Citation for published version (APA): Timmerman, I. G. H. (2004). Violent behaviour : aetiology and treatment issues

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1 UvA-DARE (Digital Academic Repository) Violent behaviour : aetiology and treatment issues Timmerman, I.G.H. Link to publication Citation for published version (APA): Timmerman, I. G. H. (2004). Violent behaviour : aetiology and treatment issues General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam ( Download date: 19 Dec 2017

2 Chapterr 5 Thee prevalence and comorbidity of Axis I and Axis II pathology in a groupp of forensic patients Summary y Inn the present study the prevalence of a broad range of DSM-HI-R Axis I disorders (Compositee International Disorder Interview) and all Axis II disorders (International Personalityy Disorder Examination) was determined with standardized semistructuredd interviews in a group of 39 male forensic inpatients. Substance abuse (75.7%),, mood (51.3%) and anxiety (40.3%) disorders were the most prevalent Axis II disorders. As to Axis II disorders, 86.8% received a personality disorder most often fromfrom the B cluster. A high percentage of the subjects received the diagnosis 'personalityy disorder not otherwise specified' (42.1%). There was a high level of comorbidityy of mood and anxiety disorders with personality (61%) and substance abusee disorders (47%) respectively. Compared to prevalence rates of the disorders in thee general population the prevalence rates of the separate disorders found among thesee forensic subjects were much higher. Additional analyses on subjects with an antisociall personality disorder diagnosis versus subjects with other personality disorderr diagnoses showed that the former had significantly more traits of the borderlinee and sadistic personality disorder. The results of the present study emphasizee the importance of the use of standardized diagnostic instruments and the assessmentt of a broad range of disorders. ** This chapter is a slightly adjusted version of Timmerman, I.G.H. & Emmelkamp, P.M.G. (2001). The prevalence andd comorbity of Axis I and Axis Ildisorders in a group of forensic patients. International Journal of Offender TherapyTherapy and Comparative Criminoloy, 45 (2),

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4 PrevalencePrevalence of Axis I and Axis II disorders 5.11 Introduction Studiess on the prevalence of mental disorders and the comorbidity of mental disorders,, using standardized instruments, are rare. Most studies on the psychopathologyy among forensic patients and prison samples have not focused on thee whole range of disorders but only on certain types of pathology: only on Axis I or Axiss II (American Psychiatric Association, 1987, 1994), only on psychotic symptomss or antisocial/borderline personality disorders or only on primary diagnoses.. Inn prison samples substance abuse disorders were found to be the most prevalentt current mental disorders (Abram and Teplin, 1991; Bulten, 1993; DeJong, Virkunnenn and Linnoila, 1992; Eronen, Hakola and Tiionen, 1996; Holley, Arboleda-Florezz and Love, 1995; Smith, O'Neill, Tobin, Walshe and Dooley, 1996; Schoemakerr and van Zessen, 1997), though the rates that were found varied considerablyy across studies, rangingfrom39% to 89%. In the studies in which one or moree personality disorders were assessed, prevalence rates of personality disorders weree found rangingfrom34% to 60% (Hare, 1983; Abram et al, 1991; Bulten, 1993; DeJong,, Virkunnen and Linnoila, 1992; Eronen et al, 1996). However, in a group of life-sentencedd prisoners, 63% did neither meet the criteria for a mental illness nor for aa personality disorder according to ICD-9 classification; prevalence rates for substancee abuse and personality disorders were rather low, 9% and 8.3% respectively (Swinton,, Maden and Gunn, 1994). Studies, reporting on lifetime diagnoses showed aa similar pattern as the studies in which current diagnoses were reported (Cöté and Hodgins,, 1992; Abram et al, 1991). Prevalence rates of the comorbidity of disorders alsoo varied across studies. Studiess among homicide recidivists in Finland and Sweden showed a high morbidityy and comorbidity of personality disorders and severe alcoholism (Tiihonen andd Hakola, 1994; Adler and Lidberg, 1995). However, the samples in these studies aree small, and therefore generalization of the results is limited. Thee above studies all refer mainly to male prisoners. Studies conducted solely inn female samples showed that substance abuse disorders and antisocial and borderlinee personality disorders are common (Jordan, Schlenger, Fairbank and Caddell,, 1996; Teplin, Abram and McClelland, 1996). Further, mood and posttraumaticc stress disorders were over-represented in these samples, when compared to thee general female population. Thee difference in prevalence of Axis I and Axis II disorders among the various studiess can partly be accounted for by assessment instruments used (self-report questionnairee versus (unstructured interview versus record survey), the diagnostic classificationn system used (various versions of DSM and ICD) and the reporting on onlyy primary diagnosis versus all diagnoses. Further, the differences in prevalence ratess of mental disorders between studies may also reflect different policies toward treatingg or detaining offenders in various countries. In a number of countries, (some) mentallyy disturbed offenders are treated or detained in special hospitals. 7

