undergone a forensic psychiatric evaluation and been convicted of homicide by the courts in Finland during the studied period of 13 years. Psychopathy is an important clinical construct in forensic psychiatry and psychology, particularly in risk assessment. Understanding the nature of psychopathy and its manifestation in females is essential, particularly regarding the treatment needs of women. The findings of the present study support the view that psychopathy may be expressed differently in women than in men. Therefore further research on the PCL-R and putative gender differences in the expression of psychopathy as well as on the putative impact of cultural differences on the instrument is needed. Studies with larger samples ought to be carried out, and above all, the confirmatory factor models of females and males within the same sample should be compared with LISREL.

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