Centre de Recherche en Défense Sociale, Tournai, Belgium b University UMONS, Belgium c Centre de Recherche en Défense Sociale,

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1 This article was downloaded by: [Pham, Thierry H.] On: 19 November 2010 Access details: Access Details: [subscription number ] Publisher Routledge Informa Ltd Registered in England and Wales Registered Number: Registered office: Mortimer House, Mortimer Street, London W1T 3JH, UK International Journal of Forensic Mental Health Publication details, including instructions for authors and subscription information: PCL-R Psychopathy and its Relation to DSM Axis I and II Disoders in a Sample of Male Forensic Patients in a Belgian Security Hospital Thierry H. Pham ab ; Xavier Saloppé c a Centre de Recherche en Défense Sociale, Tournai, Belgium b University UMONS, Belgium c Centre de Recherche en Défense Sociale, Online publication date: 19 November 2010 To cite this Article Pham, Thierry H. and Saloppé, Xavier(2010) 'PCL-R Psychopathy and its Relation to DSM Axis I and II Disoders in a Sample of Male Forensic Patients in a Belgian Security Hospital', International Journal of Forensic Mental Health, 9: 3, To link to this Article: DOI: / URL: PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: This article may be used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.

2 INTERNATIONAL JOURNAL OF FORENSIC MENTAL HEALTH, 9: , 2010 Copyright C International Association of Forensic Mental Health Services ISSN: print / online DOI: / PCL-R Psychopathy and its Relation to DSM Axis I and II Disoders in a Sample of Male Forensic Patients in a Belgian Security Hospital Thierry H. Pham Centre de Recherche en Défense Sociale, Tournai, Belgium and University UMONS, Belgium Xavier Saloppé Centre de Recherche en Défense Sociale Downloaded By: [Pham, Thierry H.] At: 13:27 19 November 2010 The purpose of this study was to examine the relationship between the psychopathy, assessed using the PCL-R, and DSM Axis I and II disorders in a Belgian adult male forensic patients (N = 84). Regarding Axis I disorders, diagnoses of psychopathy were associated only with diagnoses of substance abuse/dependence. Regarding Axis II disorder, psychopathy diagnoses were associated with antisocial personality disorder. This relationship was asymmetrical, as psychopathy was highly predictive of antisocial personality disorder but not vice versa. Furthermore, there was a significant positive association between antisocial personality disorder and PCL-R total scores, Factor 1 and 2 scores, and Facet 1, 3, and 4 scores. There was also a significant positive correlation between narcissistic personality disorder and PCL-R Factor 1 and Facet 1 scores. These findings are congruent with the international research literature and have potential therapeutic relevance, as Cluster B disorders including antisocial personality disorders are associated with low treatment motivation and compliance (Widiger & Corbitt, 1997; Robins, Tipp, & Przybeck, 1991). Overall, diagnoses of psychopathy were rather specific and unrelated to most major mental disorders (psychoses, mood or anxiety disorders) and personality disorders (Clusters A and C). Keywords: forensic patients, major mental disorder, personality disorder, psychopathy, PCL-R INTRODUCTION Psychopathy is one of the most frequently formulated diagnoses in forensic psychiatry (Pham & Saloppé, 2006). In Belgium, however, recent changes in the judicial environment are challenging the place of psychopathy under the Social Defence Law, which applies to persons recognized Address correspondence to Thierry Pham, CRDS, 94, rue Despars, (7500) Tournai, Belgique ( Thierry.pham@crds.be. This study was made possible with the support of the Equal Opportunities Office of the Social Action and Health Division of the Belgian Ministry for the Walloon Region. The authors thank the medical, paramedical, and nursing staff of the Les Marronniers Hospital (Tournai, Belgium) for their collaboration. as incapable of controlling their actions owing to mental illness (Pham, Saloppé, Bongaert & Hoebanx, 2007; Beernaert, Tulkens & Vandermeersch, 2007). The Social Defence Law embraces a very large spectrum of psychiatric diagnoses including personality disorders and psychopathy. In an early study, Pham et al. (2007), found that forensic patients presented a high co-morbidity of Axis I syndromes, and of Axis II personality disorders. The majority of patients presented both Axis diagnoses. The prevalence of a high psychopathy scores as measured by the PCL-R (Hare, 2003) among internees was between 5 and 8%. However, these earlier data on the Axis I, Axis II diagnoses and psychopathy prevalences did not consider the relations between diagnoses and different factors and facets of psychopathy.