5 ChapterChapter 5 Ass far as special hospitals are concerned two studies reported prevalence rates off Axis I and Axis II disorders based on record survey. Record survey of patients in speciall hospitals in England revealed that according to ICD-10 classification, 58% of alll patients had a psychotic disorder; 41 % had a personality disorder, 9.6% had a substancee abuse/dependency disorder and 3.2% a neurotic disorder (Taylor, Leese, Williams,, Daly and Larkin, 1998). Of the patients with a personality disorder, 59% hadd a comorbid Axis I disorder. A record survey of patients in forensic settings in the Netherlandss revealed that patients were most frequently diagnosed with personality disorderss (75%), substance abuse disorders (44%) and psychotic disorders (30%). It iss estimated that in about 59% of the forensic patient population, Axis I and Axis II disorderss co-occur (van Emmerik, 1993,1995). Inn a group of male forensic inpatients with antisocial personality disorder in the USA,, high rates of avoidant, borderline and passive-aggressive personality pathology wass reported using the Millon Clinical Multiaxial Inventory- II (MCMI-II) (Hillbrand,, Kozmon and Nelson, 1996). Sofar,, only a few studies have used structured interviews to assess either Axis I orr Axis II pathology in specific populations. In a Dutch study among forensic inpatients,, 80% of the sample had at least one current personality disorder diagnosis accordingg to the Structured Interview of personality disorders (SIDP-R) (Greeven, 1997).. The co-occurrence of personality disorders was high. In a sample of adolescentt male sexual offenders high prevalence rates of current anxiety disorder (41%),, mood disorders (31%), borderline personality disorder (35-72% depending on thee measure) and conduct disorder (79%) were found using standardized diagnostic interviews,, amongst which the Structured Clinical Interview for DSM-III-R personalityy disorders (SCID-II) and the Millon Adolescent Personality Inventory (MAPI)) (Shaw, Applegate and Rothe, 1996). In a study among paedophilic patients evenn higher prevalence rates were found for current mood (67%) and anxiety (64%) disorders;; 60% had a substance abuse disorder (Raymond, Coleman, Ohlerking, Christensonn and Miner, 1999). Further, 93% of the subjects had at least one Axis I disorderr and 60% met the criteria of a personality disorder, which implies a high comorbidityy of Axis I and Axis II pathology. The diagnoses in this study were based onn the Structured Clinical Interview for DSM-IV (SCID). Inn the present study a sample of 39 forensic psychiatric patients was studied. Thee patients were hospitalized in a forensic psychiatric clinic in the Netherlands. Crimess involved are serious crimes: murder, manslaughter, repeated armed robbery, arson,, rape and child molesting. Thee following questions were addressed in this study. Firstly, what are the prevalencee rates of Axis I and Axis II disorders? Secondly, what is the prevalence ratee of the comorbidity of Axis I and Axis II disorders? Thirdly, do patients with an antisociall personality disorder diagnosis differ from patients with other personality disorderr diagnoses, with respect to personality traits and Axis I pathology? Fourthly, howw strong is the association between personality disorders within the same cluster? 7

