Major Mental Disorder and Antisocial Personality Disorder: A Criminal Combination

Major Mental Disorder and Antisocial Personality Disorder: A Criminal Combination



Sheilagh Hodgins, PhD; and Gilles Cote,  PhD

Dr. Hodgins is affiliated with the Centre de Recherche Philippe Pine! and Department of Psychology, Univ­ ersite de Montreal. Dr.  Cote is affiliated  with the  De­partment  of Psychology,  Universite  de Quebec a Trois­ Rivieres. Reprint requests to Dr. Sheilagh Hodgins, Centre de Recherche, Institut Philippe Pine[ de Mon­ treal, l0905 est, boul. Henri-Bourassa, Montreal (Que­ bec) HIC IHI.

Bull Am Acad Psychiatry Law, Vol. 21, No. 2, 1993


Much evidence now suggests that patients with major mental disorders are at increased risk tor crimes and violence. Leading experts in forensic psychiatry have proposed that the illegal behaviors are a  consequence  of  these  major disorders. Yet, longitudinal studies have consistently indicated that adult criminality is pre­ ceded by a childhood history of antisocial behavior. We hypothesized that among offenders with major  mental disorders  there are two groups: (1)  the first group has a secondary diagnosis of antisocial personality disorder (APD), and a childhood history of antisocial and criminal behavior preceding the onset of the major disorder;

(2) the second group do not meet the criteria  for  APD,  and behave criminally  only as adults. This hypothesis was tested on a representative sample of penitentiary inmates with major mental disorders. It was found that those with APD had a significant childhood history of criminal activity and antisocial behavior, endorsing, on average, eight of ten possible indices. In comparison, the mentally disordered inmates without APD endorsed on average two indices. The mentally disordered offenders with APD began their criminal careers earlier, and had significantly more convictions and more convictions for nonviolent offenses than those without APD. APD was not associated  with violence among men with major mental disorders.

A number of recent studies have shown that many patients suffering from major mental disorders (schizophrenia and major affective disorders) commit crimes and crimes of violence.1 One in­ vestigation of an unselected birth cohort followed to age 30, demonstrated that 47  percent  of  men  and  18  percent of women   with   major   mental disorders were registered for crime.2 A number of follow-up studies of patients discharged to the community have found that they commit more crimes  and  more crimes of violence than the general popula­ tion_ 3-13 Several investigations have doc­umented elevated prevalence rates for the  major  mental  disorders  among of­fenders. 14    18   A Danish  study of all hom­icide offenders over a 25-year period revealed that 23 percent suffered from a major mental disorder. 19 A Swedish study of all homicide offenders in the Northern half of the country over an 11- year period found that 53 percent suf­ fered  from  a   major  disorder. 20   Other studies  reveal  that  persons  suffering from  major  mental  disorders   report more aggressive behavior than persons with no disorders. 1 3 21

It has  been  proposed  that  the crimi­nality and violence of persons with  ma­ jor mental disorders is a consequence of their illn ess.1  13  22 Yet, longitudinal stud­ies, conducted in several different coun­ tries and cultures, have consistently re­ vealed that adult criminality is preceded by a childhood history of antisocial be­ havior.23-26 This developmental perspec­ tive suggest that among offenders with major mental disorders, the antisocial behavior would precede the onset of the major disorder by many years.  These two competing hypotheses may both be right, each applying to a different subgroup of mentally disordered per­ sons. Individuals with both, antisocial personality disorder (APO) and a major disorder, would be expected to be anti­ sociaL and even criminal, long  before the onset of the major disorder. Their criminality and/or violence would be associated with the personality disorder rather than the major disorder. How­ ever, among the mentally  disordered with no APO, the criminality or violence may be directly related to the symptoms of the major disorder. In two of the studies of incarcerated offenders, 27 28 it was found that 66.4 percent and 67.8 percent of the male inmates with major mental disorders also met DSM-III29 cri­ teria for APO.

Whereas Robins 30 has always argued that the presence of APO indicates a pattern of antisocial behavior beginning in  childhood   and   remaining  stable tolate adulthood, the DSM-III and DSM­ III-R diagnosis of APO requires the pres­ ence of only three childhood indices of antisocial behavior. We wanted to find out if the diagnosis of APO did in fact identify, among offenders with major mental disorders, those with a significant history  of childhood  criminal  and anti­social behavior. If validated, this distinc­ tion between offenders with major dis­ orders who begin their criminal careers before the onset of the major  disorder and those whose criminality is concur­ rent with the major disorder could be important for predicting and preventing crime and violence, It would certainly have implications for both, the assess­ ment and the treatment of mentally dis­ ordered offenders.

