Publications

  • [Show abstract] [Hide abstract]
    ABSTRACT: OBJECTIVE: To describe criminal recidivism, especially violent recidivism, in a long-term follow-up of mentally disordered offenders sentenced to different types of sanctions. SUBJECTS AND METHODS: A population-based Swedish cohort of male offenders referred to pre-trial psychiatric investigations between 1988 and 1995, was sentenced to forensic psychiatric treatment (n=163), prison (n=120), or noncustodial sanctions (n=52). They were followed from the beginning of their sanctions until the end of June, 2008, through official health and crime registers. Survival analyses were used to compare time until violent recidivism across different sanctions and mental disorders, and predictors of violent recidivism were investigated using univariate comparisons, a multivariate Cox regression analysis and Receiver Operating Characteristic (ROC) curves. Finally, all criminal reconvictions until the end of follow-up were assessed (a total time period of 13 to 20years). RESULTS: Forty-seven percent of all subjects were reconvicted for violent crimes during follow-up. There were no significant differences between sanction groups. By contrast, diagnostic groups that included substance abuse had significant effects, and stood out as the strongest predictor of violent reconvictions together with the number of previous violent crimes, and age at the first registered criminal offence. Variables identified in the multivariate model together predicted violent recidivism with an area under the ROC curve of 0.72, while the corresponding figure for the age at onset of criminality as the sole predictor was 0.71. Among the different sanction forms for different time periods, time in hospital and prison were significantly less associated with violent recidivism compared to time in conditional release/probation.
    International Journal of Law and Psychiatry 05/2013; · 1.19 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Criminal recidivism was studied during 2 years in a Swedish population-based cohort (N = 318) of mentally disordered male offenders who had undergone a pretrial forensic psychiatric investigation, been convicted in subsequent trials, and been sentenced to forensic psychiatric treatment (FPT; n = 152), prison (n = 116), or noncustodial sanctions (n = 50). Recidivism was analysed in relation to index sanctions, levels of supervision, diagnoses, and criminological factors. Significantly lower recidivism in the FPT group was related to lower crime rates during periods at conditional liberty in this group alone, and recidivism was significantly more common among offenders with at least one of the two diagnoses of substance abuse disorder and personality disorder than among those with psychotic or other mental disorders alone. Age at index crime and number of previous crimes emerged as significant predictors of recidivism. The results of this study suggest that the relapse rates depend as much on level of supervision as on individual characteristics.
    International Journal of Offender Therapy and Comparative Criminology 07/2011; 56(5):749-68. · 0.84 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The prevention of aggressive behaviours is a core priority for psychiatric clinical work, but the association between the diagnostic concepts used in psychiatry and aggression remains largely unknown. Outpatients referred for psychiatric evaluations of childhood-onset neuropsychiatric disorders (n=178) and perpetrators of violent crimes referred to pre-trial forensic psychiatric investigations (n=92) had comprehensive, instrument-based, psychiatric assessments, including the Life History of Aggression (LHA) scales. Total and subscale LHA scores were compared to the categorical and dimensional diagnoses of childhood and adult DSM-IV axis I and II mental disorders, general intelligence (IQ), Global Assessment of Functioning (GAF), and personality traits according to the Temperament and Character Inventory (TCI). Overall, the two groups had similar LHA scores, but the offender group scored higher on the Antisocial subscale. Higher total LHA scores were independently associated with the hyperactivity facet of attention-deficit/hyperactivity disorder (AD/HD), childhood conduct disorder, substance-related disorders, and low scores on the Cooperativeness character dimension according to the TCI. IQ and GAF-scores were negatively correlated with the LHA subscale Self-directed aggression. Autistic traits were inversely correlated with aggression among outpatients, while the opposite pattern was noted in the forensic group. The findings call for assessments of aggression-related behaviours in all psychiatric settings.
    Psychiatry Research 01/2011; 185(1-2):280-5. · 2.68 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Neurobiological markers in cerebrospinal fluid (CSF) and in serum, previously found to co-vary with destructive personality traits in violent offenders, were explored in a general population sample of 21 patients undergoing knee surgery. Results on the Karolinska Scales of Personality (KSP) and the Temperament and Character Inventory (TCI) were compared with CSF/serum albumin ratios and serum concentrations of beta-trace protein (betaTP) (as markers for blood-brain barrier (BBB) permeability), to CSF/serum albumin ratios between the dopamine and serotonin metabolites homovanillic acid (HVA)/5-hydroxyindoleacetic acid (HIAA) and to CSF and serum ratios between activated thyroid hormone (T3) and its precursor T4. Serum betaTP concentrations correlated with CSF/serum albumin ratios (P=0.018), but not with preoperative serum creatinine concentrations. Serum betaTP correlated significantly with Monotony Avoidance and Impulsiveness; CSF HVA/5-HIAA ratios with Irritability and low Cooperativeness. The betaTP is a potential serum marker for the integrity of the BBB that does not necessitate lumbar puncture. Thyroid hormones did not correlate with personality traits. As reported in forensic psychiatric patients, aggressive, unempathic personality traits were thus associated with increased dopaminergic activity in relation to the serotonergic activity and impulsivity to increased BBB permeability also in a general population group.