6 PrevalencePrevalence of Axis I and Axis II disorders 5.22 Method Subject - In the Netherlands, offenders of serious crimes whose criminal acts aree regarded as being related to a mental disorder or illness and for whom the risk of re-offendingg is regarded high when untreated for this mental disorder, can be imposedd involuntary institutionalisation by the court. This is called a 'Ter Beschikkingg Stelling van de Staat (TBS)' order. Every two years the court decides whetherr or not the TBS should be prolonged with one or two years. The aim of treatmentt is to reduce the risk of re-offending. Most patients serve a limited sentence inn prison before they are hospitalized. Subjectss in the present study were patients of the Forensic Psychiatric Centre Veldzicht,, who participated voluntarily in a treatment outcome study. A thorough psychologicall and psychiatric assessment was done after admittance to the clinic. Subjectss who were not able to participate were excluded from the study: psychotic, severelyy confused, or unable to concentrate. The mean age of the subjects was 34.5 yearss (Sd= 11.4, range 20-70). Eighty-five percent had an educational level below highh school. Global indications of the type of offences committed are: 33.3% sexuall aggressive, 17.9% arson and 48.7% violent Procedure - The study was conducted confidentially and anonymously: the researchh data were not allowed to be used for treatment or in court. Since most patientss were very suspicious towards therapists, especially when they entered the treatmentt centre, it was expected that under these conditions, patients would be moree willing to participate and would give more straight information about themselves,, knowing that the information could not be used 'against' them. Afterr admittance to the clinic patients were individually informed about the researchh project. Participation was voluntarily and patients willing to participate signedd an informed consent. At baseline, two (semi-) structured interviews were conductedd to assess Axis I and Axis II pathologies. Interviewers were clinical psychologists,, extensively trained and certified for conducting the interviews Measures - The International Personality Disorder Examination (IPDE) (Worldd Health Organization, 1993; Diekstra, Duijsens, Eurelings-Bontekoe and Ouwersloot,, 1993) is a semi-structured interview with which all DSM-III-R as welll as ICD-10 personality disorders are assessed. Categorical as well as dimensionall scores can be obtained. The criteria are scored as either absent (0), probably presentt (1) and present (2). The presence of a criterion has to be confirmed by exampless that demonstrate the patient's behaviour, and this behaviour must have beenn present during at least the preceding five years. A dimensional personality disorderr score is obtained by summation of all scores on the criteria the personality disorderr consists of. In the present study only the DSM-III-R diagnoses are reported.. Subjects with 10 or more positively scored criteria, who do not meet the criteriaa of a specific personality disorder, are given the diagnosis 'not otherwise 75 5

7 ChapterChapter 5 specified'' (NOS). A probable diagnosis is given when the minimally required numberr of criteria for a positive diagnosis but one, are found. TheThe Composite International Disorder Examination (CIDI) (World Health Organization,, 1990; Smeets and van den Ham, 1994) is a fully structured interview forr the assessment of lifetime psychiatric disorders according to DSM-III-R and ICD-100 criteria. The CIDI is derived from the Diagnostic Interview Schedule (DIS) andd the Present State Examination (PSE) and is the result of years of international collaborationn between several institutes and experts. The CIDI assesses current as welll as past or lifetime Axis 1 disorders. In the present study the following disorders accordingg to DSM-III-R criteria are assessed: somatoform disorder, anxiety disorders,, depressive disorders, schizophrenia, schizophreniform disorder, schizoaffectivee disorder, obsessive compulsive disorder, alcohol abuse and dependence,, psychoactive substance abuse disorders and organic mental disorders. Thee CIDI has good psychometric qualities (e.g. Bijl, van Zessen, Ravelli, de Rijk and Langendoen,, 1997) Statistical analyses - Descriptive statistics were applied to determine the prevalencee rates of Axis I and Axis II disorders and of the comorbidity of Axis I and Axiss II disorders. Since the dimensional personality disorder scores were not normallyy distributed, Mann-Whitney U tests were used to determine if patients with ann antisocial personality disorder diagnosis differed from patients with other personalityy pathology. In order to reduce the risk of chance-capitalization, Bonferronii correction (Stevens, 1986) was used for the Mann-Whitney U tests. Chisquaree tests were applied to investigate whether patients with an antisocial personalityy disorder diagnosis differedfrompatients with other personality pathology withh respect to substance abuse/dependency disorders. Finally,, to determine if the personality disorders are clustered according to the DSM-III-RR cluster typology, Spearman rank correlations (rho's) were calculated betweenn the dimensional scores of the personality disorders. 533 Results Inn Table 5.1 the lifetime and current prevalence rates of Axis I disorders are reported. Twoo patients were excluded from the analyses, due to missing data. Substancee abuse and dependence disorders were the most frequently diagnosedd lifetime Axis I disorders (75.7%). Affective disorders and anxiety disorderss were also prevalent among the subjects. Thirteen subjects (35,1%) also had aa diagnosis for simple phobia. This disorder, however, was considered a minor disorderr and is therefore omittedfromthe tables. Elevenn patients (29,7%) had lifetime abuse or dependence disorders without thee presence of any other Axis I disorder. This means that 65% of the sample had at leastt one lifetime Axis I disorder other than substance abuse or dependence. As expectedd the prevalence rates of the current Axis I diagnoses were much lower than thosee of lifetime Axis I diagnoses. 76 6

