Simone Ullrich

Prevalence and correlates of psychopathic traits in the household population of Great Britain

There are no previous surveys of psychopathy and psychopathic traits in representative general population samples using standardized instruments. This study aimed to measure prevalence and correlates of psychopathic traits, based on a two-phase survey using the Psychopathy Checklist: Screening Version (PCL: SV) in 638 individuals, 16-74 years, in households in England, Wales and Scotland. The weighted prevalence of psychopathy was 0.6% (95% CI: 0.2-1.6) at a cut score of 13, similar to the noncriminal/nonpsychiatric sample described in the manual of the PCL: SV. Psychopathy scores correlated with: younger age, male gender; suicide attempts, violent behavior, imprisonment and homelessness; drug dependence; histrionic, borderline and adult antisocial personality disorders; panic and obsessive-compulsive disorders. This survey demonstrated that, as measured by the PCL: SV, psychopathy is rare, affecting less than 1% of the household population, although it is prevalent among prisoners, homeless persons, and psychiatric admissions. There is a half-normal distribution of psychopathic traits in the general population, with the majority having no traits, a significant proportion with non-zero values, and a severe subgroup of persons with multiple associated social and behavioral problems. This distribution has implications for research into the etiology of psychopathy and its implications for society.

Psychopathy among prisoners in England and Wales.

Most research into psychopathy among prisoners is based on selected samples. It remains unclear whether prevalences are lower among European populations. This study aimed to measure the prevalence of psychopathy, and the distribution and correlates of psychopathic traits in a representative national sample of prisoners. Psychopathy was measured using the revised Psychopathy Checklist (PCL-R) in a second stage, cross-sectional survey of prisoners in England and Wales in 1997 (n=496). Poisson regression analysis was carried out to examine independent associations between correlates and PCL-R total and factor scores. The prevalence of categorically diagnosed psychopathy at a cut off of 30 was 7.7% (95%CI 5.2-10.9) in men and 1.9% (95%CI 0.2-6.9) in women. Psychopathic traits were less prevalent among women. They were correlated with younger age, repeated imprisonment, detention in higher security, disciplinary infractions, antisocial, narcissistic, histrionic, and schizoid personality disorders, and substance misuse, but not neurotic disorders or schizophrenia. The study concluded that psychopathy and psychopathic traits are prevalent among male prisoners in England and Wales but lower than in most previous studies using selected samples. However, most correlates with psychopathic traits were similar to other studies. Psychopathy identifies the extreme of a spectrum of social and behavioral problems among prisoners.

Gender differences in structured risk assessment: comparing the accuracy of five instruments.

Structured risk assessment should guide clinical risk management, but it is uncertain which instrument has the highest predictive accuracy among men and women. In the present study, the authors compared the Psychopathy Checklist-Revised (PCL-R; R. D. Hare, 1991, 2003); the Historical, Clinical, Risk Management-20 (HCR-20; C. D. Webster, K. S. Douglas, D. Eaves, & S. D. Hart, 1997); the Risk Matrix 2000-Violence (RM2000[V]; D. Thornton et al., 2003); the Violence Risk Appraisal Guide (VRAG; V. L. Quinsey, G. T. Harris, M. E. Rice, & C. A. Cormier, 1998); the Offenders Group Reconviction Scale (OGRS; J. B. Copas & P. Marshall, 1998; R. Taylor, 1999); and the total previous convictions among prisoners, prospectively assessed prerelease. The authors compared predischarge measures with subsequent offending and instruments ranked using multivariate regression. Most instruments demonstrated significant but moderate predictive ability. The OGRS ranked highest for violence among men, and the PCL-R and HCR-20 H subscale ranked highest for violence among women. The OGRS and total previous acquisitive convictions demonstrated greatest accuracy in predicting acquisitive offending among men and women. Actuarial instruments requiring no training to administer performed as well as personality assessment and structured risk assessment and were superior among men for violence.

Protective Factors for Violence among Released Prisoners--Effects over Time and Interactions with Static Risk.

