Matti Holi

Comparison of the GHQ-36, the GHQ-12 and the SCL-90 as psychiatric screening instruments in the Finnish population

The aim of the study was to compare the screening properties of two General Health Questionnaire (GHQ) versions and the Symptom Checklist (SCL-90), and to evaluate them as psychiatric screening instruments in Finland. We administered the GHQ-36 and the SCL-90 to psychiatric outpatients (n = 207) and to a community sample (n = 315). Receiver operating characteristic (ROC) analysis was used to estimate the screening performance of the two instruments and of the GHQ-12 extracted from the GHQ-36. The screening properties of the scales were found to be good and similar. Suggested optimal cut-off points were 3/4 for the GHQ-12, 8/9 for the GHQ-36 and 0.90/0.91 for the SCL-90. In conclusion, the scales functioned equally well in screening. This favors the GHQ-12 for pure screening. When information on the symptom level is also needed, the GHQ-36 and the SCL-90 become better choices. The cut-off points presented here should be considered in the future Finnish psychiatric screening studies.

Validity of Simpson-Angus Scale (SAS) in a naturalistic schizophrenia population

BackgroundSimpson-Angus Scale (SAS) is an established instrument for neuroleptic-induced parkinsonism (NIP), but its statistical properties have been studied insufficiently. Some shortcomings concerning its content have been suggested as well. According to a recent report, the widely used SAS mean score cut-off value 0.3 of for NIP detection may be too low. Our aim was to evaluate SAS against DSM-IV diagnostic criteria for NIP and objective motor assessment (actometry).MethodsNinety-nine chronic institutionalised schizophrenia patients were evaluated during the same interview by standardised actometric recording and SAS. The diagnosis of NIP was based on DSM-IV criteria. Internal consistency measured by Cronbachs α, convergence to actometry and the capacity for NIP case detection were assessed.ResultsCronbachs α for the scale was 0.79. SAS discriminated between DSM-IV NIP and non-NIP patients. The actometric findings did not correlate with SAS. ROC-analysis yielded a good case detection power for SAS mean score. The optimal threshold value of SAS mean score was between 0.65 and 0.95, i.e. clearly higher than previously suggested threshold value.ConclusionWe conclude that SAS seems a reliable and valid instrument. The previously commonly used cut-off mean score of 0.3 has been too low resulting in low specificity, and we suggest a new cut-off value of 0.65, whereby specificity could be doubled without loosing sensitivity.

Suicidal ideation, deliberate self-harm behaviour and suicide attempts among adolescent outpatients with depressive mood disorders and comorbid axis I disorders

ObjectiveWe aimed to analyse and compare prevalence and associated clinical features of suicidal ideation, self-harm behaviour with no suicidal intent and suicide attempts among adolescent outpatients with depressive mood disorders with or without comorbidity.MethodA sample of 218 consecutive adolescent outpatients aged 13–19 years with depressive mood disorders was interviewed using K-SADS-PL for DSM-IV Axis I diagnoses. They filled out self-report questionnaires assessing depressive and anxiety symptoms. Suicidal behaviour was assessed by K-SADS-PL suicidality items.ResultsHalf of the subjects reported suicidal ideation or behaviour. There was no difference in prevalence of suicidal behaviour between non-comorbid and comorbid mood disorder groups. Multivariate logistic regression analyses produced the following associations: (1) suicidal ideation with self-reported depressive symptoms and poor psychosocial functioning, (2) deliberate self-harm behaviour with younger age and poor psychosocial functioning, and (3) suicide attempts with self-reported depressive symptoms and poor psychosocial functioning. ConclusionsDepressed mood disorders, whether comorbid or not, are associated with suicidal ideation and suicide attempts. Diagnostic assessment should be supplemented by self-report methods when assessing suicidal behaviour in depressed adolescents.

