系统排列英文文献2

Psychiatry Research 121 (2004) 271–280 0165-1781/04/$ - see front matter � 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0165-1781(03)00270-1 Adult psychopathic personality with childhood-onset hyperactivity and conduct disorder: a central problem constellation in forensic psychiatry Henrik Soderstrom*, Anna-Kari Sjodin, Anita Carlstedt, Anders Forsman Department of Forensic Psychiatry and Institute of Clinical Neuroscience, Goteborg University, Goteborg, Sweden¨ ¨ Received 8 October 2002; received in revised form 14 August 2003; accepted 15 September 2003 Abstract To describe lifetime mental disorders among perpetrators of severe inter-personal crimes and to identify the problem domains most closely associated with aggression and a history of repeated violent criminality, we used structured interviews, clinical assessments, analyses of intellectual functioning, medical and social files, and collateral interviews in 100 consecutive subjects of pretrial forensic psychiatric investigations. Childhood-onset neuropsychiatric disorders wattention-deficityhyperactivity disorder (ADyHD), learning disability, tics and autism spectrum disordersx affected 55% of the subjects and formed complex comorbidity patterns with adult personality disorders wincluding psychopathic traits according to the Psychopathy Checklist (PCL-R)x, mood disorders and substance abuse. The closest psychiatric covariates to high Lifetime History of Aggression (LHA) scores and violent recidivism were the PCL-R scores and childhood conduct disorder (CD). Behavioral and affective PCL-R factors were closely associated with childhood ADyHD, CD, and autistic traits. The results support the notion that childhood-onset social and behavioral problems form the most relevant psychiatric symptom cluster in relation to pervasive adult violent behavior, while late-onset mental disorders are more often associated with single acts of violent or sexual aggression. � 2003 Elsevier Ireland Ltd. All rights reserved. Keywords: Forensic psychiatry; Violent crime; Disruptive behavior disorders; Comorbidity; Risk factor 1. Introduction Psychiatric problems are over-represented among violent offenders, but the nature of the association between psychiatric features and crim- inality is far from obvious. Although dependent *Corresponding author. Present address: Department of Forensic Psychiatry, Box 4024, Hisings Backa 422 04, Sweden. Tel.: q46-31-559683; fax: q46-31-559671. E-mail address: henrik.soderstrom@rmv.se (H. Soderstrom). on inclusion criteria, legislation and availability of mental health care, surveys of mental disorders in offender groups invariably find sharply increased prevalences of disorders and needs (Fazel and Danesh, 2002). Epidemiological research has shown that psychotic disorders and mental retar- dation carry an increased risk of violent offending (Lindqvist and Allebeck, 1990; Hodgins, 1992; Hodgins et al., 1996) even if the risk increase is not always identifiable in patient groups (Skeem 272 H. Soderstrom et al. / Psychiatry Research 121 (2004) 271–280 and Mulvey, 2001). Childhood-onset disruptive behavior disorders wattention-deficityhyperactivity disorder (ADyHD), oppositional defiant disorder (ODD), and conduct disorder (CD)x carry a high risk of persisting into adulthood as antisocial behaviors (Lahey and Loeber, 1997; Moffitt and Caspi, 2002). Aggressive behavior is also a clinical feature of tic disorders and autism spectrum dis- orders wreferred to as ‘pervasive developmental disorders’ (PDDs) in DSM-IV (American Psychi- atric Association, 1994; Siponmaa et al., 2001; Soderstrom, 2002)x. Several definitions of person- ality disorders (such as borderline personality dis- order, antisocial personality disorder and psychopathy) contain aggressive behaviors as dis- criminative traits (American Psychiatric Associa- tion, 1994; Hare, 1980). The aims of the present study were to (1) analyze the comorbidity between childhood and adulthood disorders among 100 perpetrators of violent crimes investigated by means of structured interviews, clinical assessments, neuropsychologi- cal tests and file reviews and (2) identify the lifetime psychiatric characteristics most closely associated with high levels of aggression and criminal recidivism. 