Persistent violent offending: what do we know?

Personality disorders and forensic assessments: The benefits of ICD-11

A recent landmark case in the Australian state of Victoria clarified the ways in which personality disorders may be taken into account when the courts are sentencing convicted offenders. The ruling especially emphasised: the need for evidence to be 'cogent'; the need to determine 'severity' of the personality disorder; the need to consider whether there is a 'connection to the offending'; the need for caution when diagnoses are based solely on behaviour; and the need to consider rehabilitative prospects and community protection. The ruling has significant implications for how forensic experts in all jurisdictions might most effectively assist the courts with the task of sentencing offenders with personality disorders. In this paper we argue that the approach to diagnosis taken in the newly published ICD-11 manual, that eschews 'categories' of personality disorder, in favour of a dimensional model supported by trait theory, is of much greater utility to forensic mental health experts striving to address these issues, compared to traditional 'categorical' approaches.

Comorbidity and Behavior Characteristics of Russian Male Juvenile Delinquents With ADHD and Conduct Disorder

Objective: To test the previously suggested hypothesis that those with comorbid ADHD and Conduct Disorder (CD) diagnoses differ from other antisocially involved youth in terms of higher rates of violent behavior, impulsiveness, and psychopathic traits. Method: Three hundred eighty juvenile incarcerated delinquents from Northern Russia were assessed by means of semi-structured psychiatric interview and by student and teacher self-reports. Results: The study has demonstrated higher rates of psychiatric disorders and of comorbidity, as well as more complicated substance abuse and disruptive behaviors in those with combined ADHD-CD diagnosis, as compared with CD only, ADHD only, and no CD no ADHD groups. The results regarding psychopathic traits were inconclusive. Conclusion: The group with combined ADHD-CD diagnosis is more severely disturbed, both as concerns psychiatric comorbidity and more severe aggressive and disruptive behaviors. However, there is only limited evidence supporting a higher prevalence of psychopathic traits in this group.

Empathy and altruistic behavior in antisocial violent offenders with psychopathic traits

Deficiencies in empathic functioning are considered a core characteristic of violent behavior. Enhancing empathy in aggressive populations may thus represent a promising intervention target. Hence, the aims of the present work were two-fold: First, we wanted to thoroughly assess empathic competencies and second, we aimed to investigate effects of an empathy induction on experienced empathy levels and prosocial behavior in a sample of violent offenders relative to matched controls. Empathy was assessed using both self-report as well as objective measures. For the empathy induction, participants were presented with empathy inducing and control videos. To assess the effects of the empathy induction on behavior, participants played a dictator game indicative of prosocial behavior after every video. Violent offenders showed no systematic impairment in empathy measures. Despite lower shares in the dictator game across conditions, the empathy induction led to a substantial increase in prosocial behavior in both groups. Importantly, high psychopathy scores were distinctively associated with lower self-reported empathy levels, an attenuated affective responsiveness to the empathy induction, and less altruistic behavior. Treatment programs aiming to improve empathy should take individual characteristics into account and may be applied to distinctive subgroups rather than to violent offenders per se.

Dangerous and severe personality disorder and in need of treatment

The Dangerous and Severe Personality Disorder Programme was born out of a populist law and order reaction, developed on false premises, but is now evolving into an exciting initiative for providing effective services to a group of offenders with mental illness who psychiatry, and the justice services, have so long ignored. Enthusiasm, flexibility and an evidence-based approach may yet lead to real progress towards the improved management of disturbed high-risk offenders, improving the psychological and social functioning of the offenders as well as delivering a safer community.

Antisocial personality disorder: new directions

Antisocial personality disorder is a complex condition carrying high rates of comorbidity and mortality for individuals as well as harmful consequences for their families and society. Despite the publication of National Institute for Health and Care Excellence (NICE) guidelines for the disorder, the evidence base and provision of effective treatments remain inadequate, and the belief that the condition is untreatable remains widespread among psychiatrists and other professionals. This article highlights current diagnostic controversies and summarises the evidence for conceptualising antisocial personality disorder as a disorder of attachment. Informed by this developmental perspective, we provide a framework for the management and treatment of adults with antisocial personality disorder, highlighting the importance of creating a safe setting and recommending adaptations of therapeutic technique to facilitate the engagement of this ‘treatment-rejecting’ patient population. We conclude with an outline of the current government policy on the treatment of high-risk offenders with personality disorder.

LEARNING OBJECTIVES

Incentive Processing in Persistent Disruptive Behavior and Psychopathic Traits: A Functional Magnetic Resonance Imaging Study in Adolescents

BACKGROUND

Children with early-onset disruptive behavior disorder (DBD), especially those with callous-unemotional traits, are at risk of developing persistent and severe adult antisocial behavior. One possible underlying mechanism for persistence is deficient reward and loss sensitivity, i.e., deficient incentive processing. However, little is known about the relation between deficient incentive processing and persistence of antisocial behavior into adulthood or its relation with callous-unemotional and other psychopathic traits. In this study, we investigate the relationship between the neural correlates of incentive processing and both DBD persistence and psychopathic traits.