8 PrevalencePrevalence of Axis I and Axis II disorders Tablee 5.1 Number (andd r percentages) of DSM-IH-R Axis I diagnoses (N=37) Disorder r Lifetime e Current t Organicc brain syndrome Schizophrenicc disorder Anyy affective disorder Dysthymia a Majorr depression Bipolarr disorder Anyy anxiety disorder (513) ) (29.7) ) (35.1) ) (5.4) ) (405) ) (243) ) (13.5) ) (13.5) ) (29.7) ) Generalizedd anxiety disorder 5 (13.5) ) (10.8) ) Agoraphobia a Panicc disorder Sociall phobia Obsessivee compulsive disorder r Anyy substance abuse/dependency y Alcoholl dependence Alcoholl abuse Sedativee dependence Anyy drug dependence Opiod d Cocaine e Hallucinogen n Amphetamine e Pep p Inhalant t Psychoactive e Anyy drug abuse Cocaine e Hallucinogen n Opiod d Cannabiss dependence Cannabiss abuse Noo disorder (18.9) ) (8.1) ) (21.6) ) (5.4) ) (75.7) ) (40.5) ) (29.7) ) (16.2) ) (27.0) ) (16.2) ) (24.3) ) (5.4) ) (8.1) ) (8.1) ) (8.1) ) (21.6) ) (5.4) ) (162) ) (5.4) ) (10.8) ) (10.8) ) (5.4) ) (5.4) ) (8.1) ) (54.1) ) Inn Table 5.2 the number of lifetime and current Axis I disorder diagnoses are reported,, with and without substance abuse and dependency disorders. For this purposee all substance abuse and dependency disorders were regarded as one disorder. Inn Table 5.3 the nature of the lifetime (comorbid) Axis I disorders are reported. Thee highest degree of comorbidity exists with substance use related disorders. In Tablee 5.4 the type of comorbid disorders of the substance abuse disorders are reported

9 ChapterChapter 5 Tablee 5.2 Numberr of lifetime and current Axis I disorders with and without abuse/dependency (N=37) Numberr of Axis I Without substance Including substance Disorderss Abuse/dependence abuse/dependence Lifetime e Current t Lifetime e Current t >5 5 Mean n Sd d Note:: (1.3) ) (1.3) ) (2.0) 1.6(1.2) ) The values in parentheses refer to all patients, except the patient with 7 respectively 8 disorders Tablee S3 Typee of (comorbid) Axis I disorders (N=37) Disorders s Number r Noo Axis I disorder 2 Onlyy substance abuse/dependency disorders 11 Onlyy affective disorders 1 Onlyy anxiety disorders 3 Onlyy affective and anxiety disorders 3 Substancee abuse/dependency and any other Axis I 17 disorder r Tablee 5.4 Substancee abuse/dependence and comorbid Axis I lifetime disorders (N=17) Comorbidd Disorders) Number r Onlyy affective Onlyy anxiety Affectivee and anxiety Affective,, anxiety and organic Affective,, anxiety and schizophrenia Thee comorbidity between lifetime substance abuse/dependence disorders on thee one hand and lifetime affective disorders and lifetime anxiety disorders on the otherr hand was 88% and 59% respectively. Inn Table 5.5 the frequencies of patients with a personality disorder that were foundd with the IPDE are reported. One patient is left out of the analyses due to missingg data. 78 8

