The DAPP-SF as a screener for personality disorder in a forensic setting.

Studies on the Dimensional Assessment of Personality Pathology-Short Form (DAPP-SF) have shown its ability to identify treatment-seeking patients with personality disorders. This study focuses on its screening potential for personality disorder in 89 criminal suspects (77 men, 12 women; M age = 37.0 years) undergoing residential pretrial psychological assessments in a high-security setting. It was expected that Structured Interview for DSM-IV Personality (SIDP-IV) criteria met for personality disorder(s) would be associated with higher DAPP-SF scores. A floor effect was found in DAPP-SF scores: The forensic population reported less personality pathology than the general population. Only moderate associations between DAPP-SF and SIDP-IV outcome were found. Receiver operating characteristic analysis showed that some DAPP-SF subscales did not exceed chance level in their ability to screen for personality disorders. It is concluded that the DAPP-SF has limited usefulness as a screener for personality disorders in a forensic pretrial setting. Alternative forensic screening instruments are presented.

Neurobiological correlates in forensic assessment: a systematic review.

BACKGROUND: With the increased knowledge of biological risk factors, interest in including this information in forensic assessments is growing. Currently, forensic assessments are predominantly focused on psychosocial factors. A better understanding of the neurobiology of violent criminal behaviour and biological risk factors could improve forensic assessments. OBJECTIVE: To provide an overview of the current evidence about biological risk factors that predispose people to antisocial and violent behaviour, and determine its usefulness in forensic assessment. METHODS: A systematic literature search was conducted using articles from PsycINFO, Embase and Pubmed published between 2000 and 2013. RESULTS: This review shows that much research on the relationship between genetic predisposition and neurobiological alterations with aggression is performed on psychiatric patients or normal populations. However, the number of studies comparing offenders is limited. There is still a great need to understand how genetic and neurobiological alterations and/or deficits are related to violent behaviour, specifically criminality. Most studies focus on only one of the genetic or neurobiological fields related to antisocial and/or violent behaviour. To reliably correlate the findings of these fields, a standardization of methodology is urgently needed. CONCLUSION: Findings from the current review suggest that violent aggression, like all forms of human behaviour, both develops under specific genetic and environmental conditions, and requires interplay between these conditions. Violence should be considered as the end product of a chain of life events, during which risks accumulate and potentially reinforce each other, displaying or triggering a specific situation. This systematic review did not find evidence of predispositions or neurobiological alterations that solely explain antisocial or violent behaviour. With better designed studies, more correlation between diverse fields, and more standardisation, it might be possible to elucidate underlying mechanisms. Thus, we advocate maintaining the current case-by-case differentiated approach to evidence-based forensic assessment.

Psychotic disorders are more common in ethnic minority than in Dutch native defendants.

PURPOSE: The prevalence of psychotic disorders among prisoners from racial or ethnic minority groups remains uncertain. We therefore compared the frequency of psychotic disorder in ethnic minority and Dutch native defendants using the nationwide database of elaborate pre-trial reports. METHODS: Analysis of a nationwide database of pre-trial reported defendants in the Netherlands between 2000 and 2006 (n = 12,752). RESULTS: A diagnosis of a psychotic disorder was more common in ethnic minority than in Dutch native defendants (21.1 vs. 10.2%). The odds ratio of this diagnosis, adjusted for age, gender, IQ below 85 and abuse of cannabis or hard drugs, was 2.6 (95% CI 2.2-3.0). This odds ratio was highest for African defendants (OR = 5.2; 95% CI 3.7-7.4). CONCLUSIONS: Psychotic disorders were more common among pre-trial reported defendants from ethnic minorities than among their Dutch native counterparts.

The relationship between mental disorders and different types of crime.