2. Subjects Subjects were consecutively recruited among perpetrators of severe violent or sexual index crimes, i.e. crimes where the life of another person had been threatened or taken (murderymanslaugh- ter in 21 cases, attempted murderymanslaughter in 17, aggravated assault in 17, aggravated unlawful threatyrobbery in 6, rape in 3, sexual child abuse in 22 and arson in 14). All were admitted to the study department by court order to undergo foren- sic psychiatric investigations for periods up to 4 weeks. Participation required a basic Swedish edu- cation to ascertain sufficient language comprehen- sion for the diagnostic methods and to ensure access to school records. The study group was set to include 100 subjects, and data were consecu- tively collected from October 1998 until February 2001, when 92 men and eight women, aged 17– 76 (median 30) years, had been included. Another 21 subjects, 18 men and three women, aged 17– 62 (median 35) years, who met the inclusion criteria but declined participation differed from the study group by higher prevalences of psychotic disorders. After the study, the subjects were fol- lowed through trials, appeals to higher courts and sentencings. All were finally convicted of their index crimes, in some cases after a change in the legal definition. The final sanctions were prison in 51 cases, inpatient forensic psychiatric treatment in 42 and probation with community treatment in seven. All subjects were detoxified during several weeks on remand before admission to the study. All but four remained on remand and shared standardized living conditions during the study period. Sixty-four subjects had psychopharmacol- ogical therapy (minor tranquillizers in 17, major tranquillizers in 9, benzodiazepines in 5, antide- pressant medication in 19, mood stabilizers in 3, and more than one of these medications in 11), and three had medication for somatic problems. Pharmacological treatment was often initiated after admission to the study department, and both pre- treatment state and therapeutic effect were consid- ered in the diagnostic work-up and in the evaluation of test results. 3. Methods 3.1. Overall clinical diagnostic work-up DSM-IV diagnoses on Axes I and II (American Psychiatric Association, 1994) were assigned by AF and HS in consensus on the basis of the diagnostic work-up (interviews, assessments and tests) described below and data from educational and social welfare registers (including child health care and school records), medical records (includ- ing child and adolescent psychiatric contacts), and the forensic psychiatric investigation reports. All concomitant diagnoses were recorded to provide as complete a picture of comorbidity as possible. In the diagnostic work-up, psychiatric, psycholog- ical, and psychosocial aspects were rated indepen- dently to enable comparisons between the different diagnostic schemes. To conform to the most widely used terminology, we use ‘autism spectrum disor- ders (ASD)’ instead of ‘persistent developmental 273H. Soderstrom et al. / Psychiatry Research 121 (2004) 271–280 disorder’ and ‘Asperger syndrome’ instead of ‘Asperger’s disorder’. 3.2. Interviews and assessments for Axis I disorders All interviews for adult Axis I disorders, includ- ing childhood-onset neuropsychiatric disorders and disorders of impulse control, were performed by the same psychiatrist (HS) using: the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) (First et al., 1996), the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) (Good- man et al., 1989), the Asperger Syndrome Screen- ing Questionnaire (ASSQ) (Ehlers and Gillberg, 1993), the Asperger Syndrome Diagnostic Inter- view (ASDI) (Gillberg et al., 2001), yielding the Gillberg and Gillberg research diagnostic algorithm for Asperger Syndrome (Gillberg and Gillberg, 1989), and interviews assessing each DSM-IV criterion (present state and retrospectively) for diagnoses not included in the SCID (childhood- onset neuropsychiatric disorders, impulse control disorders, and paraphilias). A structured neuropsy- chiatric status was registered in each case. These interviews were carried out in 89 subjects, and in the remaining 11, diagnoses (psychosis or mental retardation) were assigned on the basis of the clinical diagnostic work-up by the forensic inves- tigation teams, the documentation, and the unstruc- tured clinical examinations made by HS and AF in all 100 subjects. Childhood files from maternity care, child health centers and schools were used in all cases, childhood mental health files in 39 cases and collateral interviews with a relative who had known the subject well as a child in 31 cases, 19 of whom were diagnosed with childhood-onset neuropsychiatric disorders. For ADyHD, the DSM- IV criterion that excludes other comorbid neuro- psychiatric disorders was disregarded, as current research does not sustain a difference between ADyHD alone and ADyHD in combination with other disorders, such as the autism spectrum dis- orders (Ghaziuddin et al., 1998; Kadesjo and Gillberg, 2001). A diagnosis of conduct disorder before the age of 15 was based on the C criterion for antisocial personality disorder according to the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) (First et al., 1997) interviews, file data and collateral information. The diagnosis of developmental coordination dis- order (DCD) required a history of gross motor clumsiness (such as problems climbing stairs with- out holding onto a rail or participating in ball games) and fine motor clumsiness (such as diffi- culty in handling eating and writing implements, buttons and shoe-laces). The prevalence rates of the childhood-onset neuropsychiatric disorders were compared by Fish- er’s exact test to the background population data derived from studies on 7-year-olds during the 1990s (Kadesjo and Gillberg, 1998, 2000; Kadesjo et al., 1999). 