3 206 PHAM & SALOPPÉ Operational Definition The definition of psychopathy has undergone major changes for more than a century (Côté, 2000). In the past few decades, the operational definition that seems to enjoy the most solid empirical support rests on Hare s Psychopathy Checklist (PCL; Hare, 1991, 2003). In its revised version (PCL-R), the instrument comprises 20 items (Hare, 1991, 2003). It is characterized for two main factors composed of 18 items, of which two do not load on either factor. The first factor covers affective, interpersonal, and narcissistic components (Factor 1); the second factor focuses on the propensity to chronic antisocial behavior (Factor 2). In the literature (Côté, Hodgins & Toupin, 2000), the scores yielded by the instrument have been considered either in terms of categories or on a continuum, depending on whether the research undertaken was comparative or linear in nature, although recent data insist on the dimensional nature of the concept (Edens, Marcus, Lilienfeld & Poythress, 2006; Guay, Ruscio, Knight & Hare, 2007). Where the category approach is concerned, Hare (1991, 2003) and colleagues proposed that the psychopathy diagnosis be established on the basis of a score of 30 or more. This cut-off necessarily implies that the person presents both highly interpersonal/affective traits and chronic antisocial behaviors. However, this point should not be considered as an absolute value. In fact, it is at the center of major discussions regarding potential intercultural variations (Cooke, 1995, 1998), taxonometric analyses (Guay et al., 2007; Edens et al., 2006; Harris, Rice & Quinsey, 1994) and the psychometric refinement of the concept (Cooke & Michie, 2001). The PCL-R s final factor structure is presently a matter of intense debate between two camps. On the one side, there are those who prefer a slimmer version of psychopathy composed of 13 criteria under three factors: (1) interpersonal, (2) affective, and (3) impulsive (Cooke & Michie, 2001; Cooke, Michie, Hart, & Clark, 2004; Cooke, Michie, Hart, & Clark, 2005). On the other, there are those who remain true to the original 20 criteria under four facets: (1) interpersonal, (2) affective, (3) impulsive and (4) antisocial behavior (Hare, 2003; Hare & Neumann, 2005; Neumann, Vitacco, Hare, & Wupperman, 2005). The difference between the two models resides in the importance given to the criteria measuring antisocial behavior. Cooke and colleagues consider these criteria to constitute secondary and consequential symptoms relative to the primary symptoms that actually describe the psychopathic personality (Cooke, Michie, & Skeem, 2007). However, Neumann and Vitacco call into question the statistical methodology used by the Cooke group and support the four-factor model (Neumann, 2007; Vitacco, 2007). Psychopathy and Major Mental Disorders Earlier data in the literature suggest a relative independence between psychopathy and major mental disorders. First, in a forensic psychiatric population, Hart and Hare (1989) observed a correlation of.26 between the psychopathy score and any Axis I diagnosis based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III; American Psychiatric Association, 1980). In an inmate population, instead, Smith and Newman (1990) found that the vast majority of psychopaths presented a diagnosis of alcohol abuse/dependence. In his first manual on the PCL-R, Hare (1991) reported correlations of.15,.08 and.13 between the PCL-R total score and, respectively, Factors 1 and 2 and the diagnosis of schizophrenia based on DSM-III criteria (American Psychiatric Association, 1980) among forensic psychiatric patients. In a similar population, Stålenheim and von Knorring (1996) noted that the diagnosis of substance dependence constituted the most common comorbidity with psychopathy. However, Côté, Lesage, Chawky, and Loyer (1997) demonstrated that, in an inmate population with major mental disorders, bipolar disorder was the only one associated with a PCL-R score of 30 or more. More recently, in a forensic psychiatric population, Hildebrand and de Ruiter (2004) revealed that the psychopathy diagnosis (PCL-R total score >26) was positively associated only with the diagnosis of alcohol or other substances abuse (OR = 2.70, p =.009). Psychopathy and Personality Disorders The diagnosis of psychopathy and that of antisocial personality disorder have generally been found to be strongly associated (Hart & Hare, 1989). However, this is not to say that