Adult psychopathic personality with childhood-onset hyperactivity and conduct disorder: a central problem constellation in forensic psychiatry

Autism Spectrum Disorders in forensic psychiatric investigations-patterns of comorbidity and criminality

Background

There are contradictory research findings regarding whether individuals with Autism Spectrum Disorders (ASDs) are more or less likely to commit crimes. The aims of the current study were to: (1) Describe psychiatric and crime-related characteristics of a large group of offenders with ASD who had undergone a Forensic Psychiatric Investigation (FPI). (2) Identify clinical subgroups among this group of offenders. (3) Investigate associations between the identified clinical subgroups and (a) psychiatric comorbidity (b) types of crimes and (c) criminal responsibility.

Methods

The study cohort consists of all subjects (n = 831) who received an ASD-diagnosis at an FPI between 2002 and 2018 in Sweden. Descriptive and clinical, as well as crime related variables were obtained from the FPIs. Non-parametric (Pearson χ2, Fisher's exact and Mann-Whitney U-test) inferential statistics were used for analyses of between-group differences and effect sizes were reported. A Latent Class Analysis was used to identify homogeneous subgroups (or classes) from categorical characteristics.

Results

The cohort consisted of 708 men and 123 women, aged 18 to 74 yrs. Two-thirds (66.7%) of the cohort had at least one other psychiatric diagnosis, the most prevalent was substance use disorder (SUD). A severe mental disorder, equivalent to lack of criminal responsibility, was most often reported among offenders with a comorbid diagnosis of schizophrenia spectrum disorder. The most common type of crime was violent crime. Three person-oriented clinical subgroups were identified; (1) ASD with few other diagnoses; (2) ASD and very high levels of SUDs, plus moderate levels of other externalizing disorders and psychotic psychopathology and (3) ASD and moderate to high levels of personality disorders (other than ASPD) and SUDs.

Conclusion

Our results highlight the importance of all parts of the CJS to be prepared to handle offenders with ASD, often with high levels of additional psychiatric problems. Traditional approaches in treatment or other psychosocial interventions for ASD may need to be adapted to at least three general clinical profiles- one with mainly neurodevelopmental problems, one with a spectrum of externalizing problems and one with complex personality related difficulties.

Adults with autism spectrum disorder and the criminal justice system: An investigation of prevalence of contact with the criminal justice system, risk factors and sex differences in a specialist assessment service

LAY ABSTRACT

There has been growing interest in offending and contact with the criminal justice system (CJS) by people with autism spectrum disorder (ASD). However, it is not clear whether people with ASD offend more than those without ASD. Studies have started to look at whether there are particular offences people with ASD are more likely to commit and whether there are any factors that can affect whether someone comes into contact with the CJS as a potential suspect. This study looked at the patients who attended an ASD diagnostic service over a 17-year period to see the rate of contact with the CJS of those who were diagnosed with ASD and whether there were any particular factors that might increase the risk of CJS contact. Nearly a quarter of the ASD group had some contact with the CJS as a potential suspect. Factors that seemed to increase whether someone with ASD was more likely to have contact with the CJS were being male, being diagnosed with ADHD, and being diagnosed with psychosis. This study is one of the largest studies to investigate the rate of CJS contact as a potential suspect in a sample of adults with ASD in an attempt to give a clearer picture of what might influence someone with ASD to engage in offending behaviour in order to try to see what mental health services can offer to reduce the likelihood of someone with ASD coming into contact with the CJS, for example, treatment for another condition or support.

Measurement properties of the life history of aggression in adolescents: Data from Morocco, Serbia, Sweden, Vietnam, and the USA

The Life History of Aggression (LHA) is a frequently used scale for assessing trait aggression, but its psychometric properties have not been evaluated among adolescents. The aim of this study was to evaluate the psychometric properties of the LHA among high school students from Morocco, Serbia, Sweden, Vietnam, and the United States of America (USA). The total sample included 4867 adolescents, aged 15-19 years, from Morocco (n = 508), Serbia (n = 1067), Sweden (n = 1570), Vietnam (n = 1401), and the USA (n = 321). A two-factor, nine-item model containing an aggression factor (5 items) and a consequences/antisocial behavior factor (4 items) was created. The two-factor model had an acceptable-to-good model fit for the data for the total sample and all five countries, including gender. Cronbach's alpha (α) was satisfactory across countries. Still, the construct was noninvariant across countries and genders. The LHA with nine items in two subscales showed sound construct validity and internal consistency and can be used for group-level or within-group assessments of trait aggression in adolescents by either gender or country. However, it should not be used for cross-gender or cross-country comparisons due to a lack of measurement invariance.

Patterns of Lifetime Criminality in Mentally Disordered Offenders - Findings From a Nationally Representative Cohort

Background: Treatment of mentally disordered offenders (MDOs) is challenging as their behavior and clinical conditions can be traced to a complex constellation of major mental disorders, substance use and antisocial lifestyle. Finding subgroups of these offenders, which could guide treatment and risk assessment, is desirable. There are few long-term, prospective studies of risk factors for persistent criminal behavior among MDOs. Aims: The aims are (1) to provide a map of lifetime criminality in MDOs, (2) to identify subgroups of offenders, and (3), if such clusters exist, to test whether they differ in lifetime criminality and patterns of negative events during in-patient treatment. Methods: Background data on all offenders from the Malmö University Hospital catchment area sentenced to forensic psychiatric in-patient treatment 1999-2005 (n = 125) was collected. Data on negative events during treatment (violence, threats, absconding and substance use) from date of admittance until discharge or until June 30, 2008 was gathered. Court decisions for 118 of the cohort-individuals were collected from the 1^st of January 1973 until December 31, 2013. We used hierarchical cluster analysis to identify subgroups and MANOVA-analysis to examine differences between these clusters on lifetime criminality variables and negative events. A MANCOVA was used to control for time in treatment. Results: The cohort was sentenced to a total of 3,380 crimes (944 violent) during the study period. Median age at first crime was 20 years (range 15-72), and at first violent crime 27 years (range 15-72). A subgroup (n = 26) was characterized by childhood adversities, neurodevelopmental disorders and later substance use disorders and was more often associated with substance-related crimes, financial crimes and lower age at first crime. During treatment, this cluster showed higher rates of substance use and threats. When controlling for treatment time, no differences in negative events were found. Conclusions: This study replicated findings from prison populations of the existence of a more criminally persistent phenotype characterized by early-onset neurodevelopmental and behavior disorders, childhood adversities and later substance use disorders. We did not find this cluster of variables to be related to negative events during inpatient treatment when controlling for length of stay.