    Psychiatry Research 08/2010; 178(3):525-30. · 2.68 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Historically, the Swedish criminal justice system conformed to other Western penal law systems, exempting severely mentally disordered offenders considered to be unaccountable. However, in 1965 Sweden enforced a radical penal law abolishing exceptions based on unaccountability. Mentally disordered offenders have since then been subjected to various forms of sanctions motivated by the offender's need for care and aimed at general prevention. Until 2008, a prison sentence was not allowed for offenders found to have committed a crime under the influence of a severe mental disorder, leaving forensic psychiatric care the most common sanction in this group. Such offenders are nevertheless held criminally responsible, liable for damages, and encumbered with a criminal record. In most cases, such offenders must not be discharged without the approval of an administrative court. Two essentially modern principles may be discerned behind the "Swedish model": first, an attempted abolishment of moral responsibility, omitting concepts such as guilt, accountability, atonement, and retribution, and, second, the integration of psychiatric care into the societal reaction and control systems. The model has been much criticized, and several governmental committees have suggested a re-introduction of a system involving the concept of accountability. This review describes the Swedish special criminal justice provisions on mentally disordered offenders including the legislative changes in 1965 along with current proposals to return to a pre-1965 system, presents current Swedish forensic psychiatric practice and research, and discusses some of the ethical, political, and metaphysical presumptions that underlie the current system.
    International Journal of Law and Psychiatry 01/2010; 33(4):220-6. · 1.19 Impact Factor
  • Source
    European Psychiatry - EUR PSYCHIAT. 01/2010; 25:181-181.
  • [Show abstract] [Hide abstract]
    ABSTRACT: This prospective study was designed to replicate previous findings of an association between the platelet monoamine oxidase B (MAO-B) activity and factors of relevance for criminal behaviour in a well-documented clinical study population. Subjects (n = 77, aged 17-76 years, median 30 years) were recruited among consecutive perpetrators of severe interpersonal violent and/or sexual crimes referred to forensic psychiatric investigation. Participants were extensively investigated by structured psychiatric, psychological and social workups, including state-of-the-art rating instruments and official records, and with laboratory tests including venous blood sampling for determination of MAO-B activity. A subset of 36 individuals had lumbar punctures to measure cerebrospinal fluid concentrations of monoamine neurotransmitter metabolites. Platelet MAO-B activity did not show any significant correlation with assessments of childhood behavioural disorders, substance abuse, or psychosocial adversity, nor with any crime-related factors, such as scores on the Life History of Aggression Scale, the Psychopathy Checklist or recidivistic violent crime. No significant correlation was found between MAO-B and any of the monoamine metabolites. Analyses in subgroups of smokers/non-smokers did not change this overall result. The findings of the present study did not support the use of MAO-B as a biological marker for aggression-related personality traits or as a predictor for violent recidivism among violent offenders.
    Neuropsychobiology 01/2010; 61(2):87-96. · 2.37 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The development of forensic psychiatric risk assessments is discussed from a clinical point of view using the example of Sweden. A central task in forensic psychiatry has traditionally been to identify dangerous, mentally disordered subjects considered to be prone to commit violent acts. Over time, "dangerousness" has been reworded into "risk". Nevertheless, such assessments have generally been based on the psychiatric factors characterising the individual patient, while group interaction, situational factors, or social and cultural circumstances, such as the availability of alcohol and drugs, have been largely overlooked. That risk assessments have a focused on people with a diagnosis of "mental disorder" and been used as grounds for coercive measures and integrity violations has somehow been accepted as a matter of course in the public and political debate. Even the basic question whether offenders with a mental disorder are really more prone to criminal recidivism than other offenders seems to have been treated light-handedly and dealt with merely by epidemiological comparisons between groups of persons with broad ranges of psychosocial vulnerability and the general population. Legal texts, instructions and guidelines from the authorities in charge are often vague and general, while actors in the judicial system seem to put their trust in psychiatric opinions. The exchange of professional opinions, general public expectations, and judicial decision processes poses a huge risk for misunderstandings based on divergent expectations and uses of terminology.