these diagnoses are equivalent. In fact, it has clearly been demonstrated that the majority of psychopaths meet the diagnostic criteria for antisocial personality disorder, whereas a large proportion of persons with antisocial personality disorder do not meet the diagnostic criteria for psychopathy as defined by the PCL-R (Hart & Hare, 1989; Stålenheim & Von Knorring, 1996). In this regard, the estimated prevalence of psychopathy as measured by the PCL-R in a sample of forensic patients (15% 30%) has been found to be much lower than that of antisocial personality disorder (50% 80%; Hare, 1985; Hart, Hare, & Forth, 1994). Moreover, PCL-R scores have proved positively correlated to the Cluster B (dramatic-erratic-emotional) personality disorders of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994) and negatively correlated to the cluster C (anxious-fearful) personality disorders (Hart & Hare, 1985; Hart, Hare, & Forth, 1994). Hart and Hare (1989) have also reported positive correlations between PCL-R total score and, respectively, antisocial personality disorder (r =.71, p<.01) and histrionic personality disorder (r =.39, p <.01) in 80 men. In the same study, PCL-R Factor 1 scores were negatively correlated to avoidant personality disorder (r =.33, p <.01) and dependent personality disorder (r =.34, p <.01), respectively. Only the psychopathy diagnosis predicted presence of antisocial personality disorder (OR = 11.32,

4 p<.01). The findings reported by Hildebrand and de Ruiter (2004) went in the same direction in that the psychopathy diagnosis was shown to predict presence of a cluster B personality disorder (OR = 25.41, p<.001) and, more particularly, antisocial personality disorder (OR = 20.39, p<.001). Finally, examining 168 Scottish and English forensic patients, Blackburn, Logan, Renwick, and Donally (2005) confirmed that the psychopathy diagnosis as established via the PCL-R was strongly associated with the cluster B personality disorders. More specifically, the PCL-R total score was strongly correlated to antisocial personality disorder (r =.66, p <.001) and narcissistic personality disorder (r =.52, p<.001), respectively, defined on the basis of the DSM-IV criteria (American Psychiatric Association, 1994). In sum, the studies above generally support the construct validity of Hare s PCL-R relative to the evaluation of DSM Axis I and II disorders. However, most of the research to date has been conducted with forensic patients and North American inmates. To our knowledge, no study had ever been undertaken specifically in a French-speaking population to examine systematically the association between the diagnosis of psychopathy as measured via the PCL-R and, respectively, major mental disorders and personality disorders. Purpose of Study Against this backdrop, we set out to investigate the relations between psychopathy scores and DSM Axis I and II disorders among male forensic patients in Belgium. On the strength of the results outlined above, we expected PCL-R scores to be negatively correlated to the major mental disorders with the exception of substance-related disorders, positively correlated to the DSM-IV Cluster B (dramatic-erratic-emotional) personality disorders, and negatively correlated to the DSM- IV Cluster C (anxious-fearful) personality disorders. To verify whether the prevalence of major mental disorders and of personality disorders was in keeping with percentages reported in previous studies with forensic psychiatric patients, we also compared our prevalence rates against those in the international literature. METHOD Participants The sample was made up entirely of male forensic patients at the Etablissement de Défense Sociale, a high-security psychiatric hospital in Tournai, Belgium. The facility has under its care 340 offenders who for the most part present major mental and personality disorders. They are hospitalized under Belgium s Social Defence Law, which provides for an undetermined measure confinement of offenders if they are recognized as incapable of controlling their actions owing to mental disorder. The mean length of stay is about eight years. Participants were evaluated for research purposes by PCL-R PSYCHOPATHY AND AXIS I AND II DISORDERS 207 the team at the Centre de Recherche en Défense Sociale (CRDS). The sample was not representative of the entire social defence population. It essentially comprised the stabilized patients, as we excluded from the study those in an acute phase, as well as those