Improving mental wellbeing of forensic psychiatric outpatients through the addition of an informal social network intervention to treatment as usual: a randomized controlled trial

BACKGROUND

Forensic psychiatric patients often suffer from a multitude of severe psychiatric and social problems. Meanwhile multimodal evidence-based interventions are scarce and treatment effectiveness is in need of improvement. The main goal of forensic psychiatric treatment is to address psychiatric and social factors and thereby mitigate criminal behaviour. Notably, a supportive social network is an important protective factor for criminal behaviour. As such, improving a poor social network may decrease the risk of criminal recidivism. This study aims to examine the effectiveness of the addition of an informal social network intervention (FNC) to treatment as usual (TAU) among forensic psychiatric outpatients.

METHODS

In a mono-center randomized controlled clinical trial with two parallel groups, forensic psychiatric outpatients with social network-related problems (N = 105) will be allocated to either TAU + FNC or TAU alone. The informal social network intervention consists of a 12-month coaching intervention, performed by the forensic network coach (a volunteer trained by an informal care institute). Assessments will be conducted at baseline and 3 months, 6 months, 9 months, 12 months, and 18 months after baseline. The primary outcome variable is mental wellbeing. Psychiatric functioning, criminal recidivism, substance abuse, quality of life, social network, social support, loneliness and self-sufficiency are included as secondary outcomes. A variety of potential mediators and moderators of effectiveness will be explored. Additionally, a qualitative evaluation of effectiveness will be performed.

DISCUSSION

This study will contribute to the existing literature of forensic treatment effectiveness as it is the first RCT examining the effectiveness of adding a social network intervention in a forensic outpatient population. If effectiveness is shown, forensic mental health care could be optimized by collaborating with informal care or community initiatives aimed at improving a positive social network. In addition, results will provide insight regarding mediators and moderators of treatment effectiveness.

TRIAL REGISTRATION

This study is registered at the Netherlands Trial Register ( NTR7163 ). Date of registration: 16 april 2018.

Identification of service development needs for incarcerated adults with autism spectrum disorders in an Australian prison system

PURPOSE

The purpose of this paper is to identify and deliberate the service development needs required for the improvement of service provision for incarcerated adults with autism spectrum disorder (ASD) in NSW, Australia.

DESIGN/METHODOLOGY/APPROACH

Consultation groups were conducted to bring together n=5 key stakeholders from heath and correctional-based services in the prison system. A facilitated asynchronous e-mail-based discussion occurred amongst group members between consultation group meetings.

FINDINGS

Two main themes were identified: detecting persons with ASD and providing appropriate care. Participants discussed current service gaps with regard to the identification of people with ASD at the point of contact with the prison service, and the difficulties associated with diagnosing prisoners with ASD. The need for effective alert systems to detect persons with ASD in custody was identified. The current absence of ASD-specific support services in prison was highlighted, and recommendations for improvement suggested.

PRACTICAL IMPLICATIONS

Current health and correctional-based service provision failed to adequately support incarcerated adults with ASD. Improvements in prison-entry screening processes, alert systems and diagnostic practices are required. Multidisciplinary collaboration between prison-based and external service providers is required for the development of a model of care based on individualised case management to adequately support incarcerated adults with ASD in prison.

ORIGINALITY/VALUE

Given the lack of reported service provision for incarcerated adults with ASD internationally, other prison-based services are likely to experience similar service development needs and see the relevance of the recommendations made directly from the study findings.

Human Resources and their Tendency to Information Security Crimes Based on Holland Theory

Security systems are often the target of cyber-criminals and professional hackers, but often they fail in hiding all traces of the attack, thereby leaving critical evidence that could lead to identifying and arresting the criminal. However, hacking skills vary from one hacker to another depending on the hacker's personal traits, behavior, and intellectual tendencies. The aim of this study is to develop a proposed descriptive model of the behavioral patterns and motives of hackers based on programmable psychological theories, modeled using object-oriented programming models. The study proposes a descriptive model of an inverse algorithm that simulates Holland's Theory of Behavioral Patterns. Findings show that this descriptive model is applicable to be produced as a code map for the human resources of an investigative nature.

Psychopathic personality in young people

This article is an overview of developments in psychopathy and their application to children and adolescents. A key question is whether or not psychopathy is stable throughout the lifespan. Some characteristics indicate phenotypic similarities with adult psychopathy, and current instruments appear to be measuring similar constructs across the age ranges. Although the literature on developmental aspects of psychopathy in young people is limited, a number of instruments have been designed to measure the construct. These tools appear to have reasonable construct, concurrent and predictive validity, but we cannot yet recommend their routine use in clinical practice or in the criminal justice system, given the limited evidence base on their predictive validity. At best, they should be viewed as a means of subtyping potentially high-risk groups with a view to treatment planning.

Mentally disordered offenders in Sweden: differentiating recidivists from non-recidivists in a 10-year follow-up study

BACKGROUND

Forensic psychiatric patients present a challenge as they manifest severe mental disorders together with criminal behaviour. There are well-known risk factors for criminal behaviour in the general population, yet knowledge of what predicts reconviction in the Swedish forensic population in the long-term perspective is still insufficient.

AIMS

The study aims to (1) describe background and clinical characteristics of forensic psychiatric patients in a 10-year follow-up, (2) analyse risk factors associated with recidivism, and (3) test the predictive validity of risk factors for general and violent criminality.

METHODS

Detailed information on all offenders from the Malmö University Hospital catchment area sentenced to forensic psychiatric in-patient treatment from 1999-2005 (n = 125) was collected. Court decisions were collected up until the end of 2008 (median follow-up time = 6.2 years, range = 0.6-9.7 years).

RESULTS

Relapse in general crime (n = 30) was predicted by low educational attainment, mental disorder in a first degree relative, and low age at first sentenced crime. Relapse in violent crime (n = 16) was predicted by low educational attainment and low GAF scores. Patients with a restriction order were less likely to relapse in both crime categories.

CONCLUSIONS

Signs of childhood adversities together with early debut in criminality appeared as important risk factors for general and violent recidivism. Forensic psychiatric treatment combined with a restriction order was demonstrated as a protective factor against recidivism, suggesting that the risk of recidivism is strongly related to the level of supervision. Although the low number of recidivism cases is highly desirable, it unfortunately reduces the power of the analyses in this paper.

The Association Between ADHD and Antisocial Personality Disorder (ASPD): A Review

OBJECTIVE

Children with ADHD have an increased risk of later developing personality disorders and criminal behavior. The object of the present review is to analyze the associations between ADHD and antisocial personality disorder (ASPD).

METHOD

A review of literature was done using EMBASE, PsycINFO, and Medline databases.