BACKGROUND: Previous studies of relationships between mental disorder and crime have tended to group the mental disorders, the crimes or both, leaving uncertainty about a more specific mental disorder: crime relationships. OBJECTIVE: To examine the relationship between types of mental disorder and types of crime in pre-trial defendants. METHOD: Data were extracted from 21,424 pre-trial forensic psychiatric reports made between 2000 and 2006 in the Netherlands. We compared the prevalence of axis I disorders, personality disorders, intellectual functioning and substance abuse in defendants charged with a range of crimes (homicide, attempted/threatened homicide, assault, battery, rape, sexual crimes, arson and/or property crimes) using chi-square tests. Relationships with diminished accountability, reflecting a direct relationship with underlying mental disorder, were calculated using multivariate regression models, adjusted for age, gender, ethnicity and history of judicial contact. RESULTS: Arson had the strongest relationship with mental disorders in our sample, then assaults, then homicidal attempts or threats. Sexual and property crimes had the weakest relationship with diminished or absent accountability. Diminished accountability had the strongest relationship with psychotic disorders, followed by organic psychosyndromes and developmental disorders, whereas other axis I disorders, personality disorders or an IQ score of <85 points were only moderately related. These relationships varied little according to the type of crime, although tended to be weaker for defendants in property crimes. Cannabis and hard drugs were significantly associated with decreased accountability only in respect of arson. DISCUSSION: Mental disorders are related to all types of crimes but especially to arson, battery and homicidal attempts or threats, with a court finding of diminished accountability providing some validation for perceived links between the disorder and crime in this study. IMPLICATIONS FOR PRACTICE: Psychiatric assessment is likely to be the most useful for defendants under charges of arson, assault or attempted homicide, as these groups are most likely to suffer from a psychiatric disorder related to the alleged offence. Psychotic, organic and some developmental disorders appear to have the strongest relationship with diminished accountability. Findings with respect to illicit drug use are likely to have more varied implications between jurisdictions but, in the Netherlands, may sometimes be accepted as diminishing accountability in defendants of arson.

Pre-trial psychiatric evaluations and ethnicity in the Netherlands.

OBJECTIVE: Black and ethnic minorities (BME) are disproportionally represented in western prisons and forensic psychiatric facilities. The authors wished to determine whether patient-related or services-related factors account for this overrepresentation. This study examined the relationship among the assessments of psychological accountability for a crime, treatment recommendations, and ethnicity among persons accused of a crime and suspected of having a mental disorder. METHOD: We examined all 21,857 pre-trial psychiatric reports requested by Dutch courts between 2000 and 2006. Ethnicity was classified as Dutch native (n=15,004), Black and minority ethnic (BME) groups (n=6202), and Whites from other western countries (n=638). Accountability assessments and treatment recommendations were compared using chi-square tests and logistic regression models, adjusted for demographic, psychiatric, and judiciary characteristics. RESULTS: Among BME and Whites from other western countries, accountability for the crimes committed was more often judged to be at the extreme ends of the spectrum, that is, "fully responsible" or "not responsible." Compulsory admission to a psychiatric hospital was more frequently recommended for BME persons (OR: 1.38, 95% CI: 1.16-1.64) and Whites from other western countries (OR: 1.54, 95% CI: 1.05-2.27), but not admission to a penitentiary hospital or use of medication. The compulsory admission findings are largely explained by a higher prevalence of psychotic disorders in BME persons (19.8%) and Whites from other western countries (19.3%) as compared to Dutch natives (9.2%). Outpatient treatment was less often recommended for BME persons (OR: 0.81, 95% CI: 0.76-0.87) and Whites from other western countries (OR: 0.83, 95% CI: 0.70-0.99) than for Dutch natives. CONCLUSION: Both patient-related and services-related factors play a role in the increased admission of BME groups and Whites from other western countries to psychiatric hospitals.

Trauma exposure and hypothalamic-pituitary- adrenal axis functioning in mentally healthy Dutch peacekeeping veterans, 10-25 years after deployment.

Hypothalamic-pituitary-adrenal (HPA) axis alterations have been found in veterans with posttraumatic stress disorder (PTSD). It is unclear whether trauma exposure during adulthood in the absence of psychopathology is also associated with HPA-axis dysregulation. Thirty-six trauma-exposed peacekeepers, 23 nonexposed peacekeepers, and 25 nonexposed civilians, all without lifetime psychopathology were studied. Basal HPA-axis functioning was assessed with salivary cortisol samples obtained over 2 days. HPA-axis reactivity was assessed with the dexamethasone/corticotropin-releasing hormone test. Lower afternoon salivary cortisol levels were found in both veteran groups versus controls after adjustment for confounders. The authors concluded that this study does not support the idea that HPA-axis functioning is durably altered by trauma exposure during adulthood in men.

Effectiveness of pharmacotherapy for severe personality disorders: meta-analyses of randomized controlled trials.

