Energy substrate metabolism among habitually violent alcoholic offenders having antisocial personality disorder

A systematic review of the effect of dietary and nutritional interventions on the behaviours and mental health of prisoners

Prisoners experience a higher burden of poor health, aggressive behaviours and worsening mental health than the general population. This systematic review aimed to identify research that used nutrition-based interventions in prisons, focusing on outcomes of mental health and behaviours. The systematic review was registered with Prospective Register of Systematic Reviews on 26 January 2022: CRD42022293370. Inclusion criteria comprised of current prisoners with no limit on time, location, age, sex or ethnicity. Only quantitative research in the English language was included. PubMed/Medline, Web of Science, EMBASE, PsycINFO and CINAHL were searched, retrieving 933 results, with 11 included for qualitative synthesis. Studies were checked for quality using the revised tool to assess risk of bias in randomised trials or risk of bias in non-randomised studies of interventions tool. Of the included studies, seven used nutritional supplements, three included diet changes, and one used education. Of the seven supplement-based studies, six included rule violations as an outcome, and only three demonstrated significant improvements. One study included mental health as an outcome; however, results did not reach significance. Of the three diet change studies, two investigated cognitive function as an outcome, with both reaching significance. Anxiety was included in one diet change study, which found a significant improvement through consuming oily fish. One study using diet education did not find a significant improvement in overall mental resilience. Overall, results are mixed, with the included studies presenting several limitations and heterogeneity. Future research should aim to consider increased homogeneity in research design, allowing for a higher quality of evidence to assess the role nutrition can play in improving the health of prisoners.

Indirect Calorimetry to Measure Metabolic Rate and Energy Expenditure in Psychiatric Populations: A Systematic Review

Psychiatric and metabolic disorders are highly comorbid and the relationship between these disorders is bidirectional. The mechanisms underlying the association between psychiatric and metabolic disorders are presently unclear, which warrants investigation into the dynamics of the interplay between metabolism, substrate utilization, and energy expenditure in psychiatric populations, and how these constructs compare to those in healthy controls. Indirect calorimetry (IC) methods are a reliable, minimally invasive means for assessing metabolic rate and substrate utilization in humans. This review synthesizes the extant literature on the use of IC on resting metabolism in psychiatric populations to investigate the interaction between psychiatric and metabolic functioning. Consistently, resting energy expenditures and/or substrate utilization values were significantly different between psychiatric and healthy populations in the studies contained in this review. Furthermore, resting energy expenditure values were systematically overestimated when derived from predictive equations, compared to when measured by IC, in psychiatric populations. High heterogeneity between study populations (e.g., differing diagnoses and drug regimens) and methodologies (e.g., differing posture, time of day, and fasting status at measurement) impeded the synthesis of results. Standardized IC protocols would benefit this line of research by enabling meta-analyses, revealing trends within and between different psychiatric disorders.

Gender/Sex as a Social Determinant of Cardiovascular Risk

The social gradient for cardiovascular disease (CVD) onset and outcomes is well established. The American Heart Association's Social Determinants of Risk and Outcomes of Cardiovascular Disease Scientific Statement advocates looking beyond breakthroughs in biological science toward a social determinants approach that focuses on socioeconomic position, race and ethnicity, social support, culture and access to medical care, and residential environments to curb the burden of CVD going forward. Indeed, the benefits of this approach are likely to be far reaching, enhancing the positive effects of advances in CVD related to prevention and treatment while reducing health inequities that contribute to CVD onset and outcomes. It is disappointing that the role of gender has been largely neglected despite being a critical determinant of cardiovascular health. It is clear that trajectories and outcomes of CVD differ by biological sex, yet the tendency for sex and gender to be conflated has contributed to the idea that both are constant or fixed with little room for intervention. Rather, as distinct from biological sex, gender is socially produced. Overlaid on biological sex, gender is a broad term that shapes and interacts with one's cognition to guide norms, roles, behaviors, and social relations. It is a fluid construct that varies across time, place, and life stage. Gender can interact with biological sex and, indeed, other social determinants, such as ethnicity and socioeconomic position, to shape cardiovascular health from conception, through early life when health behaviors and risk factors are shaped, into adolescence and adulthood. This article will illustrate how gender shapes the early adoption of health behaviors in childhood, adolescence, and young adulthood by focusing on physical activity, drinking, and smoking behaviors (including the influence of role modeling). We will also discuss the role of gender in psychosocial stress with a focus on trauma from life events (childhood assault and intimate partner violence) and work, home, and financial stresses. We conclude by exploring potential biological pathways, with a focus on autonomic functioning, which may underpin gender as a social determinant of cardiovascular health. Finally, we discuss implications for cardiovascular treatment and awareness campaigns and consider whether gender equality strategies could reduce the burden of CVD for men and women at the population level.