RESULTS

Eighteen prospective studies (n = 5,501) showed that ADHD with and without comorbid conduct disorder (CD) is a strong predictor for the risk of later development of antisocial personality disorder (ASPD). Some of the 13 cross-sectional/retrospective studies (n = 2,451) suggested that ADHD and CD might be a separate subtype of ADHD, that especially impulsivity in ADHD is a predictor for later development of ASPD, or that callous-unemotional traits in the ADHD children are called for a risk factor for later ASPD.

CONCLUSION

There is an increased risk for children with ADHD with or without comorbid CD to develop later onset of antisocial personality disorder.

["Attention deficit hyperactivity disorder in forensic psychiatry: A review"]

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is one of the most common and challenging childhood neurobehavioral disorders. ADHD may have behavioral consequences and involvements in minor and serious crimes. Our work aims to establish links between ADHD and forensic psychiatry.

METHODS

A review of international scientific literature concerning the relationship between ADHD and forensic psychiatry was conducted using the PudMed electronic database. We used the Mesh terms: "attention deficit hyperactivity disorder" and "forensic psychiatry". We also used the "related articles" function of PubMed, the bibliography of selected articles and the Google Scholar database to identify possible additional papers.

RESULTS

The prevalence of ADHD in prison populations may vary but remain higher than those found in the general population. Violence committed by a person with ADHD seems to be against other persons rather than property offences. Reactive-impulsive violence seems to be more prevalent than pro-active instrumental violence. The existence of ADHD does not appear as a risk factor of recidivism. The violence risk may be increased by the occurrence of comorbidities as conduct disorders and mental deficiency. There may exist a preferential association between ADHD and antisocial personality disorder or substance abuse which both increase the risk of violence.

DISCUSSION

To put in perspective forensic psychiatry and ADHD allowed us to identify typology of violence, epidemiological aspect of ADHD in a prison environment and comorbidities involved in the risk of violence. This research permits to precise elements of prevention, diagnosis and assistance in the management of violent behaviour in ADHD and in expert practice.

The connection of temperament with ADHD occurrence and persistence into adulthood - An investigation in 18 year old males

BACKGROUND

This study intended to determine whether certain traits of temperament are associated with former and current ADHD symptomatology in a non-clinical sample of 18 year old males.

METHODS

We performed a cross sectional descriptive study of 3280 men during the examination for military service. The investigation included a socio-demographic questionnaire, screening for substance abuse, temperament (TEMPS-M), past (WURS) and current (ADHD symptom checklist) ADHD symptomatology.

RESULTS

We found a correlation of cyclothymic (p<.001), irritable (p<.001) and anxious (p<.05) temperament with occurrence and severity of past and present ADHD symptomatology. No significant correlation has been detected for hyperthymic and depressive temperament. Judged retrospectively, ADHD symptoms were strongly consistent over time.

LIMITATIONS

The sample consists of men only. These had to be fit enough to be enlisted for military service; men with severe mental or physical disorders were thus excluded. Furthermore, the cross-sectional study design does not allow making conclusions about the temporal relationships between ADHD symptoms and substance misuse.

CONCLUSIONS

These results indicate that a temperament based approach towards those affected by ADHD might be useful. Subtyping ADHD by integrating temperament profiles in diagnosis and treatment of the disorder could help explain some of the heterogeneity of the disease.

Reactive aggression among children with and without autism spectrum disorder

Twenty-seven boys and eight girls with ASD and thirty-five controls matched for gender, age and total score intelligence were studied to ascertain whether boys and girls with ASD display stronger reactive aggression than boys and girls without ASD. Participants performed a computerized version of the Pulkkinen aggression machine that examines the intensity of reactive aggression against attackers of varying gender and age. Relative to the control group boys, the boys with ASD reacted with more serious forms of aggression when subjected to mild aggressive attacks and did not consider a child attacker's opposite sex an inhibitory factor. The girls with ASD, on the other hand, reacted less aggressively than the girls without ASD. According to the results boys with ASD may not follow the typical development in cognitive regulation of reactive aggression.

Traffic and Criminal Behavior of Adults with Attention Deficit-Hyperactivity with a Prospective Follow-Up from Birth to the Age of 40 Years

OBJECTIVE

The purpose of this study was to investigate whether individuals with attention deficit-hyperactivity disorder (ADHD) followed up to age 40 have a higher mortality, more involvement in criminal behavior, increased traffic accidents, and frequency or registered violations against traffic rules or whether they have been more frequently victims to crimes.

METHODS

The ADHD cohort (N = 122) born in 1971-1974 was isolated at the age of 9 years from the base cohort of 865 children who had known risk factors at birth and were still alive at the age of 5 years. Ninety-four healthy individuals born during the same years served as control subjects. None of the individuals with ADHD had used psychostimulants before their adolescence. The follow-up data were available from the newborn period until the ages of 5 and 9 years. At the ages of 16 and 30, the data were collected via questionnaire. For this study, the national police registers (last 5 years) were examined for traffic violations, crimes, or being an object of a criminal act when the persons reached the age of 40 years.

RESULTS

Ten men and one woman with ADHD but none of the controls had died by the age of 40. Three died of disease-related incidents, and 8 (13%) died of abnormal causes such as suicide (3), traffic accident (2), substance abuse (2), or violence (1). During the follow-up period, individuals with ADHD had been involved in violent behavior or economic criminality more frequently than the control subjects. They were also more commonly victims of criminal acts. No difference was found in traffic citations between those with ADHD and control subjects (at 35-40 years) when all traffic crimes were considered. A difference was not observed in the frequency of traffic accidents. However, there was a significant difference in drunk driving (at the ages of 30 and 35-40) and the number of persons without a driver's license.

DISCUSSION

Subjects with ADHD showed an elevated risk of being involved in criminality and had a higher risk of dying before the age of 40 years. The early detection of ADHD in childhood and appropriate treatments and family support may decrease criminality and save both money and human distress.

ADHD, autism spectrum disorder, temperament, and character: phenotypical associations and etiology in a Swedish childhood twin study

OBJECTIVE

To explore the links between neurodevelopmental disorders - attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) - and personality in a population-based, genetically sensitive study of children.

METHOD

A population-based sample of 1886 twins aged 9 and 12, enriched for childhood mental health problems, was recruited from the Child and Adolescent Twin Study in Sweden (CATSS). Parents were interviewed over the telephone using the Autism-Tics, AD/HD and other Comorbidities (A-TAC) inventory, and in a second step they rated their children according to the Junior Temperament and Character Inventory (JTCI).

RESULTS

ADHD was strongly correlated with novelty seeking, while ASD was correlated positively with harm avoidance and negatively with reward dependence. The strongest associations between personality traits and neurodevelopmental disorders were negative correlations between the character dimensions of self-directedness and cooperativeness and ADHD and ASD alike. Cross-twin cross-trait correlations between ADHD, ASD, and personality dimensions in monozygotic twins were more than double those in dizygotic twins, indicating a strong genetic effect behind the phenotypic covariation between neurodevelopmental disorders and personality.