CONTEXT: There has been little systematic attempt to validate current pharmacologic treatment algorithms and guidelines for severe personality disorder. OBJECTIVE: We evaluated studies on the effectiveness of psychoactive drugs on specific symptom domains for borderline and/or schizotypal personality disorder. DATA SOURCES: The literature was searched for placebo-controlled randomized clinical trials (PC-RCTs) on the effectiveness of psychopharmacologic drugs in personality disorder patients. The PubMed, PsychINFO, PiCarta, Cochrane, and Web of Science databases were searched using the search terms borderline personality, schizotypal personality, personality disorder, cluster A, cluster B, treatment, drug, pharmacotherapy, antipsychotic, antidepressant, mood stabilizer, effect, outcome, review, and meta-analysis for studies published between 1980 and December 2007, and references were identified from bibliographies from articles and books. STUDY SELECTION: Placebo-controlled randomized clinical trials on the efficacy of antipsychotics, antidepressants, and mood stabilizers regarding cognitive-perceptual symptoms, impulsive-behavioral dyscontrol, and affective dysregulation (with subdomains depressed mood, anxiety, anger, and mood lability) were selected in patients with well defined borderline and/or schizotypal personality disorder. Studies whose primary emphasis was on the treatment of Axis I disorders were excluded. Meta-analyses were conducted using 21 retrieved studies. RESULTS: Antipsychotics have a moderate effect on cognitive-perceptual symptoms (5 PC-RCTs; standardized mean difference [SMD]=0.56) and a moderate to large effect on anger (4 PC-RCTs; SMD=0.69). Antidepressants have no significant effect on impulsive-behavioral dyscontrol and depressed mood. They have a small but significant effect on anxiety (5 PC-RCTs; SMD=0.30) and anger (4 PC-RCTs; SMD=0.34). Mood stabilizers have a very large effect on impulsive-behavioral dyscontrol (6 PC-RCTs; SMD=1.51) and anger (7 PC-RCTs; SMD=1.33), a large effect on anxiety (3 PC-RCTs; SMD=0.80), but a moderate effect on depressed mood (5 PC-RCTs; SMD=0.55). Mood lability as an outcome measure was seldomly assessed. Mood stabilizers have a more pronounced effect on global functioning (3 PC-RCTs; SMD=0.79) than have antipsychotics (5 PC-RCTs; SMD=0.37). The effect of antidepressants on global functioning is negligible. CONCLUSIONS: Drug therapy tailored to well-defined symptom domains can have a beneficial effect on patients with severe personality disorder. The findings from this study raise questions on current pharmacologic algorithms.

Reliability and validity of the Dutch Dimensional Assessment of Personality Pathology-Short Form (DAPP-SF), a shortened version of the DAPP-Basic Questionnaire.

The Dimensional Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ) appears to be a good choice for the assessment of personality pathology. However, due to its length, administration of the instrument is rather time-consuming, hindering standard inclusion of the DABB-BQ in a battery of assessment instruments at intake. We developed the 136-item DAPP-SF (Short Form), and investigated its psychometric characteristics in various samples, i.e., a community-based sample (n = 487), patients with mood-, anxiety-, and somatoform disorders (n = 1,329), and patients with personality disorders (n = 1,393). Results revealed high internal consistency for almost all dimensions. The factor structure appeared almost identical as compared to the factor structure of the original DAPP-BQ, and was shown to be invariant across the various patient and community samples. Indices for convergent, discriminant and criterion related validity were satisfactory. It is concluded that the good psychometric characteristics of the original DAPP-BQ were preserved in the shortened version of the instrument.

Cortisol moderates the relationship between testosterone and aggression in delinquent male adolescents.

BACKGROUND: In animals, strong evidence exists for an association between testosterone and aggression. In humans, and particularly in children and adolescents, findings have been less consistent. Previous research has suggested that this may partly be due to moderating effects of other factors, e.g., hormones. This study aims to investigate the moderating effect of cortisol on the relationship between testosterone and subtypes of aggression in delinquent male adolescents. METHODS: Participants were 103 boys (mean age 13.7) referred to a delinquency diversion program. Testosterone and cortisol levels were determined from saliva samples collected during resting conditions and related to self-report scores on overt and covert aggression. RESULTS: Linear regression analyses revealed a significant interaction between cortisol and testosterone in relation to overt aggression, with a significant positive relationship between testosterone and overt aggression in subjects with low cortisol levels but not in subjects with high cortisol levels. Using the same model for covert aggression, no significant effects of testosterone, cortisol, or testosterone x cortisol interaction were found. CONCLUSIONS: These results indicate a moderating effect of cortisol on the relationship between testosterone and overt aggression in delinquent male adolescents. Implications and directions for future research are discussed.

Fluvoxamine reduces responsiveness of HPA axis in adult female BPD patients with a history of sustained childhood abuse.