10 PrevalencePrevalence of Axis I and Axis II disorders Tablee 5.5 Frequencyy of IPDE personality disorders, probable diagnoses, mean number of traite and mean dimensionall score Personality y Positive e Probable e Meann number of Meann dimensional disorder r diagnosis s diagnosis s traits s (range) ) score e (range) ) Paranoid d Schizotypal l Schizoid d Borderline e [7.9] ] [10.5] ] [10.5] ] [2.6] ] [5.3] ] [10.3] ] 1. (0-5) ) (0-4) ) 0. (0-3) ) (0-6) ) (0-11) ) 3. (0-9) ) (0-7) ) (0-12) ) Antisocial l 1 [36.8] ] 5 5 [13.2] ] beforee age 15 sincee age 15 Narcissistic c Histrionic c Avoidant t Dependent t 18 8 [47.4] ] 2 [55.3] ] [2.6] ] [10.5] ] [13.2] ] [5.3] ] [15.8] ] [10.5] ] [2.6] ] (0-11) ) (0-9) ) 1. (0-6) ) 1. (0-3) ) (0-3) ) (0-4) ) (0-22) ) (2-19) ) 4. (0-13) ) 3. (0-10) ) 2. (0-8) ) 2. (0-9) ) Obsessivee compulsive (0-3) ) (0-8) ) Passivee Aggressive Self-defeating g Sadistic c NOS S 5 5 [13.2] ] 16 6 [42.1] ] [5.3] ] [5.3] ] (0-3) ) (0-4) ) 1. (0-6) ) (11-20) ) 2. (0-8) ) 2. (0-8) ) (0-12) ) 37. (28-55) ) Noo disorder 5 5 [13.2] ] T7.9 Note:: NOS = Not Otherwise Specified; Mean number of traits and the dimensional score on NOS are reported onlyy for those subjects who do not meet the criteria of a specific personality disorder; Probable diagnosis = requiredd number of traits for a positive diagnosis minus one; percentages in brackets. Ass expected, most personality disorders were found in cluster B, followed by clusterr A. The most frequently diagnosed specific personality disorder was the antisociall personality disorder, followed by the sadistic, the borderline and the paranoidd personality disorder. Sixteen patients had positive scores on 10 or more IPDEE criteria, but did not meet the criteria of a specific personality disorder. These patients,, labelled with the personality disorder 'Not Otherwise Specified, most frequentlyfrequently enhanced traits from the antisocial, borderline, avoidant and dependen personalityy disorder. Besides positive personality disorder diagnoses, the probable personalityy disorder diagnoses are also listed in Table 5.5. The number of probable diagnoses,, which were found mainly in the B and A cluster, is 33. Sixx patients met the criteria of more than one personality disorder (Table 5.6). Off these patients, two met the criteria of the paranoid, antisocial and sadistic personalityy disorder, one of the antisocial, narcissistic and sadistic personality disorder,, one of the antisocial, borderline and sadistic personality disorder, one of the antisociall and borderline personality disorder and one of the antisocial and sadistic personalityy disorder. 79 9