    International Journal of Law and Psychiatry 09/2009; 32(6):400-7. · 1.19 Impact Factor
  • Anders Forsman, Walter Rapp, Jan Wahlström
    [Show abstract] [Hide abstract]
    ABSTRACT: The treatment of patients with severe productive psychotic symptoms, aggressiveness, and lack of insight is often problematic. Prompt neuroleptic treatment with high doses during the initial phase followed by consistent maintenance treatment to prevent relapses is recommended in such cases. In a retrospective study of this treatment strategy, several positive effects were registered, e.g. rapid neuroleptisation, rapid reduction of anxiety and aggressiveness, a marked decrease of traumatic incidences in connection with drug administration to uncooperative patients (depot form of the drug), a minimum of psychotic experiences and, consequently, a minimum of “psychotic learning”. Shorter hospital treatment periods with improved opportunities for rapid rehabilitation were also achieved. Although the patients included in this study suffered from comparatively severe degrees of psychosis, continuous maintenance treatment with neuroleptic drugs was found to give efficient relapse prophylaxis. High doses, neuroleptic therapy, perphenazine enanthate, pharmacokinetics, treatment refractory psychosis.
    07/2009; 41(2):135-140.
  • [Show abstract] [Hide abstract]
    ABSTRACT: Since cross-sectional brain-imaging studies demonstrating frontotemporal cerebral hypoactivity in violent offenders have generally been carried out around the time of trial and sentencing, the findings might be influenced by the stressful situation of the subjects. It seems that no group of offenders with this finding has yet been followed longitudinally. We have re-examined nine offenders convicted of lethal or near-lethal violence in whom single photon emission tomography (SPECT) previously had demonstrated frontotemporal hypoperfusion. The mean interval between the initial and the follow-up examination was 4 years. The initially observed hypoactivity was found to have remained virtually unchanged at follow-up: no mean change in the group exceeded 5% in 12 assessed regions of interest. Although preliminary due to the small sample size, this study suggests that frontotemporal brain hypoactivity is a trait rather than a state in perpetrators of severe violent crimes.
    Psychiatry Research 11/2007; 156(1):87-90. · 2.68 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To examine age at onset of substance abuse in relation to other factors of relevance to criminal behavior, we compared Life History of Aggression (LHA) scores, traits of psychopathy according to the Psychopathy Checklist--Revised (PCL-R), and violent recidivism in 100 violent offenders with early (before the age of 18) versus late onset of abuse or dependence. Of 56 subjects with a history of alcohol and/or drug abuse, an early onset was ascertained in 31. The duration of abuse did not correlate with the LHA and PCL-R scores or with violent recidivism, but the age at onset correlated strongly with all these factors and also remained their strongest correlate in multivariate models including childhood-onset attention deficit/hyperactivity disorder, conduct disorder, and drug abuse as covariates. Strong mathematical associations with aggression, psychopathy, and recidivism pointed to age at onset of substance abuse as a marker of possible complications that require preventive social, educational and medical measures.
    Psychiatry Research 11/2007; 153(2):195-8. · 2.68 Impact Factor
  • European Psychiatry 03/2007; 22. · 3.29 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To test the hypothesis that cerebrospinal fluid (CSF)/ serum albumin ratios are increased in violent offenders. In a previous study of violent offenders, we found significantly higher CSF/serum album ratios (as a sign of increased blood-brain barrier permeability) in violent offenders than in healthy controls. For the present replication study, we recruited a new group of 28 violent offenders, aged 45 years or younger, and 20 new control subjects. The albumin ratio was again significantly higher in the offender group (mean 6.2) than in the control group (mean 4.6) (P = 0.012). Substance abuse or current medication did not appear to explain this finding. Increased CSF/serum albumin ratios are an unspecific sign of neurological dysfunction in subgroups of violent offenders.
    Acta Neurologica Scandinavica 08/2005; 112(1):48-50. · 2.47 Impact Factor
  • Christina Lund, Anders Forsman
    [Show abstract] [Hide abstract]
    ABSTRACT: The legislation regulating sanctions for offenders with mental disorders has been under parliamentary review in Sweden, and major changes have been discussed. In the present study, we have explored the expectations and effects of the previous change in legislation, introduced in 1992 and aimed at reducing coercive psychiatric treatment. Two cohorts of male subjects, admitted for forensic psychiatric investigation before (1988-90, n = 187) and after (1993-95, n = 180) 1992, were compared regarding sanctions, diagnoses and background data with a possible impact on the study populations. Contrary to expectations, the 1993-95 cohort was characterized by increased proportions of psychotic disorders and sentences to forensic psychiatric treatment. In both cohorts, few cases had an adequate outpatient treatment. A tendency to shorter compulsory inpatient treatment periods during the last year before the index crimes was found for those with psychotic disorders in the 1993-95 cohort. The frequency of immigrants with psychotic disorders was markedly increased in the later cohort. The intention of the new legislation to minimize forensic psychiatric treatment was thus counteracted by an unexpected increase in number of offenders with psychotic disorders. To what extent these findings are ascribable to factors other than the new legislation, such as reduced inpatient treatment facilities and generally decreased economic growth rate that coincided with the observation period, cannot be estimated in a limited study population such as ours.