3.3. Intellectual functioning Intellectual functioning was assessed by trained clinical psychologists using the Wechsler Adult Intelligence Scale-Revised (ns80) (Wechsler, 1981) andyor childhood diagnoses of mental retar- dation and borderline intellectual functioning assigned at test assessments for special educational needs. 3.4. Personality disorders including psychopathy Axis II diagnoses were based on SCID-II inter- views (First et al., 1997) carried out in 74 subjects. Excluded were the 11 subjects who did not partic- ipate in the SCID-I interview, eight further subjects with longstanding major mental disorders, the impact of which would have precluded any per- sonality disorder diagnosis, and seven subjects due to practical problems. The numbers of fulfilled diagnostic criteria according to the SCID-II inter- views were used to provide dimensional ratings of dysfunctionalymaladaptive personality traits. The DSM-IV cut-off levels for personality disorders were applied to the SCID-II diagnostic interviews and checked against file information and opera- tional criteria. A personality disorder diagnosis was assigned only when dysfunctional personality traits were identified as clinical problems causing severe psychosocial maladaptation in addition to the problems that could be attributed to any other mental disorder. 274 H. Soderstrom et al. / Psychiatry Research 121 (2004) 271–280 Psychopathy was assessed according to the Psy- chopathy Checklist Revised (PCL-R) (Hare et al., 1990), a structured rating scale for categorical diagnostics of psychopathy and for dimensional assessment of psychopathic traits. The PCL-R has reliable psychometric properties and describes a continuous association with dimensional ratings of mental disorders (Hart and Hare, 1989), criminal behavior and criminal recidivism (Hart, 1998; Hemphill et al., 1998; Grann et al., 1998). Factor analysis has shown a two-factor structure, separat- ing interpersonal attitudes from impulsive, aggres- sive behavior (Harpur et al., 1989; Hare et al., 1990), but a more recent analysis (Cooke and Michie, 2001) has excluded the items describing criminal behaviors and found two distinct inter- personal facets: deceitful and arrogant interperson- al attitudes (Factor 1) and blunted affective reactivity (Factor 2), while a third factor reflects behavioral characteristics (Factor 3). PCL-R rat- ings were made in all 100 subjects. Final PCL-R scores were assigned by one of the authors (AKS) on the basis of ratings made by her psychiatric social worker colleagues and extensive file and register information in each case. Propensity for aggression was assessed in accor- dance with the Life History of Aggression Scale (LHA) (Brown et al., 1982) on the basis of self- reports, interviews and file information. Sufficient information for this assessment was available in 91 cases. In addition, we used data on previous convictions for violent crimes obtained from police registers and forensic psychiatric investigation reports to identify perpetrators of repeated violent crimes. 3.5. Statistical methods All statistics were calculated with the SPSS 10.0 or SAS 8.2 software, using two-tailed P-values. Inter-rater reliability was not assessed for pub- lished instruments administered by one rater to all subjects, with the exception of the PCL-R ratings, where a post-hoc assessment of inter-rater reliabil- ity was made to compare the final ratings by AKS to 8 independent ratings by the social worker who had personally investigated these subjects and to 20 ratings independently made by AKS and two other colleagues for a previous study. The ratings of AKS were generally found to be lower than those of the other raters. The intraclass correlation coefficient (ICC), defined as (variance between subject)y(variance between subjectqvariance of error), includes both random errors and systematic differences but is also dependent on the range of the variable measured. The ICC ranges from 0 (no agreement) to 1 (perfect agreement). Based on the 28 ratings compared, the ICCs were 0.71 (P- 0.0001) for the PCL-R total score, 0.73 (P- 0.0001) for Factor 1, 0.39 (Ps0.0184) for Factor 2 and 0.69 (P-0.0001) for Factor 3. All correlations were analyzed with Spearman’s non-parametric correlation coefficients. In compar- isons of diagnostic prevalences, Fisher’s exact tests were used for dichotomous variables. All variables with significant univariate correlations to the dependent variable were included in a stepwise logistic regression (for the dichotomous dependent variable ‘previous violent crimes’, i.e. violent recidivism) or in an ordinary stepwise regression analysis (for the continuous dependent variable ‘LHA