Current comorbidity among consecutive adolescent psychiatric outpatients with DSM-IV mood disorders

ObjectiveTo compare selected characteristics (age, sex, age of onset for depression, impairment, severity of depression, somatic comorbidity, and treatment status) of adolescents with currently comorbid and non-comorbid depression.MethodA sample of 218 consecutive adolescent (13–19 years) psychiatric outpatients with depressive disorders, and 200 age- and sex-matched school-attending controls were interviewed for DSM-IV Axis I and Axis II diagnoses.ResultsCurrent comorbidity, most commonly with anxiety disorders, was equally frequent (>70%) in outpatients and depressed controls. Younger age (OR 0.20; 95% CI 0.08, 0.51) and male gender (OR 0.02; 95% CI 0.09, 0.55) were associated with concurrent disruptive disorders. Current comorbidity with substance use disorders (SUD) was independent of age (OR 1.13; 95% CI 0.51, 2.49) and sex (OR 0.51; 95% CI 0.22, 1.17). Personality disorders associated with older age (OR 2.06; 95% CI 1.10, 3.86). In multivariable logistic regression analysis, impairment (GAF ≤60) was associated with current comorbidity (OR 3.13; 95% CI 1.53, 6.45), while severity of depression and lifetime age of onset for depression were not.ConclusionsAdolescent depression presents with age- and sex-dependent patterns of multiple co-occurring problem areas. While many clinical characteristics of adolescent depression are not affected by comorbidity, comorbidity associates with increased impairment.

Effects of MAOA-genotype, alcohol consumption, and aging on violent behavior.

BACKGROUND Environmental factors appear to interact with a functional polymorphism (MAOA-LPR) in the promoter region of the monoamine oxidase A gene (MAOA) in determining some forms of antisocial behavior. However, how MAOA-LPR modulates the effects of other factors such as alcohol consumption related to antisocial behavior is not completely understood. METHODS This study examines the conjunct effect of MAOA-LPR, alcohol consumption, and aging on the risk for violent behavior. Recidivism in severe impulsive violent behavior was assessed after 7 to 15 years in a sample of 174 Finnish alcoholic offenders, the majority of whom exhibited antisocial or borderline personality disorder or both, and featured impulsive temperament traits. RESULTS The risk for committing new acts of violence increased by 2.3% for each kilogram of increase in yearly mean alcohol consumption (p = 0.004) and decreased by 7.3% for every year among offenders carrying the high activity MAOA genotype. In contrast, alcohol consumption and aging failed to affect violent behavior in the low activity MAOA genotyped offenders. MAOA-LPR showed no main effect on the risk for recidivistic violence. CONCLUSIONS Violent offenders carrying the high activity MAOA genotype differ in several ways from carriers with the low activity MAOA risk allele previously associated with antisocial behavior. Finnish high activity MAOA genotyped risk alcoholics exhibiting antisocial behavior, high alcohol consumption, and abnormal alcohol-related impulsive and uncontrolled violence might represent an etiologically distinct alcohol dependence subtype.

Psychometric properties and clinical utility of the Scale for Suicidal Ideation (SSI) in adolescents

BackgroundAccurate assessment of suicidality is of major importance in both clinical and research settings. The Scale for Suicidal Ideation (SSI) is a well-established clinician-rating scale but its suitability to adolescents has not been studied. The aim of this study was to evaluate the reliability and validity, and to test an appropriate cutoff threshold for the SSI in a depressed adolescent outpatient population and controls.Methods218 adolescent psychiatric outpatient clinic patients suffering from depressive disorders and 200 age- and sex-matched school-attending controls were evaluated by the SSI for presence and severity of suicidal ideation. Internal consistency, discriminative-, concurrent-, and construct validity as well as the screening properties of the SSI were evaluated.ResultsCronbachs α for the whole SSI was 0.95. The SSI total score differentiated patients and controls, and increased statistically significantly in classes with increasing severity of suicidality derived from the suicidality items of the K-SADS-PL diagnostic interview. Varimax-rotated principal component analysis of the SSI items yielded three theoretically coherent factors suggesting construct validity. Area under the receiver operating characteristic (ROC) curve was 0.84 for the whole sample and 0.80 for the patient sample. The optimal cutoff threshold for the SSI total score was 3/4 yielding sensitivity of 75% and specificity of 88.9% in this population.ConclusionsSSI appears to be a reliable and a valid measure of suicidal ideation for depressed adolescents.

