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; M = .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; M = .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.
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