OBJECTIVE There is a substantial body of research on risk factors for violent behavior in adulthood but little empirical study of protective factors and desistance. METHOD This study aimed to investigate the protective effects of factors hypothesized to reduce violent reoffending among a sample of 800 male prisoners following release into the community. RESULTS Five out of 15 hypothesized protective factors significantly reduced the likelihood of a violent reconviction. Protection was primarily related to social network factors that appeared to have long-term effects. Circumstances following release (finances and nature of accommodation) did not prove to be relevant, apart from immediate provision of accommodation, which had a substantial influence on reduction of risk shortly after release into the community, and being employed, in training or education, which was relevant for the 3rd year and subsequently. Our findings support the notion of independent effects of protective factors on outcome. No effect modification was found to indicate that protective factors have different effects at different levels of risk. CONCLUSIONS The nature of the relationship between risk and protection should be considered in the assessment of risk for violence. Furthermore, risk factors focus on pathology and hazards, whereas protective factors emphasize positivism and hope for change. Future interventions may benefit from this positive approach.

Antisocial personality disorder is on a continuum with psychopathy

BACKGROUND Antisocial personality disorder (ASPD) and psychopathy are different diagnostic constructs. It is unclear whether they are separate clinical syndromes or whether psychopathy is a severe form of ASPD. METHODS A representative sample of 496 prisoners in England and Wales was interviewed in the second phase of a survey carried out in 1997 using the Schedules for Clinical Assessment in Neuropsychiatry, the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis II personality disorders, and the Psychopathy Checklist-Revised. RESULTS Among those 18 years and older (n = 470), 211 (44.9%) received a diagnosis of ASPD, of whom 67 (31.8%) were classified as psychopaths, indicated by Psychopathy Checklist-Revised scores of 25 and above. Symptoms of ASPD and psychopathy both demonstrated low diagnostic contrast when comparing subgroups of ASPD above and below the cutoff for psychopathy. There were no differences in demography, Axis I comorbidity, and treatment-seeking behavior. Psychopathic individuals with ASPD demonstrated comorbid schizoid and narcissistic personality disorder, more severe conduct disorder and adult antisocial symptoms, and more violent convictions. CONCLUSIONS Psychopathy and ASPD are not separate diagnostic entities, but psychopathic ASPD is a more severe form than ASPD alone with greater risk of violence. Dimensional scores of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition personality disorders (other than ASPD) may be helpful in identifying this specific subgroup.

Association of Violence With Emergence of Persecutory Delusions in Untreated Schizophrenia

OBJECTIVE Psychosis is considered an important risk factor for violence, but studies show inconsistent results. The mechanism through which psychotic disorders influence violence also remains uncertain. The authors investigated whether psychosis increased the risk of violent behavior among released prisoners and whether treatment reduced this risk. They also explored whether active symptoms of psychosis at the time of violent behavior explained associations between untreated psychosis and violence. METHOD The U.K. Prisoner Cohort Study is a prospective longitudinal study of prisoners followed up in the community after release. Adult male and female offenders serving sentences of 2 or more years for a sexual or violent offense were classified into four groups: no psychosis (N=742), schizophrenia (N=94), delusional disorder (N=29), and drug-induced psychosis (N=102). Symptoms of psychosis, including hallucinations, thought insertion, strange experiences, and delusions of persecution, were measured before and after release. Information on violence between release and follow-up was collected through self-report and police records. RESULTS Schizophrenia was associated with violence but only in the absence of treatment (odds ratio=3.76, 95% CI=1.39-10.19). Untreated schizophrenia was associated with the emergence of persecutory delusions at follow-up (odds ratio=3.52, 95% CI=1.18-10.52), which were associated with violence (odds ratio=3.68, 95% CI=2.44-5.55). The mediating effects of persecutory delusions were confirmed in mediation analyses (β=0.02, 95% CI=0.01-0.04). CONCLUSIONS The results indicate that the emergence of persecutory delusions in untreated schizophrenia explains violent behavior. Maintaining psychiatric treatment after release can substantially reduce violent recidivism among prisoners with schizophrenia. Better screening and treatment of prisoners is therefore essential to prevent violence.