with a pronounced intellectual deficiency for whom valid clinical evaluation could not be carried out. In all, 84 male forensic patients agreed to participate in the research. Participants were evaluated as a function of their ward within the security psychiatric hospital. They were evaluated at least one month after admission to the facility. Mean age was 43.6 years (SD = 9.87, range = 27 69) and mean total IQ (WAIS-R, 1981) was 77.2 (SD = 15.30, range = ). The offenses committed by the participants were as follows: sex offenses (48, 57%), robbery (23, 27%), assault with bodily harm (21, 25%), homicide or attempted homicide (16, 19%), robbery with violence (12, 14%) and drug-related offenses (12, 14%). Procedure Psychopathy Checklist Revised (PCL-R). The PCL-R (Hare, 1991, 2003) comprises 20 items rated on a 3-point scale: 0 indicates that the item does not apply to the person, 1 that it applies only in part, and 2 that it applies in full. Total scores thus vary from 0 to 40. The procedure suggested by Hare (1991, 2003) was applied. Information for the purposes of the evaluation was garnered from the following sources: (a) criminal, social, psychological, and psychiatric records; and (b) two semi-structured interviews. The interviews lasted about 45 minutes and served to examine, among other things, academic and professional career, family antecedents, offender career, sexual and marital relationship, medical and psychological history, drug and alcohol use, and plans for future. The French version of the instrument was validated in Quebec (Côté & Hodgins, 1991, 1996). In Belgium, it has been the focus of a psychometric evaluation in a prison setting (Pham, 1998), it has been applied with a forensic psychiatric population (Pham, Remy, Dailliet & Lienard, 1998), and it has been the focus of a predictive validation study (Pham, Ducro, Marghem & Réveillère, 2005). All raters were properly trained for the PCL-R during a threeday workshop conducted by Drs. Gilles Côté and Thierry H. Pham. Diagnostic Interview Schedule, Screening Interview (DISSI). Major mental disorders were evaluated through the DISSI (Robins & Marcus, 1987) on the basis of DSM-III criteria and on dichotomous coding (American Psychiatric Association, 1980). The DISSI is a computerized epidemiological instrument that allows, among other things, to evaluate the following diagnostic categories, based on dichotomous coding: pathological gambling, conduct disorders, anxiety disorders (panic attack, phobia, generalized anxiety, obsessivecompulsive disorders), mood disorders (major depression, dysthymia, mania), substance-related disorders (alcohol and other substances abuse/dependence), somatoform disorders,

5 208 PHAM & SALOPPÉ and schizophrenia. Diagnoses were established over two time frames, namely, six months and lifetime. This instrument was validated with a Belgian general population sample by Baruffol and Thilmany (1993). Structured Clinical Interview for DSM-IV Axis II disorders (SCID II). Personality disorders were evaluated by way of the SCID II (First, Spitzer, Gibbon, Williams, & Benjamin, 1997). It serves to evaluate 12 personality disorders described in the DSM-IV (American Psychiatric Association, 1994). It consists of one 119-item self-report questionnaire and one semi-structured interview to investigate items concerning the disorders for which the subject tests positive on the questionnaire administered beforehand. Like the SCID I (First, Spitzer, Gibbon, & Williams, 1997), this instrument follows the principle of the decision tree through which a diagnosis is arrived at progressively during the interview. Additional information required to establish one or more diagnoses were obtained from forensic records at the hospital registry. We used the French version of the SCID II validated by Bouvard and colleagues (Bouvard, Fontaine- Buffe, Cungi, Adeleine, Chapoutier, Durafour, Bouchard, & Cottraux, 1999). Data Analysis First, we carried out frequency comparisons to establish the prevalence of DSM Axis I and II disorders and their respective comorbidities. Second, a descriptive analysis was conducted of PCL-R total and facet scores. Third, to complete our analyses, odds ratios (OR) were calculated to determine whether the psychopathy diagnosis predicted some other psychiatric diagnosis. The OR indicates the probability of diagnosis A if diagnosis B is present divided by the probability of diagnosis A if diagnosis B is absent (Fleiss, 1981). Chi-squared tests