METHODS

In a sample of 128 adolescents (mean age 17.7) with a history of criminal offending before age 12, functional magnetic resonance imaging was performed during a monetary incentive delay task designed to assess neural responses during incentive processing. Neural activation during incentive processing was then associated with DBD persistence and psychopathic traits, measured with the Youth Psychopathic Traits Inventory.

RESULTS

Compared with both healthy control subjects and youths who had desisted from DBD, persistent DBD subjects showed lower neural responses in the ventral striatum during reward outcomes and higher neural responses in the amygdala during loss outcomes. Callous-unemotional traits were related to lower neural responses in the amygdala during reward outcomes, while other psychopathic traits were not related to incentive processing.

CONCLUSIONS

In the current study, aberrant incentive processing is related to persistence of childhood antisocial behavior into late adolescence and to callous-unemotional traits. This mechanism may underlie treatment resistance in a subgroup of antisocial youth and provide a target for intervention.

Identification With a Violent and Sadistic Aggressor: A Rorschach Study of Criminal Debt Collectors

This study examined personality functioning in a group of 27 incarcerated criminal debt collectors as assessed by the Rorschach Inkblot Method (RIM; Rorschach, 1921/1942) and the Psychopathy Checklist-Revised (PCL-R; Hare, 2003 ). To explore whether these individuals represent a distinct subgroup within the violent offender population, we compared them to a group of incarcerated homicide offenders (n = 23) without a previous history of significant violence and a group who had committed less serious violent crimes (n = 21). Results revealed significantly more Rorschach indicators of past trauma (Trauma Content Index), aggressive urges (Aggressive Potential) and identification (Aggressive Content) among the debt collectors than the 2 other groups. In addition, debt collectors displayed significantly more interpersonal interest (Sum Human content), and significantly higher scores on the PCL-R. Our findings suggest that the debt collector might be viewed as a hostile variant of psychopathy.

Fear extinction, persistent disruptive behavior and psychopathic traits: fMRI in late adolescence

Children diagnosed with a Disruptive Behavior Disorder (DBD, i.e. Oppositional Defiant Disorder or Conduct Disorder), especially those with psychopathic traits, are at risk of developing persistent and severe antisocial behavior. Reduced fear conditioning has been proposed to underlie persistent antisocial development. However, we have recently shown that both DBD persisters and desisters are characterized by increased fear conditioning compared with healthy controls (HCs). In this study, we investigated whether brain function during fear extinction is associated with DBD subgroup-membership and psychopathic traits. Adolescents from a childhood arrestee cohort (mean age 17.6 years, s.d. 1.4) who met criteria for a DBD diagnosis during previous assessments were re-assessed and categorized as persistent DBD (n = 25) or desistent DBD (n = 25). Functional MRI during the extinction phase of a classical fear-conditioning task was used to compare regional brain function between these subgroups and 25 matched controls. Both DBD persisters and desisters showed hyperreactivity during fear extinction, when compared with HCs. Impulsive-irresponsible psychopathic traits were positively associated with responses in the fear neurocircuitry and mediated the association between neural activation and group membership. These results suggest that fear acquisition and fear extinction deficits may provide an endophenotype for an emotionally hyperreactive subtype of antisocial development.

The Endurance of Uncertainty: Antisociality and Ontological Anarchy in British Psychiatry, 1950–2010

Research into the biological markers of pathology has long been a feature of British psychiatry. Such somatic indicators and associated features of mental disorder often intertwine with discourse on psychological and behavioral correlates and causes of mental ill-health. Disorders of sociality – particularly psychopathy and antisocial personality disorder – are important instances where the search for markers of pathology has a long history; research in this area has played an important role in shaping how mental health professionals understand the conditions. Here, I characterize the multiplicity of psychiatric praxis that has sought to define the mark of antisociality as a form of “ontological anarchy.” I regard this as an essential feature of the search for biological and other markers of an unstable referent, positing that uncertainties endure – in part – precisely because of attempts to build consensus regarding the ontology of antisociality through biomedical means. Such an account is suggestive of the co-production of biomarkers, mental disorder, and psychiatric institutions.

