Is Psychopathy a Valid DSM-5 Diagnosis?
No, psychopathy is not a standalone diagnosis in DSM-5, but it can be captured through the diagnosis of Antisocial Personality Disorder (ASPD) with a psychopathy specifier in the DSM-5 Section III Alternative Model, or through dimensional trait assessment using the Personality Inventory for DSM-5. 1, 2
Current Diagnostic Status
Psychopathy is not included as a distinct diagnostic category in the main diagnostic codes section (Section II) of DSM-5. 3, 4 The closest approximation in standard clinical practice is ASPD, which has historically been criticized for emphasizing behavioral deviance symptoms while inadequately capturing the affective-interpersonal features central to psychopathy (such as callousness, lack of empathy, and manipulativeness). 1, 4
Alternative Diagnostic Approaches in DSM-5
Section III Alternative Model
The DSM-5 Section III Alternative Model for Personality Disorders offers a more sophisticated approach that better captures psychopathic traits:
The Section III ASPD diagnosis is trait-based and demonstrates substantially stronger correlation with psychopathy measures compared to the traditional Section II ASPD diagnosis (accounting for nearly twice the variance in psychopathy scores). 1, 5
This approach includes assessment of personality functioning impairments and pathological personality traits across five domains: Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism. 6
A psychopathy specifier was specifically created for Section III ASPD to make the diagnosis more congruent with the construct of psychopathy, though research shows this specifier adds limited incremental validity beyond the trait-based approach itself. 1
Dimensional Trait Assessment
Psychopathy and its distinctive facets can be effectively assessed using the dimensional traits from the Personality Inventory for DSM-5 (PID-5). 2 This approach captures:
- Impulsive externalization and callous aggression facets through traits relevant to ASPD 2
- The boldness facet of psychopathy through additional PID-5 traits 2
Clinical Implications
For Standard Practice
In routine clinical settings using DSM-5 Section II, diagnose ASPD when criteria are met, recognizing this captures primarily the behavioral deviance aspects of psychopathy rather than the full construct. 4
For Specialized Settings
In forensic, research, or specialized mental health settings where precise characterization of psychopathy is clinically important for treatment planning or risk assessment, use the Section III Alternative Model for ASPD with dimensional trait specification. 1, 5 This provides:
- More accurate representation of psychopathic personality structure 5
- Better prediction of antisocial behaviors and psychopathy-related outcomes 1
- Enhanced clinical utility through dimensional assessment of specific trait domains 6
Important Caveats
The psychopathy specifier in Section III, while conceptually appealing, demonstrates minimal incremental validity beyond the general trait-based ASPD diagnosis, except for capturing fearless dominance features. 1 The primary improvement in capturing psychopathy comes from the shift to trait-based assessment rather than from psychopathy-specific additions. 1
Training in specialized assessment instruments (such as the PCL-R) remains necessary for precise diagnosis of psychopathy in forensic and research contexts, as the DSM-5 approaches, while improved, still represent approximations of the full psychopathy construct. 3