CONCLUSIONS

Neurodevelopmental disorders are linked specifically to particular temperament profiles and generally to hampered development of the self-governing strategies referred to as "character." Poor self-agency and cooperation may be core functional outcomes in the separation of children with handicapping conditions from those with traits only reminiscent of neurodevelopmental disorders. The associations between neurodevelopmental disorders and personality are at least partly due to genetic effects influencing both conditions. As a consequence, personality must be broadly considered in neuropsychiatry, just as neuropsychiatric disorders and their genetic, neurodevelopmental, and cognitive susceptibilities have to be in personality research and clinical treatment.

A controlled trial of a cognitive skills program for personality-disordered offenders

OBJECTIVE

There is a need to find effective treatments for individuals with antisocial and borderline personality disorder who are known to be difficult to engage and treat. Many of these individuals share considerable overlap with symptoms of ADHD, hence this study aimed to evaluate the Reasoning and Rehabilitation ADHD program (R&R2 ADHD) among patients with severe personality disorder.

METHOD

A total of 31 males detained in a "dangerous and severe personality disorder" unit completed questionnaires at baseline and post treatment to assess social problem solving, violent attitudes, anger, ADHD symptoms, emotional control, and social functioning. A total of 16 patients participated in the group condition, and their scores were compared with 15 waiting-list controls who received treatment as usual.

RESULTS

In all, 76% of group participants completed the program. In contrast to controls, they showed significant improvements in scores with mainly medium effect sizes.

CONCLUSION

R&R2 ADHD was effective in a small sample of severely personality-disordered offenders.

Attention deficit hyperactivity disorder in a Canadian prison population

Previous research has shown that a significant percentage of offenders are affected by adult attention deficit hyperactivity disorder (ADHD) and its related symptoms, however it is unknown the extent to which this disorder affects federal inmates in Canada and the impact ADHD has on key correctional outcomes. Four hundred and ninety-seven male federal offenders were assessed at intake over a fourteen month period using the Adult ADHD Self-Report Scale (ASRS). Approximately 16.5% scored in the highest range, which is consistent with the clinical threshold for diagnosis for the disorder; a further 25.2% reported sub-threshold symptoms in the moderate range. ADHD symptoms were found to be associated with unstable job history, presence of a learning disability, lower educational attainment, substance abuse, higher criminal risk and need levels, and other mental health problems. ADHD symptoms were also found to predict institutional misconduct. Additionally, offenders with high levels of ADHD symptomatology fared more poorly on release to the community. Implications for institutional behavior management and the need for additional resources and adapted interventions are discussed.

Long-term criminal outcome of children with attention deficit hyperactivity disorder

BACKGROUND

Long-term outcome studies of child psychiatric populations are often limited by attrition. Our study uses the Danish National Crime Register to report on the largest and most complete prospective study of adult criminality as an outcome for children with socioeconomic status attention deficit hyperactivity disorder (ADHD) and is the first to report on the adult criminal outcome of girls with ADHD.

AIMS

To estimate the relative risk (RR) of adult criminal convictions of children with ADHD compared with the rate in the general population.

METHODS

A clinical sample of 206 children who had attended a regional child and adolescent psychiatric clinic in Denmark between 1968 and 1989 and received a diagnosis of ADHD was identified. Official criminal conviction data were collected for all of them up to the year 2000 when their mean age was 31 years. Their rate of sustaining at least one criminal conviction was compared with that in an age-matched general population sample.

RESULTS

Ninety-seven (47%) of the children with ADHD had criminal convictions in adulthood. Children with ADHD were about five times more likely to sustain convictions than their peers in the general population (rate ratio (RR) 5.6, 95% confidence interval 5.2-6.1) and twelve times more likely to have violent convictions (RR 12.0, 95% confidence interval 9.9-14.5). Fifty-four (26%) of the children with ADHD without any conduct problems in childhood were convicted in adulthood. Girls with ADHD were also at increased risk of criminal convictions.

CONCLUSIONS

Children with ADHD have a higher risk of criminal convictions in adulthood than previously documented, and both girls and boys are at increased risk. Co-morbid conduct problems in childhood are highly predictive of criminal convictions in adulthood. Even in the absence of conduct problems, however, childhood ADHD is associated with increased risk of criminality.

Aggression in children and adolescents

Aggressive behaviour is a common phenomenon during childhood and adolescence, but at the same time it is an important associated feature of many psychiatric disorders during this age period. Persistent aggression is related to a variety of negative outcomes in adulthood, including low socioeconomic status and unemployment, criminal behaviour and social isolation. The great heterogeneity of aggressive behaviour still hampers our understanding of causal mechanisms. Still, over the past years, the identification of specific subtypes of aggression has opened possibilities for new and individualized treatment approaches. This article provides information on different subtypes of aggression in children and adolescents, on individual differences that contribute to aggression during development and on possible underlying processes related to aggressive behaviour in young people. Current treatment approaches as well as new emerging treatment possibilities are discussed.

Toward a theory of childhood learning disorders, hyperactivity, and aggression

Learning disorders are often associated with persistent hyperactivity and aggression and are part of a spectrum of neurodevelopmental disorders. A potential clue to understanding these linked phenomena is that physical exercise and passive forms of stimulation are calming, enhance cognitive functions and learning, and are recommended as complementary treatments for these problems. The theory is proposed that hyperactivity and aggression are intense stimulation-seeking behaviors (SSBs) driven by increased brain retinergic activity, and the stimulation thus obtained activates opposing nitrergic systems which inhibit retinergic activity, induce a state of calm, and enhance cognition and learning. In persons with cognitive deficits and associated behavioral disorders, the retinergic system may be chronically overactivated and the nitrergic system chronically underactivated due to environmental exposures occurring pre- and/or postnatally that affect retinoid metabolism or expression. For such individuals, the intensity of stimulation generated by SSB may be insufficient to activate the inhibitory nitrergic system. A multidisciplinary research program is needed to test the model and, in particular, to determine the extent to which applied physical treatments can activate the nitrergic system directly, providing the necessary level of intensity of sensory stimulation to substitute for that obtained in maladaptive and harmful ways by SSB, thereby reducing SSB and enhancing cognitive skills and performance.