The aim of the study is to test whether fluvoxamine affects the function of the hypothalamic pituitary adrenal (HPA) axis in female borderline (borderline personality disorder, BPD) patients with and without a history of sustained childhood abuse. Special attention is given to the presence of comorbid major depressive disorder (MDD) and post-traumatic stress disorder (PTSD). The HPA axis of 30 female BPD patients with (n = 17) and without (n = 13) a history of sustained childhood abuse was challenged with a combined dexamethasone and corticotropin releasing hormone test (DEX/CRH test) before and after 6 (n = 14) and 12 (n = 16) weeks of fluvoxamine treatment (150 mg/day). Both 6- and 12-week fluvoxamine treatments were associated with a significant and robust reduction of the adrenocorticotrophic hormone (ACTH) and cortisol response to the DEX/CRH test. The magnitude of the reduction was dependent on the presence of sustained childhood abuse, but not on the presence of comorbid MDD or PTSD: patients with a history of sustained childhood abuse showed the strongest reduction in ACTH and cortisol. In conclusion, Fluvoxamine treatment reduces the hyperresponsiveness of the HPA axis in BPD patients with a history of sustained childhood abuse. This effect is likely to be obtained in the first 6 weeks of treatment.

Hyperresponsiveness of hypothalamic-pituitary-adrenal axis to combined dexamethasone/corticotropin-releasing hormone challenge in female borderline personality disorder subjects with a history of sustained childhood abuse.

BACKGROUND: High coincidence of childhood abuse, major depressive disorder (MDD), and posttraumatic stress disorder (PTSD) has been reported in patients with borderline personality disorder (BPD). Animals exposed to early trauma show increased stress-induced hypothalamic-pituitary-adrenal (HPA) axis activity due to an enhanced corticotropin-releasing hormone (CRH) drive and glucocorticoid feedback resistance. In humans, PTSD and MDD are associated with decreased and increased resistance to glucocorticoid feedback, respectively, which might reflect persistent changes in neuroendocrine sequelae following childhood abuse. METHODS: We investigated the relationship between childhood abuse and HPA axis function using a combined dexamethasone/CRH (DEX/CRH) test in 39 BPD patients with (n = 24) and without (n = 15) sustained childhood abuse and comorbid PTSD (n = 12) or MDD (n = 11) and 11 healthy control subjects. RESULTS: Chronically abused BPD patients had a significantly enhanced corticotropin (ACTH) and cortisol response to the DEX/CRH challenge compared with nonabused subjects. Comorbid PTSD significantly attenuated the ACTH response. CONCLUSIONS: Hyperresponsiveness of the HPA axis in chronically abused BPD subjects might be due to the enhanced central drive to pituitary ACTH release. Sustained childhood abuse rather than BPD, MDD, or PTSD pathology accounts for this effect. Possibly due to an enhanced efficacy of HPA suppression by dexamethasone, PTSD attenuates the ACTH response to DEX/CRH.

SSRI treatment of borderline personality disorder: a randomized, placebo-controlled clinical trial for female patients with borderline personality disorder.

OBJECTIVE: Selective serotonin reuptake inhibitors (SSRIs) are recommended for treatment of affect lability, impulsivity, and aggression in patients with borderline personality disorder. This recommendation is based on positive findings in at least 10 open studies and one small double-blind study of SSRIs for patients with borderline personality disorder and one study of impulsive aggressive patients with different personality disorders. A randomized, placebo-controlled SSRI study with borderline personality disorder patients, however, provided inconclusive results because of a large response to placebo. It was, therefore, decided to conduct a new randomized trial with a larger study group. METHOD: A double-blind, placebo-controlled, randomized trial using the SSRI fluvoxamine for 6 weeks followed by a blind half-crossover for 6 weeks and an open follow-up for another 12 weeks was conducted with 38 nonschizophrenic, nonbipolar female patients with borderline personality disorder. The outcome measures were the rapid mood shift, impulsivity, and aggression subscales from the Borderline Personality Disorder Severity Index. RESULTS: Fluvoxamine but not placebo produced a robust and long-lasting reduction in the scores on the subscale for rapid mood shifts. In contrast, no difference between the fluvoxamine and placebo groups was observed in the effect on the impulsivity and aggression scores. CONCLUSIONS: In this study, fluvoxamine significantly improved rapid mood shifts in female borderline patients, but not impulsivity and aggression. This latter finding may be due to gender-specific differences in impulsivity and aggression.