Fear conditioning, persistence of disruptive behavior and psychopathic traits: an fMRI study

Children diagnosed with Disruptive Behavior Disorders (DBD), especially those with psychopathic traits, are at risk of developing persistent and severe antisocial behavior. Deficient fear conditioning may be a key mechanism underlying persistence, and has been associated with altered regional brain function in adult antisocial populations. In this study, we investigated the associations between the neural correlates of fear conditioning, persistence of childhood-onset DBD during adolescence and psychopathic traits. From a cohort of children arrested before the age of 12 years, participants who were diagnosed with Oppositional Defiant Disorder or Conduct Disorder in previous waves (mean age of onset 6.5 years, s.d. 3.2) were reassessed at mean age 17.6 years (s.d. 1.4) and categorized as persistent (n=25) or desistent (n=25) DBD. Using the Youth Psychopathic Traits Inventory and functional magnetic resonance imaging during a fear conditioning task, these subgroups were compared with 26 matched healthy controls from the same cohort. Both persistent and desistent DBD subgroups were found to show higher activation in fear processing-related brain areas during fear conditioning compared with healthy controls. In addition, regression analyses revealed that impulsive-irresponsible and grandiose-manipulative psychopathic traits were associated with higher activation, whereas callous-unemotional psychopathic traits were related to lower activation in fear-related areas. Finally, the association between neural activation and DBD subgroup membership was mediated by impulsive-irresponsible psychopathic traits. These results provide evidence for heterogeneity in the neurobiological mechanisms underlying psychopathic traits and antisocial behavior and, as such, underscore the need to develop personalized interventions.

Personality disorders in men with sexual and violent criminal offense histories

Little is known about personality disorders (PDs) in offenders with histories of both sexual and (nonsexual) violent offenses. This study aimed to identify possible differences of PD profiles across three different offender groups with both sexual and violent (S+V), only sexual (S), and only violent (V) offenses. Nonviolent (N) offenders were used as a comparison group. Typing of individuals according to their offensive histories was performed on the basis of 259 psychiatric court reports that included the Structured Clinical Interview (SCID)-II for PD diagnostics. Men from the S+V group committed significantly more acts of rape and sexual coercion than the mere sexual offenders. Furthermore, S+V offenders showed the highest rates of PDs overall (68.3%), with every second offender being diagnosed with an antisocial PD and every third offender with a borderline PD. In summary, the results suggest that S+V offenders form a group of individuals with remarkable differences regarding PD profiles, the relatively highest frequencies of conduct disorders, familial addictive problems, and PDs overall.

Practitioner review: The victims and juvenile perpetrators of child sexual abuse--assessment and intervention

BACKGROUND

The assessment of victims of child sexual abuse (CSA) is now a recognized aspect of clinical work for both CAMH and adult services. As juvenile perpetrators of CSA are responsible for a significant minority of the sexual assaults on other children, CAMH services are increasingly approached to assess these oversexualized younger children or sexually abusive adolescents. A developmental approach to assessment and treatment intervention is essential in all these cases.

METHOD

This review examines research on the characteristics of child victims and perpetrators of CSA. It describes evidence-based approaches to assessment and treatment of both groups of children. A selective review of MEDLINE, Psycinfo, Cochrane Library, and other databases was undertaken. Recommendations are made for clinical practice and future research.

FINDINGS

The characteristics of CSA victims are well known and those of juvenile perpetrators of sexual abuse are becoming recognized. Assessment approaches for both groups of children should be delivered within a safeguarding context where risk to victims is minimized. Risk assessment instruments should be used only as adjuncts to a full clinical assessment. Given high levels of psychiatric comorbidity, assessment, treatment, and other interventions should be undertaken by mental health trained staff.

CONCLUSIONS

Victims and perpetrators of CSA present challenges and opportunities for professional intervention. Their complex presentations mean that their needs should be met by highly trained staff. However, their youth and developmental immaturity also give an opportunity to nip problem symptoms and behaviors in the bud. The key is in the earliest possible intervention with both groups. Future research should focus on long-term adult outcomes for both child victims and children who perpetrate CSA. Adult outcomes of treated children could identify problems and/or strengths in parenting the next generation and also the persistence and/or desistence of sexualized or abusive behavior.

Antisocial personality disorder and anxiety disorder: a diagnostic variant?

Antisocial personality disorder (ASPD) with co-morbid anxiety disorder may be a variant of ASPD with different etiology and treatment requirements. We investigated diagnostic co-morbidity, ASPD criteria, and anxiety/affective symptoms of ASPD/anxiety disorder. Weighted analyses were carried out using survey data from a representative British household sample. ASPD/anxiety disorder demonstrated differing patterns of antisocial criteria, co-morbidity with clinical syndromes, psychotic symptoms, and other personality disorders compared to ASPD alone. ASPD criteria demonstrated specific associations with CIS-R scores of anxiety and affective symptoms. Findings suggest ASPD/anxiety disorder is a variant of ASPD, determined by symptoms of anxiety. Although co-morbid anxiety and affective symptoms are the same as in anxiety disorder alone, associations with psychotic symptoms require further investigation.