Facets of psychopathy among mentally disordered offenders: clinical comorbidity patterns and prediction of violent and criminal behavior

The complexity and consequences of psychopathy are still debated, and its relation to other mental disorders, pathological personality traits, and criminality needs to be further investigated by clinical, longitudinal studies using structured diagnostic instruments. The present study used two groups of mentally disordered offenders (N=153) investigated with in-depth clinical assessments and prospective long-term follow-up to identify the convergence between 1) the four facets of psychopathy defined by the Psychopathy Checklist-Revised (PCL-R; Interpersonal, Affective, Lifestyle, and Antisocial), 2) mental disorders according to SCID I and II interviews, 3) personality traits as measured by the Karolinska Scales of Personality, and 4) criminal recidivism. The Interpersonal facet differed substantially from the other three facets by not being significantly associated with substance use disorders, antisocial personality disorder (the other facets at P≤0.001 level), or personality traits involving impulsive and aggressive antisocial behaviors (the other facets at P<0.01 level). Furthermore, the interpersonal facet could not predict violent recidivism better than random. The Antisocial facet outperformed not only the other facets but also the total PCL-R score in the prediction of violent recidivism, P<0.001.The findings confirm psychopathy as a heterogeneous phenomenon and have clinical implications for assessments of psychopathy and violence risk assessments in clinical and forensic contexts.

Addiction in developmental perspective: influence of conduct disorder severity, subtype, and attention-deficit hyperactivity disorder on problem severity and comorbidity in adults with opioid dependence

This retrospective cross-sectional study examines whether conduct disorder and attention deficit hyperactivity disorder are associated with problem severity and psychiatric comorbidity in 193 middle-aged, opioid-dependent patients. Conduct disorder history, attention deficit hyperactivity disorder, psychiatric comorbidity, and problem severity were assessed by structured interviews and validated instruments. A conduct disorder history was confirmed in 116 (60.1%) participants. Conduct disorder patients had significantly higher problem severity scores, more frequent comorbid substance use disorders, and more severe psychiatric comorbidity. Attention deficit hyperactivity disorder was found to increase the risk for psychiatric comorbidity. Conduct disorder persistence is a useful model for elucidating complex psychiatric comorbidity of opioid-dependent patients.

Are patients deemed 'dangerous and severely personality disordered' different from other personality disordered patients detained in forensic settings?

BACKGROUND

In 1999, the UK government initiated a programme for the assessment and treatment of individuals deemed to have 'dangerous and severe personality disorder' (DSPD). After over 10 years of specialist service development, it is not clear whether DSPD patients represent a distinct group.

AIMS

The aim of this study was to establish whether people admitted to DSPD hospital units could be distinguished in presentation or personality traits from people with personality disorder admitted to standard secure hospital services.

METHODS

Thirty-eight men detained in high-security hospital DSPD units were compared with 62 men detained in conventional medium or high security hospital units, using the Psychopathy Checklist-Revised (PCL-R) and other standard personality disorder, clinical and offending measures.

RESULTS

Compared with their counterparts in standard services, the DSPD group had higher scores on PCL-R psychopathy, significantly more convictions before age 18 years, greater severity of institutional violence and more prior crimes of sexual violence. Regression analysis confirmed that only PCL-R Factor 1, reflecting core interpersonal and affective features of psychopathy, predicted group membership.

CONCLUSION

The DSPD group emerged as having higher psychopathy scores, but as there is currently no evidence that the core personality features of psychopathy are amenable to treatment, there is little justification for treating high-psychopathy forensic patients differently from those with other disorders of personality.

Attention deficit hyperactivity disorder does not predict criminal recidivism in young adult offenders: Results from a prospective study

As the state of research on the relationship between attention deficit hyperactivity disorder (ADHD) and recidivism can be considered controversial, our prospective study investigated whether ADHD predicts recidivism in a sample of 283 male, German, young adult prisoners. Currently existing ADHD symptoms and symptoms that were present in childhood were screened according to the DSM-IV checklist criteria. Information on general and violent recidivism was gathered using government records with a follow-up period of up to five years. The prevalence of adult ADHD was six times greater than in the general population, and the number of participants who retrospectively met the criteria for a diagnosis with ADHD in childhood was ten times greater than found in community samples. Survival analyses did not identify ADHD as a predictor of recidivism. Controlling for conduct disorder, substance dependence, and other relevant variables did not alter results. However, among individuals who were released from prison and then reconvicted for a new crime, offenders diagnosed with ADHD were found to reoffend sooner after release. These findings stress the necessity of differentiating between risk factors for delinquency and risk factors for recidivism.

Adolescent-onset alcohol abuse exacerbates the influence of childhood conduct disorder on late adolescent and early adult antisocial behaviour

This study tested the hypothesis that adolescent-onset alcohol abuse (AOAA) would both mediate and moderate the effect of childhood conduct disorder on antisocial behaviour in late adolescence and early adulthood. A sample comprising 504 young men and women strategically recruited from the community were grouped using the criteria of the Diagnostic and Statistical Manual (DSM-IV, American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: APA), as follows: neither childhood conduct disorder (CCD) nor alcohol abuse/dependence; CCD but no alcohol abuse or dependence; alcohol abuse/dependence but no CCD; both CCD and alcohol abuse/dependence. The outcome measure was the sum of positive responses to 55 interview items capturing a variety of antisocial behaviours engaged in since age 15. Severity of lifetime alcohol-related and CCD problems served as predictor variables in regression analysis. Antisocial behaviour problems were greatest in individuals with a history of co-occurring conduct disorder (CD) and alcohol abuse/dependence. While CCD was strongly predictive of adult antisocial behaviour, this effect was both mediated and moderated (exacerbated) by AOAA.

Violent recidivism: a long-time follow-up study of mentally disordered offenders

Background

In this prospective study, mentally disordered perpetrators of severe violent and/or sexual crimes were followed through official registers for 59 (range 8 to 73) months. The relapse rate in criminality was assessed, compared between offenders sentenced to prison versus forensic psychiatric care, and the predictive ability of various risk factors (criminological, clinical, and of structured assessment instruments) was investigated.

Method

One hundred perpetrators were consecutively assessed between 1998 and 2001 by a clinical battery of established instruments covering DSM-IV diagnoses, psychosocial background factors, and structured assessment instruments (HCR-20, PCL-R, and life-time aggression (LHA)). Follow-up data was collected from official registers for: (i) recidivistic crimes, (ii) crimes during ongoing sanction.

Results

Twenty subjects relapsed in violent criminality during ongoing sanctions (n = 6) or after discharge/parole (n = 14). Individuals in forensic psychiatric care spent significantly more time at liberty after discharge compared to those in prison, but showed significantly fewer relapses. Criminological (age at first conviction), and clinical (conduct disorder and substance abuse/dependence) risk factors, as well as scores on structured assessment instruments, were moderately associated with violent recidivism. Logistic regression analyses showed that the predictive ability of criminological risk factors versus clinical risk factors combined with scores from assessment instruments was comparable, with each set of variables managing to correctly classify about 80% of all individuals, but the only predictors that remained significant in multiple models were criminological (age at first conviction, and a history of substance abuse among primary relatives).