We hypothesized that  among  men with major mental disorders who com­ mit crimes and/or violence there are two groups. Those with APO have a history of antisocial behavior and criminality from childhood, long before the onset of the major disorder. Whereas the diag­ nosis of APO requires the presence of three childhood indices of antisocial be­ havior, we are proposing that most men­ tally disordered men with APO have demonstrated a pattern of antisocial and criminal behavior in childhood. Those without APO have no childhood history of antisocial or criminal  behavior. Rather, these behaviors seem to be con­ current with the major disorder. We also hypothesized that among the mentally disordered, those with APO would com­ mit more crimes than those with only a major disorder.3-0 32 To verify these hy­ potheses,   we  studied   a representative sample of incarcerated offenders with major mental disorders.



A random sample of 456 male in­ mates of penitentiaries situated in Que­ bec were assessed with the Diagnostic Interview Schedule (DIS). 33 Criminality was documented by records from the Correctional Service of Canada. Details of subject selection, instruments and procedure are provided in Hodgins and Cote. 18 One-hundred-seven inmates re­ ceived a diagnosis of a major disorder, and 71 of them also received a diagnosis of APO.



The ten items from the DIS that are indicative of childhood behaviors are presented in Table I. As can be ob­ served, in nine of ten childhood behav­ iors there are highly significant differ­ ences between the mentally disordered offenders diagnosed with APO and the mentally disordered offenders with no APO. Of those with APO, 87 percent reported having a juvenile arrest record as compared with 28 percent of those without APD. Similarly, on the two items tapping illegal activities, the pro­ portions of subjects with APO who en­ dorsed the items far exceeded the pro­ portions without APO. Of those with APO, 92 percent reported stealing  and 59 percent reported vandalism, as op­ posed to 44 percent and eight percent of those without APO.

Although the diagnosis of APD re­ quires the presence of only three of these childhood characteristics, most of the mentally disordered offenders with APO had many more. By according one point for each behavior present, a score of childhood antisocial behavior ranging from O to IO was calculated. Those with APD  received  a  mean  score  of  7.8 (SD= 2.3) while those without APO received a mean  score of 2.8 (SD=  2.2) (l  (105)=  10.83,  p = .000).

The mentally disordered inmates with APD had a  mean  age of 30.3 years (SD= 7.5) at the time of the diagnostic in­ terview, considerably younger than the mentally disordered inmates without APO who had a mean age of 36.9 years (SD  =   10.8)  (t   (52.93)  =  -3.30,  p =.002). Consequently, to evaluate group differences in criminality, each subject’s number of convictions in adult  court was divided by the number of years be­ tween his 18th birthday and the date of the diagnostic interview. Mentally dis­ ordered inmates with APD, as compared with those without, had more convic­ tions (M  =  2.28; =  .71: t (101.57) =, p = .00 l ), more convictions for nonviolent offenses (M = 1.71; M = .26; t (76.92) = 3.59, p = .001), and approx­ imately equal numbers of  convictions for violent offenses (M  =  .57; = .44; t (54.53) = .51, p = .611). The mean age at first sentence to a penitentiary for those with APD was 24.7 years (SD = 9), and 30.4 years (SD= 9.6) for those without  APO  (t  (49.04)  =  -3.31,  p  =.002).



Among incarcerated male offenders with major mental disorders, most of those with a secondary diagnosis of APO have  a  childhood  history  of antisocial behavior and 87 percent reported having a juvenile record. They endorsed, on average, eight of ten childhood indices of antisocial behavior. Comparatively few of those without APO had a history of childhood antisocial behavior, report­ ing on average only two of those behav­ iors. Not surprisingly then, the mentally disordered inmates without APO began their criminal careers significantly later than those with APO. These results con­ firm our hypothesis of the existence  of two types of mentally disordered of­ fenders. The criminal careers  of  these two groups of mentally disordered of­ fenders  differed.   Those   with APO  had more convictions and more convictions for nonviolent offenses than those with­ out APO. Among these mentally disor­ dered offenders, APD was not associated with violent crime.

If replicated, these results have a num­ ber of important clinical implications. First, they demonstrate the need for complete clinical workups to document the presence of all concurrent disorders. Second, when APD is diagnosed in com­ bination with a major disorder, the pa­ tient’s risk of crime is increased as com­ pared with patients with only a major disorder. However, the patient with a major disorder and APD is no  more likely than a patient with a major dis­ order and no APD to behave violently. Third, pharmacological treatment of the symptoms of the major disorder  would be expected to affect the criminal behav­ ior only of those patients with a major disorder and no APD. Consequently, treatment teams in  forensic  settings must set realistic treatment goals for pa­ tients with both a major disorder and APO.


Table 1



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