The prevalence of comorbid alcohol use disorder in the presence of personality disorder: Systematic review and explanatory modelling

Comorbid personality disorder (PD) worsens outcome in mental state disorders; however, the proportion of people with PD who have an alcohol use disorder (AUD) is poorly described. A systematic review of the literature for studies reporting on AUD in those with PD was completed. Lifetime prevalence figures were meta-analysed using multilevel models, accounting for type of PD and population examined. Sixteen unique studies contributed data to the analysis. PD type accounted for most of the heterogeneity in lifetime AUD prevalence. People with antisocial PD had the highest lifetime AUD prevalence, at 76.7%, followed by those with borderline PD at 52.2%, while those with other forms of PD, or undifferentiated PD, had a prevalence of 38.9%. Lifetime AUD prevalence was not significantly higher in clinical compared with population samples. The majority of people with PD experience an AUD at some time in the life course. This has clinical screening and management implications. Copyright © 2018 John Wiley & Sons, Ltd.

Insulin and glucagon in plasma and cerebrospinal fluid in suicide attempters and healthy controls

Mental disorders and related behaviors such as suicidality and violence have been associated to dysregulation of e g carbohydrate metabolism. We hypothesized that patients after suicide attempt, compared to healthy controls, would have higher insulin and lower glucagon levels in plasma and cerebrospinal fluid and that these changes would be associated to violent behavior. Twenty-eight medication-free patients (10 women, 18 men), hospitalized after suicide attempt, and 19 healthy controls (7 women, 12 men) were recruited with the aim to study risk factors for suicidal behavior. Psychological/psychiatric assessment was performed with SCID I and II or the SCID interview for healthy volunteers respectively, the Karolinska Interpersonal Violence Scale (KIVS) for assessment of lifetime violence expression behavior, the Montgomery-Åsberg-Depression-Scale (MADRS) and the Comprehensive Psychological Rating Scale (CPRS) for symptomatic assessment of depression and appetite. Fasting levels of insulin and glucagon were measured in plasma (P) and cerebrospinal fluid (CSF). Suicide attempters had higher insulin- and lower glucagon-levels in plasma- and CSF compared to controls. Except for P-glucagon these associations remained significant after adjusting for age and/or BMI. Patients reported significantly more expressed interpersonal violence compared to healthy volunteers. Expressed violence was significantly positively correlated with P- and CSF-insulin and showed a significant negative correlation with P-glucagon in study participants. These findings confirm and extend prior reports that higher insulin and lower glucagon levels in plasma and cerebrospinal fluid are associated with suicidal behavior pointing towards a potential autonomic dysregulation in the control of insulin and glucagon secretion in suicidal patients.

The effects of a HTR2B stop codon and testosterone on energy metabolism and beta cell function among antisocial Finnish males

Herein, we examined insulin resistance (IR), insulin sensitivity (IS), beta cell activity, and glucose metabolism in subjects with antisocial personality disorder (ASPD), and whether the serotonin 2B (5-HT2B) receptor and testosterone have a role in energy metabolism. A cohort of subjects belonging to a founder population that included 98 ASPD males, aged 25-30, was divided into groups based on the presence of a heterozygous 5-HT2B receptor loss-of-function gene mutation (HTR2B Q20*; n = 9) or not (n = 89). Serum glucose and insulin levels were measured in a 5 h oral glucose tolerance test (75 g) and indices describing IR, IS, and beta cell activity were calculated. Body mass index (BMI) was also determined. Concentrations of the serotonin metabolite 5-hydroxyindoleacetic acid were measured in cerebrospinal fluid, and testosterone levels from serum. An IR-like state comprising high IR, low IS, and high beta cell activity indices was observed among ASPD subjects without the HTR2B Q20* allele. By contrast, being an ASPD HTR2B Q20* carrier appeared to be preventive of these pathophysiologies. The HTR2B Q20* allele and testosterone predicted lower BMI independently, but an interaction between HTR2B Q20* and testosterone lead to increased insulin sensitivity among HTR2B Q20* carriers with low testosterone levels. The HTR2B Q20* allele also predicted reduced beta cell activity and enhanced glucose metabolism. Reduced 5-HT2B receptor function at low or normal testosterone levels may be protective of obesity. Results were observed among Finnish males having an antisocial personality disorder, which limits the generality.