Conclusions

Only one in five relapsed into serious criminality, with significantly more relapses among subjects sentenced to prison as compared to forensic psychiatric care. Criminological risk factors tended to be the best predictors of violent relapses, while few synergies were seen when the risk factors were combined. Overall, the predictive validity of common risk factors for violent criminality was rather weak.

Is the severity of adolescent conduct disorder associated with the level of nicotine dependence?

Our aim was to investigate the relationship between the number of Conduct Disorder (CD) symptoms and specific DSM-IV symptom subscales (i.e., aggression towards people and animals, destruction of property, deceitfulness or theft, and serious violations of rules) and nicotine dependence (ND) among adolescent psychiatric inpatients in Finland. A total of 171 adolescents with CD (99 boys and 72 girls; age 12-17 years) were admitted to inpatient psychiatric hospitalization between April 2001 and March 2006. Information on their psychiatric DSM-IV diagnoses was obtained using the Schedule for Affective Disorder and Schizophrenia for School-Age Children (K-SADS-PL). The level of ND was assessed with the modified Fagerström Tolerance Questionnaire (mFTQ). The total number of CD symptoms correlated with the level of ND among both the boys (adj. r = 0.31, p = 0.002) and the girls (adj. r = 0.324, p = 0.006). For the boys, the number of conduct symptoms correlated with the level of ND on all subscales except for aggression, while the only statistically significant correlation for the girls was found with the deceitfulness or theft subscale. A comorbid substance use disorder was statistically significant and associated with a high level of ND among the boys (p < 0.001) and the girls (p = 0.019). Our results suggest that both in adolescent boys and girls, the greater the number of CD symptoms, the higher the level of ND. Future studies are needed on the relationship between environmental factors, non-aggressive CD symptoms and the development of ND among adolescents with CD.

Psychopathy, ADHD, and brain dysfunction as predictors of lifetime recidivism among sex offenders

This study examines the best predictor of lifetime recidivism among Hare's psychopathy scores (PCL-R), attention deficit hyperactivity disorder (ADHD) diagnosis, and brain dysfunction measures in a sample of 1,695 adult male sexual, violent, and nonviolent offenders. Results indicated that most variables were associated with significantly more frequent recidivism. The best predictor of overall recidivism was the PCL-R, but more specifically, it was its items on criminal history that were associated with recidivism. Sexual offense recidivism was predicted by the presence of learning disorders; however, all measures were poor predictors. General recidivism was primarily associated with past criminal history and secondarily with learning disorders and ADHD. Results suggest that ADHD and brain dysfunction with criminal history measures are the best predictors for addressing the problem of criminal recidivism.

Life History of Aggression scores are predicted by childhood hyperactivity, conduct disorder, adult substance abuse, and low cooperativeness in adult psychiatric patients

The prevention of aggressive behaviours is a core priority for psychiatric clinical work, but the association between the diagnostic concepts used in psychiatry and aggression remains largely unknown. Outpatients referred for psychiatric evaluations of childhood-onset neuropsychiatric disorders (n=178) and perpetrators of violent crimes referred to pre-trial forensic psychiatric investigations (n=92) had comprehensive, instrument-based, psychiatric assessments, including the Life History of Aggression (LHA) scales. Total and subscale LHA scores were compared to the categorical and dimensional diagnoses of childhood and adult DSM-IV axis I and II mental disorders, general intelligence (IQ), Global Assessment of Functioning (GAF), and personality traits according to the Temperament and Character Inventory (TCI). Overall, the two groups had similar LHA scores, but the offender group scored higher on the Antisocial subscale. Higher total LHA scores were independently associated with the hyperactivity facet of attention-deficit/hyperactivity disorder (AD/HD), childhood conduct disorder, substance-related disorders, and low scores on the Cooperativeness character dimension according to the TCI. IQ and GAF-scores were negatively correlated with the LHA subscale Self-directed aggression. Autistic traits were inversely correlated with aggression among outpatients, while the opposite pattern was noted in the forensic group. The findings call for assessments of aggression-related behaviours in all psychiatric settings.

Mental health problems in youths committed to juvenile institutions: prevalences and treatment needs

Many international studies show that adolescents in coercive institutional care display high prevalences of mental disorders, especially in the form of disruptive behavior disorders [including attention-deficit/hyperactivity disorder (AD/HD), oppositional defiant disorder, and conduct disorder], anxiety disorders, and mood disorders. High degrees of overlap across mental disorders have also been reported. In addition, institutionalized adolescents are often traumatized. Despite this well-documented psychiatric morbidity, the mental health care needs of detained adolescents are often overlooked. The main objective of this study is to assess prevalences of psychiatric disorders, results of intelligence tests, and previous contacts with child and adolescent psychiatric services among adolescents in institutional care. DSM-IV diagnoses, mental health contacts, substance abuse, neurocognitive abilities, and school performance were registered in 100 adolescents (92 boys, 8 girls) aged 12-19 years (mean age 16.0; SD ± 1.5) consecutively committed to Swedish juvenile institutions between 2004 and 2007. At least one psychiatric disorder was diagnosed in 73% of the subjects: 48% met DSM-IV diagnostic criteria for AD/HD, 17% for an autism spectrum disorder, and 10% for a mental retardation. The collapsed prevalence for psychiatric disorders requiring specialist attention was 63%. Our data indicate that systematic diagnostic procedures are crucial in the treatment planning for institutionalized adolescents. Adequate treatment strategies need to be designed and implemented to meet the extensive mental health care needs of this vulnerable population.

The precarious practice of forensic psychiatric risk assessments

The development of forensic psychiatric risk assessments is discussed from a clinical point of view using the example of Sweden. A central task in forensic psychiatry has traditionally been to identify dangerous, mentally disordered subjects considered to be prone to commit violent acts. Over time, "dangerousness" has been reworded into "risk". Nevertheless, such assessments have generally been based on the psychiatric factors characterising the individual patient, while group interaction, situational factors, or social and cultural circumstances, such as the availability of alcohol and drugs, have been largely overlooked. That risk assessments have a focused on people with a diagnosis of "mental disorder" and been used as grounds for coercive measures and integrity violations has somehow been accepted as a matter of course in the public and political debate. Even the basic question whether offenders with a mental disorder are really more prone to criminal recidivism than other offenders seems to have been treated light-handedly and dealt with merely by epidemiological comparisons between groups of persons with broad ranges of psychosocial vulnerability and the general population. Legal texts, instructions and guidelines from the authorities in charge are often vague and general, while actors in the judicial system seem to put their trust in psychiatric opinions. The exchange of professional opinions, general public expectations, and judicial decision processes poses a huge risk for misunderstandings based on divergent expectations and uses of terminology.