were performed to determine the significance of each OR. These OR were calculated with the PCL-R cut-off at 30 and 26. Thus, we were able to verify which of these two values constituted the better cut-off to discriminate between psychopathy and other psychiatric disorders. In order to reduce the risk of Type I error, we carried out a separate analysis for each DSM axis (Stevens, 1986). In following the methodology used by Hart and Hare (1989), the significance threshold was calculated on the basis of diagnostic categories with a base rate above 10%. Finally, correlations between the PCL-R scores and DSM Axis II disorders were calculated. The data were analyzed with the Statistical Package for Social Sciences (Statistical Package for the Social Sciences, 2007), version RESULTS Prevalence of Major Mental Disorders Major mental disorders were very common in the sample (Table 1). Seventy-nine patients (94%) presented at TABLE 1 Base Rate of DSM III Axis I Disorders (N = 84) Diagnostic group N % Mood disorders Depressive disorder Bipolar disorder 6 7 Anxiety disorders Generalized anxiety disorder Panic disorder 3 4 Phobic disorder Obsessive-Compulsive disorder 7 8 Schizophrenia/other psychotic disorder Eating disorders 9 11 Anorexia 4 5 Bulimia 6 7 Substance-related disorders Alcohol abuse/dependence Psychoactive substance abuse/dependence Pathological gambling Somatoform disorder Any Axis I disorder least one DSM-III Axis I disorder (American Psychiatric Association, 1980). Substance-related disorders were the most prevalent at 69%. These broke down into 60.7% alcohol abuse/dependence and 33.3% psychoactive substance abuse/dependence. Forty-seven patients (57%) presented an anxiety disorder and 37 patients (44%), a mood disorder. Fifteen patients (18%) met the diagnostic criteria for schizophrenia or some other psychotic disorder; 17 patients (20%), a somatoform disorder; 15 patients (18%), pathological gambling; and 9 patients (11%), an eating disorder. Twenty-one patients (25%) presented a major mental disorder other than a substance-related disorder. Comorbidity is a concept employed in the fields of clinical practice and research alike. It is defined as the presence of two or more concurrent diagnoses in the same person. Comorbidity was very common in our sample, as 94% of the patients evaluated presented at least one major mental disorder and 67.8% presented an Axis I comorbidity. Mean number of diagnoses per participant was 2.8 (SD = 1.9). Prevalence of Personality Disorders Personality disorders, too, were very frequent in the sample (Table 2), as 60 patients (71%) presented at least one DSM-IV Axis II disorder (American Psychiatric Association, 1994). For the sample as a whole, cluster B (dramatic, emotional or erratic) personality disorders (62%) were the most prevalent in the following order: antisocial (48%), borderline (25%), narcissistic (18%), and histrionic (2%). The next most prevalent were cluster A (odd or eccentric) personality disorders (29%), followed by cluster C (anxious or fearful) personality disorders (23%).

6 TABLE 2 Base Rate of DSM-IV Axis II Disorders (N = 84) Personality Disorder N % Cluster A odd or eccentric Paranoid PD Schizoid PD 5 6 Schizotypal PD 4 5 Cluster B dramatic, emotional or erratic Antisocial PD Borderline PD Narcissistic PD Histrionic PD 2 2 Cluster C anxious or fearful Avoidant PD 3 4 Dependent PD 2 2 Obsessive-Compulsive PD Any personality disorder Thirty-six patients (43%) presented a DSM-IV Axis II comorbidity (American Psychiatric Association, 1994). The mean number of diagnoses per patient was 1.62 (SD = 1.61). Regarding comorbidity between DSM Axes I and II disorders, 57 patients (68%) presented one or more major mental disorders associated with one or more personality disorders. Distribution of PCL-R Psychopathy Scores The mean PCL-R total score was (SD = 8.37), with a range of 2 to 36 and a median score of The Kurtosis coefficient for the PCL-R total score was.927 (SE =.520), and the Pearson measure of skewness,.009 (SE =.263). We cannot state that the PCL-R scores do not follow a normal distribution (Kolmogorov-Smirnov Z =.086, p =.178). Mean scores on Factors 1 and 2 were 7.78 (SD = 3.99) and 9.59 (SD = 4.46), respectively. Means scores on the four facets to emerge from Hare s factorial structure (Hare, 2003) were, in order from 1 to 4, as follows: 2.86 (SD = 2.36), 4.79 (SD = 2.14), 5.45 (SD = 2.57), and 4.64 (SD = 3.31). With the cut-off at 30 (Hare, 1991), our sample contained 