11 ChapterChapter 5 Tablee 5.6 Numberr (and percentages) of personality disorders Personalityy disorders Alll disorders without NOS 21 (55.3) 11 (28.9) 2 (5.3) Alll disorders including 5 (13.2) 27 (71.1) 2 (5.3) NOS S Note:: NOS = Not Otherwise Specified (10.5) ) (10.5) ) AA high degree of comorbidity between lifetime Axis I and Axis II pathologies wass found (Table 5.7): 89% of the patients with a personality disorder diagnosis, had att least one lifetime Axis I diagnosis. Sixteen patients met the criteria of one or more specificc personality disorder and of one or more lifetime Axis I disorders. Further, ninee patients met the criteria of a personality disorder 'Not Otherwise Specified' and off one or more lifetime Axis I disorders. Five patients did not meet the criteria of a personalityy disorder, but did meet the criteria of one or more lifetime Axis I disorder (seee Table 5.7).. Tablee 5.7 Comorbidityy between personality disorders and lifetime psychiatric disorders (N=36) Comorbidityy of disorders AH Axis I disorders Only abuse/dependency disorders s Noo Axis I and Axis II disorders Axiss I and no Axis II disorder Axiss I and specific Axis II disorder r Axiss I and NOS Axis II disorder Note:: Lifetime e 22 (6) 22 (6) 166 (44) Current t 22 (6) 99 (25) 166 (44) 77 (19) Percentages in parentheses; NOS = Not Otherwise Specified Lifetime e 11 (3) 33 (8) 77 (19) Current t 22 (6) 11 (3) Inn order to determine differences between patients with an antisocial personalityy disorder and other personality disorders, the following groups were comparedd (see Table 5.8): (1) antisocial personality disorder (2) any personality disorderr other than the antisocial personality disorder, including NOS; and (3) no personalityy disorder. Inspection of Table 5.8 reveals that, as expected, the 'no personalityy disorder' group scored lower than the other two groups on nearly all dimensionss of personality disorders. No significant differences were found between thee antisocial group and the 'other personality disorder' group with respect to the numberr of Axis I diagnoses and the percentages of subjects with substance abuse disorders.. Comparisons of dimensional personality scores between both groups, usingg Mann-Whitney U tests, however, showed that the former has significantly moree antisocial pathology before the age of 15 (U=19.5, p <.0001) and after (U=30.0,, p <.0001) the age of 15 and also more sadistic pathology (U=37, p <.0004).. Both groups did not differ significantly on the borderline and narcissistic 8

12 PrevalencePrevalence of Axis I and Axis II disorders dimensionall personality scores, but there was a trend, with the antisocial group havingg more borderline (U=64.5, p <.02) and narcissistic (U=76.5, p <.06) pathology.. Tablee 5.8 Axiss I disorders and dimensional personality disorder scores among two personality disordered groupss and a non-personality disordered group (N=36) Meann Axis I disorders w/oo abuse/dependency Abuse/dependence e Alcohol l Cannabis s Sedative e Harddrug g Paranoid d Schizotypal l Schizoid d Borderline e Antisociall < 15 years Antisociall > 15 years Narcissistic c Histrionic c Avoidant t Dependent t Obsessivee compulsive Passivee aggressive Selff defeating Sadistic c Total l Antisociall (N=14) 2.4/2.0* * 1.6/1.2* * ) l) 12.66» 5.2 3) ) } } 64.6!) ) [86] ] [79] ] [43] ] [29] ] [53] ] (3.2) ) (3.0) ) (1.5) ) (2.6) ) (5.6) ) (3.1) ) (3.3) ) (2.9) ) (2.2) ) (2.3) ) (1.9) ) (2.6) ) (2.0) ) (3.5) ) (19.3) ) OtherPD(N=18) ) [72] ] [72] ] [17] ] [11] ] [17] ] (2.8) ) (2.0) ) (1.9) ) (2.9) ) (3.8) ) (3.7) ) (2.3) ) (2.2) ) (2.5) ) (2.5) ) (2.1) ) (1.5) ) (2.3) ) (2.2) ) (12.5) ) NoPD D (N=4) ) [50] ] [25] ] 1. [25] ] 1. (0.8) ) 2. (3.4) ) (1.0) ) (1.2) ) (3.1) ) 5. (3.2) ) (3.7) ) (2.4) ) 1. (1.4) ) 1. (1.2) ) (1.0) ) (0.6) ) 0. (0-5) ) 1. (1.2) ) (8.0) ) Note:: percentages in brackets, standard deviations in parentheses; * in the second mean scores, the personn with 8 respectively 7 disorders is excluded; Mann - Whitney U tests between antisocial groupp and 'other personality disorder' group: 1} sign, at.003 (Bonferroni corrected), 2) sign, at.02, ^^ sign, at.06 Inn Table 5.9 the correlations between the dimensional scores on the personalityy disorders are shown. The sadistic personality disorder correlated positivelyy with all the personality disorders from the B cluster (except with the narcissistic)) as well as with the paranoid and passive aggressive personality disorder. Off all three clusters, the strongest association of personality disorders were found in thee B- cluster. 8