[Prevalence and factors associated with behavioral disorders in adolescents: a population-based study]

This study proposed to estimate the prevalence of behavioral disorders and associated factors in adolescents (11-15 years), using a cross-sectional design (n = 1,145). Subjects answered a self-administered questionnaire. Behavioral disorder was assessed with the Mini International Neuropsychiatric Interview (MINI). The study analyzed disorders in relation to gender, age, socioeconomic status, schooling, failure in school, religion, smoking, sedentary lifestyle, alcohol consumption, drug use, depression, and bullying (as victim). Ordinal regression was used for the statistical analysis, with a hierarchical model for the outcome. An estimated 29.2% of the sample presented behavioral disorders. In the multivariate analysis, the odds ratio for a male adolescent to present one additional point on the behavioral disorder scale was 2.04 (95%CI: 1.53-2.71). Alcohol consumption, drug use, and suffering bullying were associated with higher scores on the behavioral disorder scale. The findings also showed that the factors associated with behavioral disorder showed a strong interrelationship between health behaviors in adolescence.

ADHD in adult psychiatry. Minimum rates and clinical presentation in general psychiatry outpatients

The objective of the study was to determine the prevalence and comorbidity of persisting attention-deficit hyperactivity disorder (ADHD) in adult psychiatric outpatients. Consecutive patients, first visits excluded, at a general psychiatric outpatient clinic were offered a screening for childhood ADHD with the Wender Utah Rating Scale (WURS). One hundred and forty-one patients out of 398 (35%) completed and returned the scale. Patients above or near cut-off for ADHD (n=57) were offered an extensive clinical evaluation with psychiatric as well as neuropsychological examination. The attrition was analysed regarding age, sex and clinical diagnoses. Out of the screened sample, 40% had scores indicating possible childhood ADHD. These 57 patients were invited to the clinical part of the study, but 10 declined assessment, leaving 47 (37 women and 10 men) who were actually examined. Thirty of these (21 women and nine men) met diagnostic criteria for ADHD at the time of examination. Among the patients with ADHD, affective disorders were the most common psychiatric diagnoses. The rate of alcohol and/or substance abuse, as noted in the medical records, was also high in the ADHD group. In the WURS-screened group, 22% (30 patients assessed as part of this study and one person with ADHD previously clinically diagnosed) were shown to have persisting ADHD. Therefore, it is clearly relevant for psychiatrists working in general adult psychiatry to have ADHD in mind as a diagnostic option, either as the patient's main problem or as a functional impairment predisposing for other psychiatric disorders.

Effects of diagnostic comorbidity and dimensional symptoms of attention-deficit–hyperactivity disorder in men with antisocial personality disorder

OBJECTIVE

Although children with attention deficit hyperactivity disorder (ADHD) are at increased risk for later onset of antisocial personality disorder (APD) as adults, the utility of ADHD as either a comorbid diagnosis (ADHD(c)) or dimensional symptoms (ADHD(d)) in predicting behaviour and substance use problems in APD subjects has not been examined.

METHOD

A total of 105 adult male offenders with Structured Clinical Interview for Axis II Disorders (SCID-II)-based DSM-III-R APD were studied in terms of: (i) psychopathy scores on the Hare Psychopathy Checklist-Revised (PCL-R); (ii) ADHD(c) diagnostic comorbidity on clinically administered DSM-IV questionnaire; and (iii) ADHD(d) dimensional symptoms by means of Wender Utah Rating Scale (WURS) and Conners Adult ADHD Rating Scale (CAARS) during a 12 month study period (May 2005-May 2006).

RESULTS

Sixty five per cent of APD subjects met criteria for ADHD(c) diagnostic comorbidity with significantly increased rates of childhood neglect, parental divorce and suicide attempt, but not of psychopathy. APD subjects with ADHD(d) symptoms were noted to have earlier onset and increased rate of self-injurious behaviour (SIB), suicide attempt, and psychopathy. The psychopathy scores, in turn, were predictive of earlier onset of SIB and behavioural problems.

CONCLUSION

Both ADHD(c) diagnostic comorbidity and ADHD(d) symptoms need to be assessed in APD subjects and the dimensional measures may be better in detecting earlier onset SIB, suicide attempt and other behavioural problems.

Autism spectrum disorders in institutionalized subjects

What do we know about the prevalence and the specific features of autism spectrum disorders (ASDs) among subjects in forensic psychiatry and special youth centres? A clinical case series consisting of 42 subjects with ASD, recruited from three well-characterized populations in forensic psychiatry and special youth care, was used to determine: 1) the prevalence of ASD in these institutions (at least 13%), 2) the distribution of diagnostic criteria in this special population (mostly social interaction and communication problems, few or atypical flexibility problems), 3) the degree of comorbidity (the rule rather than the exception), 4) neuropsychological test profiles (lowered IQ with uneven profiles), 5) types of crimes and offences (very heterogeneous, often stress-related with dissociated features), 6) mental health care needs (high), and 7) special clinical features (especially expressions of flexibility deficits in non-classical areas and proneness to dissociation). This descriptive study indicates that ASD is a clinically relevant problem among forensic populations that has to be considered in diagnostics, assessments of needs and treatment planning.

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.

Age at onset of substance abuse: a crucial covariate of psychopathic traits and aggression in adult offenders

To examine age at onset of substance abuse in relation to other factors of relevance to criminal behavior, we compared Life History of Aggression (LHA) scores, traits of psychopathy according to the Psychopathy Checklist--Revised (PCL-R), and violent recidivism in 100 violent offenders with early (before the age of 18) versus late onset of abuse or dependence. Of 56 subjects with a history of alcohol and/or drug abuse, an early onset was ascertained in 31. The duration of abuse did not correlate with the LHA and PCL-R scores or with violent recidivism, but the age at onset correlated strongly with all these factors and also remained their strongest correlate in multivariate models including childhood-onset attention deficit/hyperactivity disorder, conduct disorder, and drug abuse as covariates. Strong mathematical associations with aggression, psychopathy, and recidivism pointed to age at onset of substance abuse as a marker of possible complications that require preventive social, educational and medical measures.

Impaired nitric oxide synthase signaling dissociates social investigation and aggression

A combination of social withdrawal and increased aggression is characteristic of several mental disorders. Most previous studies have investigated the neurochemical bases of social behavior and aggression independently, as opposed to how these behaviors are regulated in concert. Neuronal nitric oxide synthase (nNOS) produces gaseous nitric oxide, which functions as a neurotransmitter and is known to affect several types of behavior including mating and aggression. Compared with wild-type mice, we observed that nNOS knockout mice showed reduced behavioral responses to an intruder behind a wire barrier. Similar results were observed in mice treated with the selective nNOS inhibitor 3-bromo-7-nitroindazole (3BrN). In habituation-dishabituation tests, treatment with 3BrN did not block recognition of male urine but did attenuate investigation time compared with oil-treated animals. Finally, nNOS knockout mice and 3BrN treated mice were significantly more aggressive than wild-type and oil-treated males, respectively. In general, these behavioral effects are less pronounced in pair-housed males compared with singly-housed males. Thus, nNOS inhibition results in a phenotype that displays reduced social investigation and increased aggression. These data suggest that further study of nNOS signaling is warranted in mental disorders characterized by social withdrawal and increased aggression.

