Adult psychopathic personality with childhood-onset hyperactivity and conduct disorder: a central problem constellation in forensic psychiatry
Introduction
Psychiatric problems are over-represented among violent offenders, but the nature of the association between psychiatric features and criminality is far from obvious. Although dependent on inclusion criteria, legislation and availability of mental health care, surveys of mental disorders in offender groups invariably find sharply increased prevalences of disorders and needs (Fazel and Danesh, 2002). Epidemiological research has shown that psychotic disorders and mental retardation carry an increased risk of violent offending (Lindqvist and Allebeck, 1990, Hodgins, 1992, Hodgins et al., 1996) even if the risk increase is not always identifiable in patient groups (Skeem and Mulvey, 2001). Childhood-onset disruptive behavior disorders [attention-deficit/hyperactivity disorder (AD/HD), oppositional defiant disorder (ODD), and conduct disorder (CD)] carry a high risk of persisting into adulthood as antisocial behaviors (Lahey and Loeber, 1997, Moffitt and Caspi, 2002). Aggressive behavior is also a clinical feature of tic disorders and autism spectrum disorders [referred to as ‘pervasive developmental disorders’ (PDDs) in DSM-IV (American Psychiatric Association, 1994, Siponmaa et al., 2001, Soderstrom, 2002)]. Several definitions of personality disorders (such as borderline personality disorder, antisocial personality disorder and psychopathy) contain aggressive behaviors as discriminative traits (American Psychiatric Association, 1994, Hare, 1980).
The aims of the present study were to (1) analyze the comorbidity between childhood and adulthood disorders among 100 perpetrators of violent crimes investigated by means of structured interviews, clinical assessments, neuropsychological tests and file reviews and (2) identify the lifetime psychiatric characteristics most closely associated with high levels of aggression and criminal recidivism.
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Subjects
Subjects were consecutively recruited among perpetrators of severe violent or sexual index crimes, i.e. crimes where the life of another person had been threatened or taken (murder/manslaughter in 21 cases, attempted murder/manslaughter in 17, aggravated assault in 17, aggravated unlawful threat/robbery in 6, rape in 3, sexual child abuse in 22 and arson in 14). All were admitted to the study department by court order to undergo forensic psychiatric investigations for periods up to 4 weeks.
Overall clinical diagnostic work-up
DSM-IV diagnoses on Axes I and II (American Psychiatric Association, 1994) were assigned by AF and HS in consensus on the basis of the diagnostic work-up (interviews, assessments and tests) described below and data from educational and social welfare registers (including child health care and school records), medical records (including child and adolescent psychiatric contacts), and the forensic psychiatric investigation reports. All concomitant diagnoses were recorded to provide as complete a
Diagnostic work-up
All categories of mental disorder showed strikingly high prevalences. At least one DSM-IV diagnosis was registered in all but four subjects. The distribution of diagnoses in the other 96 subjects is given in Table 1. Fifty-five percent of the study group fulfilled DSM-IV diagnostic criteria for childhood-onset disorders (not including borderline intellectual functioning or CD) and 48% met those for CD. A global IQ <85 was recorded in 37, 17 of whom with IQ scores <70 (including subjects first
Limitations
Correlations between ratings of current and retrospective features can be shown, but relationships cannot be predicted in a cross-sectional study such as this. What this less than perfect design may allow, however, is to trace lifetime patterns not discernible by other methods, as detailed mapping of a broad range of clinical conditions is not possible in prospective population-based groups.
In the older subjects who grew up at a time when data were not as routinely recorded as they are today,
Acknowledgements
The study was supported by grants from the National Board of Forensic Medicine and the Göteborg Medical Society, Sweden. We are indebted to Professor Christopher Gillberg and Associate Professor Agneta Nilsson for constructive criticism of early versions of the paper, to Gunnar Ekeroth for excellent statistical collaboration, to the psychologists and social workers at the study department for providing test results, and to Stefan Axelsson, Agneta Brimse and Monika Montell for technical,
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