Inverse correlation between severity of psychopathic traits and serum cortisol levels in young adult violent male offenders

The aim of the present study was to fi nd out if there is an association between the severity of psychopathic traits and S cortisol levels in young adult violent male offenders. We recruited 20 healthy, detoxifi ed, medication-free adolescent and young adult (age range 16–22 years, mean 18.9, SD 1.77) male offenders with a history of violent acts. They were charged with either murder, manslaughter, attempted murder, attempted manslaughter or assault, and were recruited from a pre-trial forensic psychiatric examination lasting approximately 2 months. None of the participants had an acute mood disorder, psychosis or organic brain syndrome. All of the participants fulfi lled criteria for antisocial personality disorder. Psychopathy was assessed using the 20-item Hare Psychopathy Checklist-Revised (PCL-R), a semi-structured interview, which includes also a review of fi le information. Each item is rated on a 3-point scale, with a total score of the scale ranging from 0 to 40. The PCL-R reportedly consists of two factors; factor 1 taps affective-interpersonal features and factor 2 socially deviant lifestyle and behaviors [1] . The PCL-R rating was based on the consensus of a team of a forensic psychiatrist, a social worker and a clinically experienced psychologist. The internal consistency of the PCL-R was checked by calculating Cronbach’s coeffi Psychopathy is a clinical construct traditionally defi ned by a constellation of interpersonal and affective characteristics that are associated with a socially deviant lifestyle [1] . Criminal psychopaths typically begin their antisocial and criminal activities at a relatively early age, and continue throughout much of their lives [2] . The neurobiological correlates of criminal psychopathy are relatively unknown. Psychopathy has been associated with low level of both autonomic and cortical arousal [3] . Psychopaths are reported to be under-reactive to stressful, exciting or frightening stimuli and insensitive to several types of fear and punishment contingencies [4] . The limbic system, the neural basis for emotions and social interactions [5] , infl uences functions of both the hypothalamus and the pituitary gland [6] . Many kinds of psychological stress have been shown to affect the level of pituitary-adrenal activity [7] . The HPA axis meets the demands of stress primarily through the synthesis and/or release of corticotropin-releasing hormone, adrenocorticotropic hormone and cortisol [7] . These HPA axis hormones may refl ect alterations of the limbic system functioning in individuals with criminal psychopathy. More specifi cally, the degree of psychopathic tendencies might be refl ected in serum (S) cortisol levels as a sign of reactivity to stress in forensic population. Published online: January 17, 2006

MAOA Alters the Effects of Heavy Drinking and Childhood Physical Abuse on Risk for Severe Impulsive Acts of Violence Among Alcoholic Violent Offenders

BACKGROUND A polymorphism in the promoter region of the monoamine oxidase A gene (MAOA) has been shown to alter the effect of persistent drinking and childhood maltreatment on the risk for violent and antisocial behaviors. These findings indicate that MAOA could contribute to inter-individual differences in stress resiliency. METHODS Recidivism in severe violent crimes was assessed after 8 years of nonincarcerated follow-up in a male sample of 174 impulsive Finnish alcoholic violent offenders, the majority of whom exhibited antisocial (ASPD) or borderline personality disorder (BPD) or both. We examined whether MAOA genotype alters the effects of heavy drinking and childhood physical abuse (CPA) on the risk for committing impulsive recidivistic violent crimes. RESULTS Logistic regression analyses showed that both heavy drinking and CPA were significant independent predictors of recidivism in violent behavior (OR 5.2, p = 0.004 and OR 5.3, p = 0.003) among offenders having the high MAOA activity genotype (MAOA-H), but these predictors showed no effect among offenders carrying the low MAOA activity genotype (MAOA-L). CONCLUSION Carriers of the MAOA-H allele have a high risk to commit severe recidivistic impulsive violent crimes after exposure to heavy drinking and CPA.