Impulsive alcohol-related risk-behavior and emotional dysregulation among individuals with a serotonin 2B receptor stop codon

A relatively common stop codon (Q20*) was identified in the serotonin 2B receptor gene (HTR2B) in a Finnish founder population in 2010 and it was associated with impulsivity. Here we examine the phenotype of HTR2B Q20* carriers in a setting comprising 14 heterozygous HTR2B Q20* carriers and 156 healthy controls without the HTR2B Q20*. The tridimensional personality questionnaire, Brown-Goodwin lifetime aggression scale, the Michigan alcoholism screening test and lifetime drinking history were used to measure personality traits, impulsive and aggressive behavior, both while sober and under the influence of alcohol, and alcohol consumption. Regression analyses showed that among the HTR2B Q20* carriers, temperamental traits resembled a passive-dependent personality profile, and the presence of the HTR2B Q20* predicted impulsive and aggressive behaviors particularly under the influence of alcohol. Results present examples of how one gene may contribute to personality structure and behaviors in a founder population and how personality may translate into behavior.

Basal insulin secretion, PCL-R and recidivism among impulsive violent alcoholic offenders

Current risk assessment tools have a moderate predicting value for violence. Their power may be enhanced with certain biological indicators, which may serve as predictors of recidivistic violence itself. The aim of our study was to determine the strength of serum insulin levels to predict violence, and compare these results with those from the Revised Psychopathy Checklist (PCL-R). The study population consisted of 105 Finnish alcoholics who were severely violent offenders, recruited from 1991 to 1998. After exclusion, 75 cases were followed until March 2008, or until a new offense was registered. Cox regression analysis was used to evaluate the risk of recidivism. The age and weight adjusted effect of insulin to recidivism risk showed a 7.2% increase for each International Unit (IU), or 19% for the mean difference (2.5IU) between recidivists and non-recidivist, which corresponds to a medium effect size (Cohen׳s d=0.46). Adjusting the insulin model with PCL-R factor 1 enhanced the predictive power slightly. Serum fasting insulin level was equivalent to the PCL-R factor 2 score as a predictor, and better than the total PCL-R score. However, the significance of these results was too low for predicting recidivism in the process of judicial decision-making.

Revisiting the serotonin-aggression relation in humans: a meta-analysis

The inverse relation between serotonin and human aggression is often portrayed as "reliable," "strong," and "well established" despite decades of conflicting reports and widely recognized methodological limitations. In this systematic review and meta-analysis, we evaluate the evidence for and against the serotonin deficiency hypothesis of human aggression across 4 methods of assessing serotonin: (a) cerebrospinal fluid levels of 5-hydroxyindoleacetic acid (CSF 5-HIAA), (b) acute tryptophan depletion, (c) pharmacological challenge, and (d) endocrine challenge. Results across 175 independent samples and over 6,500 total participants were heterogeneous, but, in aggregate, revealed a small, inverse correlation between serotonin functioning and aggression, anger, and hostility (r = -.12). Pharmacological challenge studies had the largest mean weighted effect size (r = -.21), and CSF 5-HIAA studies had the smallest (r = -.06). Potential methodological and demographic moderators largely failed to account for variability in study outcomes. Notable exceptions included year of publication (effect sizes tended to diminish with time) and self- versus other-reported aggression (other-reported aggression was positively correlated to serotonin functioning). We discuss 4 possible explanations for the pattern of findings: unreliable measures, ambient correlational noise, an unidentified higher order interaction, and a selective serotonergic effect. Finally, we provide 4 recommendations for bringing much needed clarity to this important area of research: acknowledge contradictory findings and avoid selective reporting practices; focus on improving the reliability and validity of serotonin and aggression measures; test for interactions involving personality and/or environmental moderators; and revise the serotonin deficiency hypothesis to account for serotonin's functional complexity.