12 psychopaths (14%). With the cut-off at 26 as suggested by European studies (Grann, Längtröm, Tengström, & Stålenheim, 1998; Rasmussen, Storsaeter, & Levander, 1999), the number of patients obtaining a psychopathy diagnosis doubled to 24 (29%). Comorbidity Between Psychopathy and Axes I and II Disorders Psychopathy and Axis I Disorders. The analyses conducted in this section focused on major mental disorders with a base rate above 10% (Hart & Hare, 1989). Accordingly, diagnostic categories comprising fewer than 8 patients were excluded. Consequently, the significance threshold was set at p =.10/10 =.01, as 10 comparisons were carried out for the DSM-III Axis I disorders. PCL-R PSYCHOPATHY AND AXIS I AND II DISORDERS 209 As shown in Table 3, the analyses performed between the psychopathy diagnosis and Axis I diagnoses yielded only one significant result, namely, with respect to the diagnosis of non-alcohol substance abuse/dependence, X 2 = 5.2, p =.01. The OR indicates that individuals with a PCL-R score above 30 were five times as likely to present a psychoactive substance abuse/dependence disorder as they are a somatoform disorder. Setting the cut-off at 26 did not result in greater comorbidity between the psychopathy diagnosis and Axis I disorders. Psychopathy and Axis II disorders. As with major mental disorders, the analyses were run only on personality disorders with a base rate above 10% (Hart & Hare, 1989). Accordingly, the diagnostic categories comprising fewer than 8 patients were excluded. Consequently, the significance threshold was set at p =.10/9 =.01, as 9 comparisons were conducted for the DSM-IV Axis II disorders. As shown in Table 4, a significant relationship emerged from the analyses between the psychopathy diagnosis and the cluster B personality disorders, X 2 = 6.54, p =.01, particularly antisocial personality disorder, X 2 = 13.41, p<.001. As was the case with the Axis I disorders, lowering the PCL-R cut-off score to 26 did not yield a higher degree of comorbidity between the psychopathy diagnosis and the Axis II disorders. Computing positive predictive power (PPP), which corresponds to the likelihood of an individual presenting a given diagnosis in the presence of another, demonstrated that the psychopathy diagnosis was highly predictive of antisocial personality disorder, PPP =.83. However, the inverse was not true, that is, antisocial personality disorder did not predict the psychopathy diagnosis, PPP =.25. Correlations between PCL-R Scores and Personality Disorders As shown in Table 5, correlations indicated a significant positive association between PCL-R total score and antisocial personality disorder, Tau-b =.43. The same was true for the PCL-R Factors 1 and 2 scores, Tau-b =.25 and.49, respectively; and the PCL-R Facets 1, 3, and 4 scores, Taub =.31,.36, and.51, respectively. Moreover, Factor 1 and Facet 1 were significantly positively correlated to narcissistic personality disorder, Tau-b =.24 and.31, respectively. DISCUSSION The purpose of our study was to analyze the prevalence of mental disorders and DSM Axes I and II comorbidity in a sample of male forensic psychiatric patients. We also set out to investigate the relations between psychopathy scores and DSM Axes I and II disorders among male forensic patients in Belgium. Major mental disorders were very common in the sample. Seventy-nine patients (94%) presented at least one DSM-III Axis I disorder. Alcohol abuse/dependence

7 210 PHAM & SALOPPÉ TABLE 3 Number of Patients with Low (<20), Medium (20 29) and High (>30) PCL-R Scores by Axis I Disorders, and Association (Odds Ratio) with Categorical Diagnosis of PCL-R Psychopathy (N = 84) PCL-R score OR Axis I disorders Diagnostic group a < >30 26 p b 30 Downloaded By: [Pham, Thierry H.] At: 13:27 19 November 2010 Psychoactive substance abuse/dependence No psychoactive substance abuse/dependence Alcohol abuse/dependence No alcohol abuse/dependence Generalized anxiety disorder No generalized anxiety disorder Phobic disorder No phobic disorder Depressive disorder No depressive disorder Schizophrenia/other psychotic disorder No schizophrenia/other psychotic disorder Eating disorders No Eating disorders Pathological gambling No Pathological gambling Somatoform disorder No Somatoform disorder Any Axis I disorder No Any Axis I disorder a Diagnostic categories >8 patients (see text). b Chi-squared test TABLE 4 Number of Patients with Low (<20), Medium (20-29) and High (>30) PCL-R Scores by Axis II Disorders, and Association (Odds Ratio) with Categorical Diagnoses of PCL-R Psychopathy (N = 84) PCL-R score Axis II disorders Personality disorder (PD) a < >30 26 p b 30 Antisocial PD < No Antisocial PD Borderline PD No Borderline PD Narcissistic PD No Narcissistic PD Paranoid PD No Paranoid PD Obsessive-Compulsive PD No Obsessive-Compulsive PD Cluster B No Cluster B Cluster A No Cluster A Cluster C No ClusterC Any personality disorder No personality disorder OR a Diagnostic categories >8 patients (see text). b Chi-squaredtest