13 ChapterChapter 5 Par r Sty y Sid d Bor r Cd d As s Nar r His s Avo o Dep p Obc c Pas s Tablee 5.9 Spearmann correlations between dimensional IPDE personality disorder scores Parr Sty Sid Bor Cd As Nar His Avo Pep Obc Pas Sde Sad Nos A A.6.6 B B C C.4 Sdee -.59 Sadd -.55 Nos s Note:: Par = Paranoid, Sty = Schizotypal, Sid = Schizoid, Bor = Borderline, Cd = Conduct disorder, As = Adult antisocial,, Nar = Narcissistic, His = Histrionic, Avo = Avoidant, Dep = Dependent, Obc = Obsessive compulsive,, Pas = Passive aggressive, Sde = Self defeating, Sad = Sadistic, Nos = Not otherwise specified. Onlyy significant correlations are reported. Correlations >.50 are significant at.001, correlations <.51 are significantt at.01. A = cluster A, B = cluster B, C = cluster C Discussion Inn the present study psychiatric disorders and personality disorders according to DSM-III-RR criteria were assessed in a group of 39 hospitalized, mentally disturbed offenderss who participated voluntarily in the study. Axis I disorders were assessed withh the CIDI, a fully structured interview. Valid data were obtained from 37 subjects.. Personality disorders were assessed with the IPDE. Valid data were obtainedd from 38 subjects. Comparisonss of CIDI prevalence rates of Axis I disorders between the present groupp and the Dutch general male population (Bijl, van Zessen and Ravelli, 1998) revealedd that in the present group the lifetime prevalence of at least one Axis I diagnosiss was more than twice as high (94.6% versus 42.5%). Affective and anxiety disorderss are present in about 13 to 14 percent of the male general population. In the presentt group these rates were higher, 51 respectively 41 percent. Lifetime substance abusee and dependency disorders are present in 30% of the general male Dutch population,, compared to 76% in the present group. The picture that emerges from thesee comparisons is that all Axis I disorders were more prevalent in the present groupp than in the general population and that the most prevalent disorders in both groupss are substance abuse disorders. This finding is consistent with most other studiess in forensic groups which also found substance abuse disorders to be the most frequentlyfrequently diagnosed disorders (i.e. Eronen et al, 1996, DeJong et al, 1992; v Emmerik,, 1995). 8

14 PrevalencePrevalence of Axis I and Axis II disorders Aboutt more than half of the subjects in this sample (51%) had a lifetime diagnosiss of an affective disorder, which is higher than most other studies on prison orr forensic patient samples have found (i.e. Coté et al, 1992, Taylor et al, 1998). The presentt results corroborate the results of a study by Abram and Teplin (1991). They found,, also based on structured interviews, similar prevalence rates of co-occurrence off substance abuse/ dependency disorders and other severe lifetime mental disorders inn a mentally ill jail population, as in the present study. AA high proportion of the subjects (87%) was characterized by personality pathologyy according to the IPDE. Of the 33 subjects with one or more personality disorderr diagnoses, 17 met the criteria of one or more specific personality disorder. Ass was expected, the antisocial personality disorder appeared to be the most frequentlyfrequently diagnosed disorder, followed by the sadistic, borderline and paranoid personalityy disorder. The remaining sixteen subjects had a personality disorder diagnosiss 'not otherwise specified'. The most frequently endorsed traits in this categoryy were traits from the B and C cluster. Additionally, 33 probable personality disorderr diagnoses were found, mainly from cluster B, followed by cluster A. The factt that the IPDE criteria were scored very stringently might have led to an underestimationn of the true level of personality disorder pathology in this study. If a patientt confirmed a character trait, but was unable to give examples of situations, demonstratingg this trait, the criterion was scored as absent. In order to be able to give clearr examples requires an ability of the patient to reflect on his behaviour in differentt situations. Not all patients were able to do so, also because most patients functionn on an intelligence level below average. Thee percentage of patients with a personality disorder, however, is similar to thee percentage given by van Emmerik (1993) for all forensic TBS patients, which is basedd on hospital records, rather than on structured interviews. However, the frequencyfrequency of specific personality disorders in the present study is low (45%) as comparedd to the findings of Greeven (1997), who found that 80% of a sample of the TBSS population met the criteria of at least one specific personality disorder accordingg to SIDP-R. In the Greeven study, however, the interviewers also used informationn obtainedfromofficial medical and judicial records, whereas in this study interviewerss were kept blind with respect to this information. In contrast, the informationn on personality disorders in the present study was obtained from the patientss themselves, and not from informants, which might have led to an underestimationn of the real personality pathologies in some individuals. On the other hand,, since the present study was conducted anonymously and confidentially (patientss knew that clinicians or court judges did not have insight into the informationn obtained in this study) we felt that most patients were rather honest in theirr responses. Thee comorbidity between lifetime Axis I and Axis II disorder diagnoses was ratherr high (89%). As expected, the comorbidity between current Axis I and II disorderr diagnoses was lower, namely 44%. 8