Central nervous changes in social dysfunction: Autism, aggression, and psychopathy

Neurodevelopmental disorders such as autism and schizophrenia involve social interaction problems and poor mentalizing abilities, associated with abnormal regional cerebral activity. Similar problems may be present in aggressive personality disorders and psychopathy. This paper reviews brain imaging data from research aiming at establishing possible central nervous correlates to aggression and psychopathy. Studies in this field are associated with a range of method problems. Differences between criminal offenders and controls may be confounded by a number of factors unrelated to personality traits or aggression per se. Phenotypical characterisation varies between studies as do the laboratory methods and their interpretation. In spite of these problems, there are some recurrent findings in the present literature. Hypoactivity or structural reduction of the prefrontal cortex is a consistent finding in violent offenders or subjects with antisocial personality disorder. When defined as a personality disorder of social interaction and empathy, psychopathy seems to be associated rather with central abnormalities in the limbic circuitry. Indications of an increased dopaminergic neurotransmission relative to the serotonergic have also been connected to such personality traits, especially to the AD/HD-related behavioural aspects. Further studies using strict phenotypical definitions or experimental models are clearly warranted to establish a pathophysiological background to destructive personality traits and the propensity to violent acting out.

Ätiologie und Verlauf kindlichen dissozialen Verhaltens - Risikofaktoren für die Entwicklung einer antisozialen Persönlichkeitsstörung

Zusammenfassung: Gegenstand: Störungen des Sozialverhaltens gehören zu den häufigsten Erkrankungen in unserem Fachgebiet. Methode: Die an der Entstehung von Störungen des Sozialverhaltens wesentlich beteiligten biologischen und psychosozialen Faktoren sowie deren Interaktion werden in dieser Übersichtsarbeit dargestellt. Dabei wird speziell auf Veränderungen der autonomen Reagibilität eingegangen. Ergebnis: Bei den unterschiedlichen Entwicklungspfaden hin zu einer antisozialen Persönlichkeitsstörung kommt frühen Formen von Störungen des Sozialverhaltens und dem psychopathischen Subtyp eine besondere Aussagekraft zu. Schlussfolgerung: Es wird die Bedeutung einer frühzeitigen Förderung gefährdeter Kinder zur Vermeidung einer dissozialen Entwicklung herausgestellt.

A long-term follow-up of conduct disorder adolescents into adulthood

This study focuses on young male and female adults (n=290) who were diagnosed with conduct disorder (CD) during adolescence at the inpatient child and adolescent psychiatric unit in Lund, Sweden. Their adulthood is described using seven outcome variables: in custody, crime, illicit drug use, mental health, teenage parenthood, transference income and educational attainment. Together, the seven outcome variables represent a wide perspective of individual life and known risks for both genders. The variables are compared, scaled and described in an outcome that identifies successful outcome. Although this was a severe clinical inpatient group of adolescents, a relatively large number-about a third of the males and close to half of the females-exhibit a successful outcome by their early twenties. This study highlighted the merits use gender-sensitive outcome variables. The take-home message from a societal perspective is that many improvements are needed, a message that has been voiced in several Swedish commissions.

Personality disorders: new data versus old concepts

PURPOSE OF REVIEW

The purpose of this paper is to review the most recent literature on personality disorders.

RECENT FINDINGS

Recent data suggest that individual personality disorder criteria and full diagnosis may remit within 1-2 years. The same line of evidence disputes the separation of axis I and axis II disorders and suggests the presence of a continuum. Neuropsychological, neurobiological and genetic studies favor the presence of cognitive disorders and a non-specific mode of hereditability concerning all externalizing disorders. How to best treat personality disorders remains elusive. The most impressive news in the forensic field concerns the introduction of a new concept, dangerous and severe personality disorder by the UK government, for prevention and treatment purposes.

SUMMARY

The most recent data do not adequately support a separate axis II. Future classification may need to move personality disorders to axis I, each under a suitable group of diseases and eliminate the very term 'personality' from the nomenclature, since it constitutes an empirically unsupported theoretical invasion in a system supposed to be 'atheoretical'.

The childhood-onset neuropsychiatric background to adulthood psychopathic traits and personality disorders

Childhood conduct disorder (CD) and adult psychopathic traits according to the Psychopathy Checklist Revised (PCL-R) were the closest psychiatric covariates to repeated violent crimes and aggression among offenders under forensic psychiatric investigation in Sweden. As psychopathy is not included in the present psychiatric diagnostic systems, we compared total and factor PCL-R scores to Axis I disorders, including childhood-onset neuropsychiatric disorders, and to Axis II personality disorders, to establish the convergence of psychopathic traits with other psychiatric diagnoses, and to identify possible unique features. Psychopathic traits were positively correlated with bipolar mood disorder and negatively with unipolar depression. The total PCL-R scores as well as the Factor 2 (unemotionality) and Factor 3 (behavioral dyscontrol) scores were significantly correlated with attention-deficit/hyperactivity disorder, Asperger's syndrome/high-functioning autistic traits, CD, substance abuse, and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Cluster B personality disorders. The interpersonal Factor 1 showed none of these correlations and may capture features that are specific to psychopathy, distinguishing core psychopathy from other diagnostic definitions.

Linking adult psychopathy with childhood hyperactivity-impulsivity-attention problems and conduct problems through retrospective self-reports

The purpose of the present study was to test whether adult criminals with psychopathy diagnoses, more than those without, have histories of hyperactivity-impulsivity-attention problems (HIA) and conduct problems (CP). We compared psychopathic and nonpsychopathic violent criminal offenders on retrospective reports of conduct problems before the age of 15 and hyperactivity-impulsivity-attention problems before the age of 10. We used a sample of 186 adult men sentenced to prison in Sweden for 4 years or more for violent, nonsexual crimes. The mean age was 30.7( SD = 9.4). The results showed that a combination of childhood HIA problems and CP was typical for adult psychopathic offenders. They were four times more likely than chance to have had a combination of HIA problems and CP during childhood and only one-fifth as likely than chance to have had neither problem. Nonpsychopathic offenders, on the other hand, were five times more likely than chance to have had neither problem and only one-quarter as likely than chance to have had both problems.