8 PCL-R PSYCHOPATHY AND AXIS I AND II DISORDERS 211 TABLE 5 Correlations (Kendall s tau-b) Between PCL-R Psychopathy Scores and Axis II Scores (N = 84) PCL-R Personality Disorder Total Factor 1 Factor 2 Facets 1 Facets2 Facets 3 Facets 4 Paranoid PD Schizoid PD Schizotypal PD Antisocial PD Borderline PD Narcissistic PD Histrionic PD Avoidant PD Dependent PD Obsessive-Compulsive PD p<.001 Downloaded By: [Pham, Thierry H.] At: 13:27 19 November 2010 proved the most prevalent disorder at 61%. This is comparable to the rates obtained by Blackburn, Logan, Donnelly, and Renwick (2003) in their Scottish and English samples (88% and 62%, respectively). Thirty-three percent of our patients currently or previously presented a psychoactive substance-related disorder, compared with rates reported in the international literature ranging from 27% (Timmerman & Emmelkamp, 2001) to 62% (Blackburn, Logan, Donnelly,& Renwick, 2003; Hildebrand & de Ruiter, 2004). The prevalence of anxiety disorders in our sample reached 47%, which is just as high as observed by Blackburn and colleagues (2003) in English and Scottish samples (41% and 48%, respectively) and by Timmerman and Emmelkamp (2001) in a Dutch sample (41%). Coïd (2003), instead, observed a markedly lower rate of 20%. The prevalence of mood disorders in the literature varies from 18% (Coïd, Kahtan, Gault, & Jarman, 1999) to 51% (Timmerman & Emmelkamp, 2001). In our sample, the rate was around at 44%. Fifteen of our patients (17.9%) presented a current or lifetime psychotic disorder. The prevalence rates for schizophrenic disorders in the literature run from 3% (Timmerman & Emmelkamp, 2001) to 69% (Coïd, Kahtan, Gault, & Jarman, 1999). The low prevalence found in the Dutch study can be explained by the sampling criteria employed, which excluded any patient in an acute state of psychotic decompensation. Finally, somatoform disorder occurred more frequently in our sample at 20%, compared with the figures reported in the literature, which set the average prevalence at 7% (Coïd, 2003; Blackburn, Logan, Donnelly, & Renwick, 2003). There was a very high prevalence of DSM-III Axis I comorbidity in our sample, with 94% of the patients evaluated presenting at least one major mental disorder and 68% presented an Axis I comorbidity. The mean number of diagnoses per patient was 2.8. The major studies in this regard noted a strong co-occurrence between the major mental disorders identified in forensic psychiatric hospital patients. The mean number of diagnoses per patient has ranged from 1.6 to 2.7 in past studies (Coïd, 2003; Timmerman & Emmelkamp, 2001; Blackburn, Logan, Donnelly, & Renwick, 2003). The prevalence of personality disorders in our sample was very high as well. Sixty patients (71%) presented at least one DSM-IV Axis II disorder. The cluster B personality disorders were the most prevalent (62%). The prevalence of personality disorders among individuals hospitalized under Belgium s Social Defence Law is, all told, in line with the numbers reported in the international literature. Indeed, 48% of our patients presented an antisocial personality disorder, compared with 37% to 56% in the literature (Blackburn, Logan, Donnelly, & Renwick, 2003; Coïd, 2003; Coid, 1999; de Ruiter, Peter & Greeven, 2000; Hildebrand & de Ruiter, 2004, Timmerman & Emmelkamp, 2001). Twenty-five percent of our patients presented with a borderline personality disorder, whereas the prevalence ranges from 25% to 35% in the literature (Coid, 1999; de Ruiter, Peter & Greeven, 2000; Hildebrand & de Ruiter, 2004). Lastly, narcissistic personality disorder was slightly less common in our sample (17.9%) than in the international literature, where it varies from 21% to 28% (Blackburn, Logan, Donnelly, & Renwick, 2003; Coid, 1999; de Ruiter, Peter & Greeven, 2000; Hildebrand & de Ruiter, 2004). Comorbidity of DSM-IV Axis II disorders was very frequent in our sample, with 36 patients (43%) presenting a comorbid personality disorder. The mean number of diagnoses per patient was 1.62, which places it at the lower limit of the range (1.6 to 3.6) reported in international studies (Blackburn, Logan, Donnelly, & Renwick, 2003; Coïd, 2003; de Ruiter & Greeven, 2000; Hildebrand & de Ruiter, 2004; Timmerman & Emmelkamp, 2001). Regarding comorbidity between DSM Axes I and II, 57 patients (68%) presented one or more major mental disorders associated with one or more personality disorders. This figure is slightly lower than earlier numbers in the literature, where the percentage of persons with personality disorders who also met the diagnostic criteria for a major mental