Psychopathic traits and offender characteristics – a nationwide consecutive sample of homicidal male adolescents

BackgroundThe aim of the study was to evaluate psychopathy-like personality traits in a nationwide consecutive sample of adolescent male homicide offenders and to compare the findings with those of a randomly sampled adult male homicide offender group. A further aim was to investigate associations between psychopathic traits and offender and offence characteristics in adolescent homicides.MethodsForensic psychiatric examination reports and crime reports of all 15 to19- year- old male Finnish offenders who had been subjected to a forensic psychiatric examination and convicted for a homicide during 1995–2004 were collected (n = 57). A random sample of 57 adult male homicide offenders was selected as a comparison group. Offence and offender characteristics were collected from the files and a file-based assessment of psychopathic traits was performed using the Hare Psychopathy Checklist-Revised (PCL-R) by trained raters.ResultsNo significant differences existed between the adolescents and adults in PCL-R total scores, factor 2 (social deviance) scores, or in facets 3 (lifestyle) and 4 (antisocial). Adults scored significantly higher on factor 1 (interpersonal/affective) and facets 1 (interpersonal) and 2 (affective). The adolescent group was divided into two subgroups according to PCL-R total scores. One in five homicidal male adolescents met criteria for psychopathic personality using a PCL-R total score of 26 or higher. These boys significantly more often had a crime history before the index homicide, more frequently used excessive violence during the index homicide, more rarely lived with both parents until 16 years of age, had more institutional or foster home placements in childhood, had more school difficulties, more often had received special education, and, more often had contact with mental health services prior to age 18 years than boys scoring low on the PCL-R. They also more often had parental criminal history as well as homicide history of parents or near relatives than the group scoring low on the PCL-R.ConclusionHomicidal boys behaved as antisocially as the homicidal adults. The adults, however, showed more both affective and interpersonal features of psychopathy. Homicidal adolescents with psychopathy-like personality character form a special subgroup among other homicidal youngsters. Recognizing their characteristics, especially in life course development, would facilitate effective prevention and intervention efforts.

Tridimensional Personality Questionnaire data on alcoholic violent offenders: specific connections to severe impulsive cluster B personality disorders and violent criminality

BackgroundThe validity of traditional categorical personality disorder diagnoses is currently re-evaluated from a continuous perspective, and the evolving DSM-V classification may describe personality disorders dimensionally. The utility of dimensional personality assessment, however, is unclear in violent offenders with severe personality pathology.MethodsThe temperament structure of 114 alcoholic violent offenders with antisocial personality disorder (ASPD) was compared to 84 offenders without ASPD, and 170 healthy controls. Inclusion occurred during a court-ordered mental examination preceded by homicide, assault, battery, rape or arson. Participants underwent assessment of temperament with the Tridimensional Personality Questionnaire (TPQ) and were diagnosed with DSM-III-R criteria.ResultsThe typical temperament profile in violent offender having ASPD comprised high novelty seeking, high harm avoidance, and low reward dependence. A 21% minority scored low in trait harm avoidance. Results, including the polarized harm avoidance dimension, are in accordance with Cloningers hypothesis of dimensional description of ASPD. The low harm avoidance offenders committed less impulsive violence than high harm avoidance offenders. High harm avoidance was associated with comorbid antisocial personality disorder and borderline personality disorder.ConclusionResults indicate that the DSM based ASPD diagnosis in alcoholic violent offenders associates with impulsiveness and high novelty seeking but comprises two different types of ASPD associated with distinct second-order traits that possibly explain differences in type of violent criminality. Low harm avoidance offenders have many traits in common with high scorers on the Hare Psychopathy Checklist-Revised (PCL-R). Results link high harm avoidance with broad personality pathology and argue for the usefulness of self-report questionnaires in clinical praxis.