Genetic determinants of aggression and impulsivity in humans

Human aggression/impulsivity-related traits have a complex background that is greatly influenced by genetic and non-genetic factors. The relationship between aggression and anxiety is regulated by highly conserved brain regions including amygdala, which controls neural circuits triggering defensive, aggressive, or avoidant behavioral models. The dysfunction of neural circuits responsible for emotional control was shown to represent an etiological factor of violent behavior. In addition to the amygdala, these circuits also involve the anterior cingulated cortex and regions of the prefrontal cortex. Excessive reactivity in the amygdala coupled with inadequate prefrontal regulation serves to increase the likelihood of aggressive behavior. Developmental alterations in prefrontal-subcortical circuitry as well as neuromodulatory and hormonal abnormality appear to play a role. Imbalance in testosterone/serotonin and testosterone/cortisol ratios (e.g., increased testosterone levels and reduced cortisol levels) increases the propensity toward aggression because of reduced activation of the neural circuitry of impulse control and self-regulation. Serotonin facilitates prefrontal inhibition, and thus insufficient serotonergic activity can enhance aggression. Genetic predisposition to aggression appears to be deeply affected by the polymorphic genetic variants of the serotoninergic system that influences serotonin levels in the central and peripheral nervous system, biological effects of this hormone, and rate of serotonin production, synaptic release and degradation. Among these variants, functional polymorphisms in the monoamine oxidase A (MAOA) and serotonin transporter (5-HTT) may be of particular importance due to the relationship between these polymorphic variants and anatomical changes in the limbic system of aggressive people. Furthermore, functional variants of MAOA and 5-HTT are capable of mediating the influence of environmental factors on aggression-related traits. In this review, we consider genetic determinants of human aggression, with special emphasis on genes involved in serotonin and dopamine metabolism and function.

Cholesterol, CSF 5-HIAA, violence and intent in suicidal men

Associations between suicide, violent behaviour and both hypocholesterolaemia and low 5-hydroxyindolacetic acid (5-HIAA) in the cerebrospinal fluid (CSF) have been suggested. The relationships between lipids, the serotonergic system, suicidal and aggressive behaviors are complex. We explored relationships between serum cholesterol, CSF 5-HIAA, the planning subscale of suicide intent and violence of attempted suicide method in 13 medication-free male suicide attempters and eight healthy volunteers. Serum high-density lipoprotein cholesterol (HDL-C) levels were significantly lower in suicide attempters than in controls. HDL-C showed a significant positive correlation with the planning subscale of suicide intent in non-violent suicide attempters. A positive association was observed between CSF 5-HIAA and serum cholesterol in suicides. The role of cholesterol may be different in planned non-violent suicide attempts compared with violent suicide attempts.

Altered glucose tolerance in women with deliberate self-harm

Disturbances in glucose metabolism are of importance for violent behaviour in men, but studies in women are lacking. We used the 5h-oral glucose tolerance test (OGTT) in this study of 17 female psychiatric patients, selected for violent behaviour directed against themselves (deliberate self-harm) and 17 healthy controls matched for age and BMI. Following OGTT, patients had higher glucose levels at 30 min (p=0.007) and increased glucagon area under the curve (p=0.011). Since a co-morbid eating disorder might affect results, we as a post-hoc analysis subgrouped the patients and found that the increased glucagon levels only were present in patients with an eating disorder. In contrast, those without an eating disorder showed a significantly lower p-glucose nadir (p=0.015) and unaltered glucagon levels compared to controls. There were no significant differences in insulin and C-peptide levels between patients and controls. We conclude that deliberate self-harm in women may be associated with alterations in carbohydrate metabolism in certain groups. Eating disorder is a confounding factor.