9 212 PHAM & SALOPPÉ disorder has varied from 72% to 89% (Blackburn, Logan, Donnelly, & Renwick, 2003; Hildebrand & de Ruiter, 2004; Timmerman & Emmelkamp,2001). These data rather suggest a good homogeneousness across samples and studies. Regarding psychopathy, the mean PCL-R total score (19.6, SD = 8.37) in our sample was slightly lower than those obtained by Hare (1991) and Hildebrand and de Ruiter (2004), that is, 20.6 (SD = 7.8) and 21.4 (SD = 8.4), respectively. The mean Factor 1 scores obtained with our sample (7.93, SD = 3.90) were nearly identical to those reported by Hare (1991) in his sample (7.78, SD = 3.99). Hare (1991) obtained a mean Factor 2 score of (SD = 4.12) against 9.59 (SD = 4.46) for our sample. With the cut-off at 30, 12 (14.3%) of our patients were considered psychopathic, whereas 10 (12.5%) patients presented a psychopathy diagnosis in the research conducted by Hart and Hare (1989). In line with the international literature (Stålenheim & Von Knorring, 1996; Hart & Hare, 1989; Hildebrand & de Ruiter, 2004; Côté, Lesage, Chawky, & Loyer, 1997), psychopathy scores proved relatively independent of major mental disorders. Analysis of the relationship between the psychopathy diagnosis and major mental disorders in a population of forensic psychiatric hospital patients suggests that the psychopathy diagnosis is positively associated only with the diagnosis of psychoactive substance abuse/dependence. The psychopathy diagnosis was strongly associated with antisocial personality disorder. Like Hart and Hare (1989), we were able to verify the asymmetry of this relationship, as the psychopathy diagnosis proved highly predictive of antisocial personality disorder but not vice versa. Moreover, correlation analysis confirmed a significant positive association between antisocial personality disorder and, respectively, PCL-R total score and Facets 1, 3 and 4 scores. PCL-R Facet 1 was also significantly positively correlated to narcissistic personality disorder. The PCL-R Factor 2 score was more strongly correlated to antisocial personality disorder. These positive associations are also of high interest in the field of therapeutic interventions. Indeed, cluster B comorbidities including antisocial personality disorders have been described, as pertinent variable in terms of motivation and compliance (Widiger & Corbitt, 1997; Robins, Tipp, & Przybeck, 1991). There are two principal conclusions to be drawn from our study. First, our results concerning psychopathy converge with the data in the international literature regarding forensic psychiatric hospital patients (Hart & Hare, 1989; Stålenheim & Von Knorring, 1996; Hildebrand & de Ruiter, 2004; Blackburn, Logan, Renwick, & Donnelly, 2005) and, consequently, support the PCL-R s transcultural stability (Cooke et al., 2005). Second, in line with the data from the European literature (Grann, Längtröm, Tengström, & Stålenheim, 1998; Rasmussen, Storsaeter, & Levander, 1999), our results tend to confirm the possibility of setting the PCL-R cut-off score below 30 for the purpose of establishing a psychopathy diagnosis in a French-speaking population. Indeed, a cut-off of 30 does not allow discriminating more accurately between psychopaths and non-psychopaths in terms of associated mental disorders. One of the limitations of our study lies in the measure of DSM-III Axis I with the DISSI. Future research will need to harmonize the Axes I and II with an instrument such as the SCID. Our study was also limited to male forensic patients. A further study may evaluate if these diagnoses and psychopathy data apply or differ to female forensic patients inside the Social Defense System, in light of previous studies suggesting a gender difference in prevalence of psychopathy (Strand & Belfrage, 2005). 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