15 ChapterChapter 5 Comparisonss between patients with an antisocial personality disorder and with otherr personality disorders snowed that the antisocial group had significantly more traits,, not only of the antisocial but also of the sadistic personality disorder. Further, theree is a trend that the antisocial group had more borderline and narcissistic traits, butt the differences were not statistically significant. These findings give to some extentt support to the concept of a criminal personality and psychopathy of Wulach (1988)) which is comprised of the traits of the antisocial, borderline, narcissistic and histrionicc personality disorder. As in the study in male forensic patients of Hillbrand, Kozmonn and Nelson (1996), borderline and narcissistic pathologies were found to coexistt in antisocial individuals, but for the histrionic pathology support was lacking. Inn a study into gender differences (Hamburger, Lillienfield and Hogbon, 1996), psychopathicc females were found to have more histrionic traits than males, whereas psychopathicc males had more antisocial traits than females. The finding that in the presentt sample no differences between both personality-disordered groups were foundd on histrionic traits may be ascribed to the fact that the sample consisted only of men.. Thee finding that in the present study the antisocial group also had significantlyy more traits of the sadistic personality disorder lends even more supportt to the hypothesis that a combination of traits refers to the concept of psychopathy.. Perhaps it was premature to skip the sadistic personality disorder fromfrom DSM-IV, since in forensic samples this disorder may supply additional informationn on the severity of the pathology, the dangerousness of the patient and off his treatability. For example, antisocial individuals with sadistic personality traitss might be more dangerous or difficult to treat than antisocial individuals withoutt these traits. In a study among sex offenders, 27.2% met the criteria of a sadisticc personality disorder (Berger, Berner, Bolteraurer, Gutierrez and Berger, 1999).. The authors suggested on the basis of their findings that the sadistic personalityy disorder may be seen as an important subdimension of antisocial personalityy disorder, distinct from more exploitative forms of antisocial behaviour withh less violence. Stuart,, Battaglia, Bellodi, Grove and Cadoret (1998) demonstrated strong associationss between personality disorders within the same cluster of personality disorders.. In the present study correlations of the dimensional personality disorder scoress showed a similar pattern of associations for the B cluster as found by Stuart: thee antisocial personality disorder was correlated significantly only with the borderlinee personality disorder; the other personality disorders from the B cluster weree relatively strongly correlated with each other except for the borderline and narcissisticc personality disorder. In the present study no clear correlation patterns weree found within cluster A and C. Thee results from the present study show that studies on the prevalence of mentall disorders among forensic samples should not only focus on Axis I pathology orr on personality disorders but on both, and also on the comorbidity of Axis I and Axiss II disorders. Further it is preferable that standardized diagnostic instruments are 8

16 PrevalencePrevalence of Axis I and Axis II disorders usedd that are psychometrically healthy, since clinical diagnostic assessment was foundd to be unreliable (Belfrage and Lidberg, 1996; Bergman, Belfrage and Grann, 1999).. Thee present study has several limitations. The sample size is relatively small, soo generalisation of the findings is limited. Some of the most severely disturbed patientss were excluded from the study, because they were unable to participate, due too a florid psychosis or limited mental capacities. This implies that on average the prevalencee of psychopathology of the patients in the clinic as a group may be higher thann is reported in this study. 85 5

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