The childhood-onset neuropsychiatric background to adulthood psychopathic traits and personality disorders
Introduction
In a recent study of violent offenders, conduct disorder (CD) and psychopathic traits according to the Psychopathy Checklist Revised (PCL-R) [1], independently, were the closest psychiatric covariates to repeated violent crimes and high aggression scores [2]. The relevance of childhood-onset CD for adult social maladaptation has long been well known [3] as reflected by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) definition of antisocial personality disorder [4]. Psychopathy assessed by the 20-item PCL-R instrument has attracted interest mainly in the area of risk prediction, but studies addressing its neuropsychologic [5], neurologic [6], [7], [8], and neurophysiologic [9], [10], [11], [12], [13] basis indicate that psychopathy may be a specific childhood-onset disorder of empathy and social functioning [14]. Personality disorders are not diagnosed in child and adolescent psychiatry. Aberrations in empathy, communicative skills, and executive control are instead captured by diagnostic definitions for the autism spectrum disorders, attention-deficit/hyperactivity disorder (AD/HD), learning disabilities, and tic disorders (including Tourette's syndrome) [15], [16]. In analogy with adult personality disorders having childhood precedents, these disorders have been found to carry an increased risk of adjustment problems and aggression in adulthood [2], [17], [18], [19], [20].
Common to personality disorders, AD/HD, autistic traits, and learning disabilities is that they may be regarded as categorical disorders or as extreme constellations of normally distributed traits [15], [21], [22], [23]. In the DSM-IV, personality disorders are defined as maladaptive patterns of cognitions, affects, interpersonal functioning, and impulse control that have caused psychosocial problems since adolescence. As indicated by the common features of these definitions, childhood-onset neuropsychiatric disorders and adult personality disorders may form a continuum describing the same underlying mechanisms in different terminologies. The erratic Cluster A personality disorders (paranoid, schizoid, and schizotypal) are thought to be related to psychotic disorders [24] or autism spectrum disorders [25], [26] and the phobic Cluster C disorders (avoidant, dependent, and obsessive-compulsive) to anxiety disorders [27], whereas the dramatic Cluster B disorders (histrionic, narcissistic, borderline, and antisocial personality disorders) clearly share core features with AD/HD [28]. The DSM-IV definition of antisocial personality disorder is mainly based on behavioral characteristics noted before the age of 15 years (CD) and continued into adulthood, whereas psychopathy, as first defined by Cleckley [29], describes a specific constellation of personality traits, including dominance-seeking (through the instrumental use of manipulation, cruelty, and fear) and deficits in emotional reactivity, attachment, purposefulness, and consistency.
To study the extent to which the features and problems assessed by the PCL-R correlate with DSM-IV diagnostic definitions of mental and personality disorders aiming at identifying possible unique features for psychopathy, we compared PCL-R ratings to independent ratings of childhood-onset neuropsychiatric disorders and adult psychiatric and personality disorders in perpetrators of severe crimes against other persons.
Section snippets
Subjects
With the approval of the Research Ethics Committee at Göteborg University, 100 consecutive informed and consenting subjects (92 men and 8 women, aged 17-76; median, 30 years) were recruited among all consecutive admissions to the Department of Forensic Psychiatry in Göteborg between 1998 and 2001. Participation required a basic Swedish education to ascertain sufficient language comprehension for diagnostic interviews and self-ratings. All were under prosecution for severe violent and/or sexual
Methods
Because subjects were free to determine the extent of their participation, the number of subjects varied somewhat between the different parts of the study. DSM-IV diagnoses were assigned in consensus by the first and senior author (HS and AF) on the basis of complete diagnostic work-up (described below), all records assembled for the investigation (school, welfare, and lifetime medical), and the forensic psychiatric investigation reports. The psychiatric, psychologic, and psychosocial
Results
The overall prevalence of mental disorders was high: 96% had one or several Axis I diagnoses, 43% fulfilled the criteria for mood disorders, 20% for psychotic disorders, 52% for substance abuse or dependence, and 26% for anxiety disorders.
Discussion
In this court-referred group of offenders, childhood and adult problems in regulating aggression, impulse control, and social interaction were common. Traits generally regarded as either “neuropsychiatric” or “personality” dysfunctions were closely linked and may describe common underlying phenomena. The problem constellation most closely associated with violent crimes, that is, AD/HD, CD/antisocial personality disorder, and the behavioral and emotional facets of psychopathy (as reflected by
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 design may allow, however, is to trace lifetime patterns not discernable by other methods, as detailed mapping of a broad range of clinical conditions is not possible in prospective population-based groups when studying relatively rare phenomena such as autism and violence.
Acknowledgments
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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