Getting the phenotypes right: an essential ingredient for understanding aetiological mechanisms underlying persistent violence and developing effective treatments

In order to reduce societal levels of violence, it is essential to advance understanding of the neurobiological mechanisms involved in initiating and maintaining individual patterns of physical aggression. New technologies such as Magnetic Resonance Imagining and analyses of DNA provide tools for identifying these mechanisms. The reliability and validity of the results of studies using these tools depend not only on aspects of the technology, but also on the methodological rigour with which the studies are conducted, particularly with respect to characterizing the phenotype. The present article discusses five challenges confronting scientists who aim to advance understanding of the neurobiological mechanisms associated with persistent violence. These challenges are: (1) to develop evidence-based hypotheses and to design studies that test alternate hypotheses; (2) to recruit samples that are homogeneous with respect to variables that may be linked to neurobiological mechanisms underpinning violent behaviour; (3) to use reliable and valid measures in order to fully characterize participants so that the external validity of the results is evident; (4) to restrict the range of age of participants so as not to confuse developmental change with group differences; and (5) to take account of sex. Our goal is to contribute to elevating methodological standards in this new field of research and to thereby improve the validity of results and move closer to finding effective ways to reduce violence.

Violent behavior in acute psychiatric inpatient facilities: a national survey in Italy

Violence committed by acute psychiatric inpatients represents an important and challenging problem in clinical practice. Sociodemographic, clinical, and treatment information were collected for 1324 patients (677 men and 647 women) admitted to Italian public and private acute psychiatric inpatient facilities during an index period in 2004, and the sample divided into 3 groups: nonhostile patients (no episodes of violent behavior during hospitalization), hostile patients (verbal aggression or violent acts against objects), and violent patients (authors of physical assault). Ten percent (N = 129) of patients showed hostile behavior during hospitalization and 3% (N = 37) physically assaulted other patients or staff members. Variables associated with violent behavior were: male gender, <24 years of age, unmarried status, receiving a disability pension, having a secondary school degree, compulsory admission, hostile attitude at admission, and a diagnosis of schizophrenia, bipolar disorder, personality disorder, mental retardation, organic brain disorder or substance/alcohol abuse. Violent behavior during hospitalization was a predictive factor for higher Brief Psychiatric Rating Scale scores and for lower Personal and Social Performance scale scores at discharge. Despite the low percentage of violent and hostile behavior observed in Italian acute inpatient units, this study shed light on a need for the careful assessment of clinical and treatment variables, and greater effort aimed at improving specific prevention and treatment programs of violent behavior.

Looking Forward in Records of Youth Abused as Infants: Risks for Homicidal, Violent, and Delinquent Offenses

To study risks for abuse and later homicidal behavior, 192 abused infants ( M age = 3.12 yr., SD = 1.48; 82 girls, 110 boys) and 192 controls were matched on demographics and examined; data discriminating abused and later homicidal cases were analyzed with Shao's bootstrapped logistic regression. Predictors of Abused status were injury, burn, poisoning, fetal substance exposure ( OR = 2.47), later parental or youth court contacts ( OR = 1.86e+12), and parental alcohol abuse (OR = .54; AUC = .99; 95% CI= .96−.99). Youth tracked through records 12 years (to M age = 12.17 yr., SD =1.89) were classified into Abused Later Homicidal (11%, n = 21), Abused Later Violent (14%, n = 27), Abused Later Delinquent (31%, n = 60), Abused Later Nondeliquent ( n = 44), and Control groups ( n = 192). Data were analyzed similarly. When the Abused Later Homicidal was contrasted with the Control group, predictors of homicide were three or more home/school moves ( OR = .78), illnesses ( OR = .90), and later court contacts ( OR= 1.75e+07; AUC=.99; 95% CI=.90−.98). When the Abused Later Homicidal was compared with the Abused Later Nondelinquent group, predictors of homicide were poorer executive function ( OR = 2.29) and later court contacts ( OR = 7.78e+06; AUC=.94; 95% CI= .90−.98).

A review of effective interventions for reducing aggression and violence

This paper addresses the question of whether individual violence can be reduced in frequency or severity, if so to what extent and by which methods. It opens with a brief overview of the nature of personal violence and discussion of some key definitional and methodological problems. However, its principal focus is on the findings obtained from a series of meta-analytic reviews of structured programmes for adolescents and adults who have shown repeated aggression or been convicted of personal violence, drawing together the results of studies conducted in prison, probation, youth justice and allied services. Additional results are considered from a systematic review of studies of violence prevention among offenders with mental disorders. This incorporates the preliminary findings of a meta-analysis of controlled trials of psychosocial interventions with that population. Overall, it is concluded that there is sufficient evidence currently available to substantiate the claim that personal violence can be reduced by psychosocial interventions, but that much more research is required to delineate the parameters of effectiveness in this context. Proposals are made for future investigations with reference to the theoretical understanding of causal relationships and the design of experimental trials.