score’) after transforming the scores to a normal distribution by calculating normal score as described by Blom (1958). In multivariate statis- tics, the PCL-R total score was entered as a continuous variable after normal transformation, whereas the factor scores were used as dichoto- mous variables by median splits due to their skewed distributions. Used in comparisons requiring dimensional assessments of traits rather than categorical diag- noses were the number of fulfilled Gillberg and Gillberg criteria for Asperger syndrome and of DSM-IV criteria for ADyHD (statistically ana- lyzed separately for AD and HD) met during childhood, tics (rated as no tics, childhood tics, chronic tics, or Tourette syndrome), DCD (rated as no DCD, childhood DCD, and persistent DCD), and global IQ. 4. Results 4.1. Diagnostic work-up All categories of mental disorder showed strik- ingly high prevalences. At least one DSM-IV 275H. Soderstrom et al. / Psychiatry Research 121 (2004) 271–280 diagnosis was registered in all but four subjects. The distribution of diagnoses in the other 96 subjects is given in Table 1. Fifty-five percent of the study group fulfilled DSM-IV diagnostic cri- teria for childhood-onset disorders (not including borderline intellectual functioning or CD) and 48% met those for CD. A global IQ -85 was recorded in 37, 17 of whom with IQ scores -70 (including subjects first diagnosed with mental retardation in the present study as well as those so diagnosed when assessed for special education needs in childhood). ASSQ interviews yielded scores between 0 and 38 points (median 6 points), 36% had G10 points, the score indicative of autism spectrum disorder, and 8% had G20 points, the score showing explicit autism spectrum disorder. The six Gillberg and Gillberg research criteria for Asperger syndrome were assessed by the ASDI. All 18 subjects with autism spectrum diagnoses fulfilled the first Gillberg and Gillberg criterion for social interaction problems and 17 fulfilled the fifth criterion for non-verbal communication prob- lems wroughly corresponding to the first DSM-IV symptom cluster for autistic disorder and the first symptom area in ‘Wing’s triad’ (Wing, 1981)x, nine had verbal communication problems (criteri- on 4, in the subjects diagnosed with autism cor- responding to the second DSM-IV symptom cluster for autistic disorder), nine had monomanic interests (criterion 2), 10 had repetitive routines (criterion 3, these two criteria roughly correspond- ing to the third DSM-IV symptom cluster ‘lack of flexibility’), and 13 had motor clumsiness (crite- rion 6, not included among the DSM-IV autism criteria). According to DSM-IV, five subjects met the criteria for autistic disorder, three those for Asperger syndrome, and 10 those for ASD NOS. Thirty-nine subjects had ADyHD (13 in remission) and 18 had a current tic disorder (Tourette syn- drome in 5, chronic motor tics in 13), while another four reported childhood tics. Twenty-three had DCD. Compared to seven-year-olds in the general population, all childhood-onset neuropsychiatric disorders were significantly over-represented among our subjects wADyHD 39y100 (39%) vs. 15y409 (3.7%) P-0.001, autism spectrum disor- ders 18y100 (18%) vs. 10y826 (1.2%) P-0.001, tic disorders 18y100 (18%) vs. 17y435 (3.9%) P-0.001x. Twenty subjects fulfilled the DSM-IV criteria for a psychotic disorder, four of them due to a medical condition (drug-induced brain damage, normal pressure hydrocephalus, epilepsy, and Par- kinson’s disease, respectively). Forty-three sub- jects had a mood disorder, most often major depressive disorder, which included currently euthymic cases with previous episodes and double depressions. None had a current manic episode; one had current hypomania. The prevalence of current affective disorders was calculated accord- ing to status at the time of the crime; no case was assigned an affective disorder diagnosis if depres- sive symptoms at the time of the investigation could be regarded as a reaction to the index crime and its consequences. All anxiety disorders except obsessive–compulsive disorder were less markedly increased than the other Axis I disorders in the study group. In no case could the content of obsessionsycompulsions be related to the index crime. Among the impulse control disorders, the prevalence of intermittent explosive disorder would have been considerably higher if the DSM- IV criteria had included violent outbursts without destruction of property or bodily harm. The major- ity, 52 subjects, had a diagnosis of substance abuse or dependence, most often alcohol (44 subjects), alone or in combination with one or more drugs (30 subjects). The collapsed prevalence of personality disor- ders was 67% and 54% had at least one Cluster B disorder, 39% had a Cluster A disorder and 29% had a Cluster C disorder. The PCL-R scores were generally low, ranging from 0 to 27 points on the 40-point scale (median 8). The upper quartile i