Recidivistic offending and mortality in alcoholic violent offenders: a prospective follow-up study

Predictive data supporting prevention of violent criminality are scarce. We examined risk factors for recidivism and mortality among non-psychotic alcoholic violent offenders, the majority having antisocial or borderline personality disorders, or both, which is a group that commits the majority of violent offences in Finland. Criminal records and mortality data on 242 male alcoholic violent offenders were analysed after a 7- to 15-year follow-up, and compared between themselves and with those of 1210 age-, sex- and municipality-matched controls. Recidivism and mortality rates were high. The risk of recidivistic violence was increased by antisocial or borderline personality disorder, or both, childhood maltreatment, and a combination of these. A combination of borderline personality disorder and childhood maltreatment was particularly noxious, suggesting an additive risk increase for a poor outcome. Accurate diagnosis and careful childhood interview may help to predict recidivism and premature death.

Low non-oxidative glucose metabolism and violent offending: an 8-year prospective follow-up study

Violent offenders have abnormalities in their glucose metabolism as indicated by decreased glucose uptake in their prefrontal cortex and a low blood glucose nadir in the glucose tolerance test. We tested the hypothesis that low non-oxidative glucose metabolism (NOG) predicts forthcoming violent offending among antisocial males. Glucose metabolism was measured using the insulin clamp method among 49 impulsive, violent, antisocial offenders during a forensic psychiatric examination. Those offenders who committed at least one new violent crime during the 8-year follow-up had a mean NOG of 1.4 standard deviations lower than non-recidivistic offenders. In logistic regression analysis, NOG alone explained 27% of the variation in the recidivistic offending. Low non-oxidative metabolism may be a crucial component in the pathophysiology of habitually violent behavior among subjects with antisocial personality disorder. This might suggest that substances increasing glycogen formation and decreasing the risk of hypoglycemia might be potential treatments for impulsive violent behavior.

Effects of MAOA-genotype, alcohol consumption, and aging on violent behavior

BACKGROUND

Environmental factors appear to interact with a functional polymorphism (MAOA-LPR) in the promoter region of the monoamine oxidase A gene (MAOA) in determining some forms of antisocial behavior. However, how MAOA-LPR modulates the effects of other factors such as alcohol consumption related to antisocial behavior is not completely understood.

METHODS

This study examines the conjunct effect of MAOA-LPR, alcohol consumption, and aging on the risk for violent behavior. Recidivism in severe impulsive violent behavior was assessed after 7 to 15 years in a sample of 174 Finnish alcoholic offenders, the majority of whom exhibited antisocial or borderline personality disorder or both, and featured impulsive temperament traits.

RESULTS

The risk for committing new acts of violence increased by 2.3% for each kilogram of increase in yearly mean alcohol consumption (p = 0.004) and decreased by 7.3% for every year among offenders carrying the high activity MAOA genotype. In contrast, alcohol consumption and aging failed to affect violent behavior in the low activity MAOA genotyped offenders. MAOA-LPR showed no main effect on the risk for recidivistic violence.

CONCLUSIONS

Violent offenders carrying the high activity MAOA genotype differ in several ways from carriers with the low activity MAOA risk allele previously associated with antisocial behavior. Finnish high activity MAOA genotyped risk alcoholics exhibiting antisocial behavior, high alcohol consumption, and abnormal alcohol-related impulsive and uncontrolled violence might represent an etiologically distinct alcohol dependence subtype.

Personality disorders and violence

PURPOSE OF REVIEW

To review the most recent literature on the relationship between personality disorders and violent behavior. The review does not aim to address the issue of a possible etiological connection between previously being the victim of violent acts and later developing a personality disorder.

RECENT FINDINGS

Recent data suggest that personality disorders, especially antisocial and borderline, are strongly related to the manifestation of violent acts. Substance abuse is another strong factor which could act either independently or additively. Biological factors seem to constitute a risk factor for violent behavior independently of personality. Although intelligence does not seem to be related to violence, some patients may manifest specific cognitive deficits. The ethical and legal questions posed by the above correlations are difficult to answer, and research has not yet provided enough data on this issue.

SUMMARY

The most recent data support the relationship between antisocial personality and violence, especially when substance abuse is also present, although the presence of confounding factors in the diagnostic criteria suggest caution in the interpretation of the literature.