Most items in structured risk assessment instruments do not predict violence

The predictive ability of static risk assessment instruments may be explained by a limited number of their items. This study examined the independent predictive accuracy of individual items in the Psychopathy Checklist-Revised (PCL-R), Violence Risk Appraisal Guide (VRAG) and Historical-Clinical-Risk Management-20 (HCR-20) for violent reconvictions following release among 1353 male prisoners in England and Wales. The study found most items in the three instruments were not independently predictive. Items not independently predictive were removed and all significant items in the original three instruments were combined, resulting in negligible gains in predictive accuracy for the VRAG and HCR-20, but a small improvement in the PCL-R. The study demonstrated that the predictive power of the PCL-R, VRAG and HCR-20 are based on a small number of their items. This may partly explain the ‘glass-ceiling’ effect beyond which further improvement cannot be achieved. Instruments lack outcome-specificity for violence, and independently predictive items include measures of general criminality.

Gang membership, violence, and psychiatric morbidity.

OBJECTIVE Gang members engage in many high-risk activities associated with psychiatric morbidity, particularly violence-related ones. The authors investigated associations between gang membership, violent behavior, psychiatric morbidity, and use of mental health services. METHOD The authors conducted a cross-sectional survey of 4,664 men 18-34 years of age in Great Britain using random location sampling. The survey oversampled men from areas with high levels of violence and gang activities. Participants completed questionnaires covering gang membership, violence, use of mental health services, and psychiatric diagnoses measured using standardized screening instruments. RESULTS Violent men and gang members had higher prevalences of mental disorders and use of psychiatric services than nonviolent men, but a lower prevalence of depression. Violent ruminative thinking, violent victimization, and fear of further victimization accounted for the high levels of psychosis and anxiety disorders in gang members, and with service use in gang members and other violent men. Associations with antisocial personality disorder, substance misuse, and suicide attempts were explained by factors other than violence. CONCLUSIONS Gang members show inordinately high levels of psychiatric morbidity, placing a heavy burden on mental health services. Traumatization and fear of further violence, exceptionally prevalent in gang members, are associated with service use. Gang membership should be routinely assessed in individuals presenting to health care services in areas with high levels of violence and gang activity. Health care professionals may have an important role in promoting desistence from gang activity.

Detecting personality disorders in the prison population of England and Wales: comparing case identification using the SCID-II screen and the SCID-II clinical interview

The cross-instrument validity of the SCID-II screen and the SCID-II structured clinical interview was examined in a sub-sample of 496 male and female prisoners from a national survey in England and Wales. Participants completed the SCID-II screen and were interviewed two weeks later by clinicians using the SCID-II interview. The screen was adjusted on the basis of interview results. Diagnostic categories were compared before and after adjustment of the screen. Diagnostic cut-off adjustments to the screen resulted in moderate agreement between instruments for categorical and dimensional evaluations. The screen retained good internal consistency with improved discrimination between personality disorders and clinical syndromes following adjustment. The SCID-II screen is a valid self-report instrument for diagnosing personality disorders. It may be preferable for prison populations but is not a substitute for a structured clinical interview.

Gender- and violence-related prevalence of mental disorders in prisoners

ObjectivesTo clarify the prevalence of mental diseases including personality disorders in a sample of German prisoners regarding delinquency and gender specificity.MethodCrime history, present state and lifetime mental disorders, as well as personality disorders, were assessed amongst 415 inmates and compared regarding gender and type of delinquency.ResultsFemale offenders more often committed homicide while male offenders more frequently committed assault and robbery. Men had a higher prevalence of alcohol abuse and dissocial PD while women more often showed depression, anxiety disorders and Borderline PD. Violent offences were related to a higher prevalence of alcohol abuse and dissocial PD, as well as higher comorbidities of mental disorders.ConclusionResults emphasize the complexity of the needs and requirements of imprisoned offenders. Our findings reveal an urgent need for psychiatric–psychotherapeutic services to provide suitable care to inmates in order to contribute to a more favorable legal prognosis.