    Nordic Journal of Psychiatry 02/2005; 59(5):381-7. · 1.22 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Childhood conduct disorder (CD) and adult psychopathic traits according to the Psychopathy Checklist Revised (PCL-R) were the closest psychiatric covariates to repeated violent crimes and aggression among offenders under forensic psychiatric investigation in Sweden. As psychopathy is not included in the present psychiatric diagnostic systems, we compared total and factor PCL-R scores to Axis I disorders, including childhood-onset neuropsychiatric disorders, and to Axis II personality disorders, to establish the convergence of psychopathic traits with other psychiatric diagnoses, and to identify possible unique features. Psychopathic traits were positively correlated with bipolar mood disorder and negatively with unipolar depression. The total PCL-R scores as well as the Factor 2 (unemotionality) and Factor 3 (behavioral dyscontrol) scores were significantly correlated with attention-deficit/hyperactivity disorder, Asperger's syndrome/high-functioning autistic traits, CD, substance abuse, and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Cluster B personality disorders. The interpersonal Factor 1 showed none of these correlations and may capture features that are specific to psychopathy, distinguishing core psychopathy from other diagnostic definitions.
    Comprehensive Psychiatry 01/2005; 46(2):111-6. · 2.38 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Changes in the metabolism of tryptophan, other amino acids, and steroid hormones have been implicated in aggression. We compared tryptophan, competing long amino acids (CAAs), and cortisol in serum (S) and CSF in 22 violent offenders and 15 healthy controls. Offenders had significantly increased S-L-tryptophan, S-free tryptophan, S-CAAs, S-cortisol and CSF-cortisol, indicating abnormal neurophysiological processes. Larger studies on the interplay between violence, serotonin precursors, and stress hormones need to integrate personality traits, life situations, and physiological adaptation.
    Journal of Neural Transmission 01/2005; 111(12):1605-10. · 3.05 Impact Factor
  • H Soderstrom, A Forsman
    [Show abstract] [Hide abstract]
    ABSTRACT: We assessed a total range of peripheral thyroid hormone fractions, binding globulins, and thyroid-active antibodies in 37 medication-free, violent or sexual offenders, aged 17-45 years, to describe possible mechanisms involved in the thyroid metabolism of aggressive men. The ratio between T3 and T4 correlated with ratings of psychopathy, indicating increased peripheral deiodination as a biological covariate to callous personality traits. Autoimmune antibodies, hepatic failure, abnormal binding globulins, or substance abuse did not affect the association.
    Journal of Neural Transmission 07/2004; 111(6):739-44. · 3.05 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To describe lifetime mental disorders among perpetrators of severe inter-personal crimes and to identify the problem domains most closely associated with aggression and a history of repeated violent criminality, we used structured interviews, clinical assessments, analyses of intellectual functioning, medical and social files, and collateral interviews in 100 consecutive subjects of pretrial forensic psychiatric investigations. Childhood-onset neuropsychiatric disorders [attention-deficit/hyperactivity disorder (AD/HD), learning disability, tics and autism spectrum disorders] affected 55% of the subjects and formed complex comorbidity patterns with adult personality disorders [including psychopathic traits according to the Psychopathy Checklist (PCL-R)], mood disorders and substance abuse. The closest psychiatric covariates to high Lifetime History of Aggression (LHA) scores and violent recidivism were the PCL-R scores and childhood conduct disorder (CD). Behavioral and affective PCL-R factors were closely associated with childhood AD/HD, CD, and autistic traits. The results support the notion that childhood-onset social and behavioral problems form the most relevant psychiatric symptom cluster in relation to pervasive adult violent behavior, while late-onset mental disorders are more often associated with single acts of violent or sexual aggression.
    Psychiatry Research 02/2004; 121(3):271-80. · 2.68 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Do the CNS monoaminergic (MA) systems regulate thyroid hormone metabolism in humans? In 23 unmedicated, male, violent offenders without signs of thyroid disease, we found positive correlations between the catecholaminergic CSF metabolites HVA and MHPG and the peripheral T3/T4 ratio (rho=0.55, p=0.010 and 0.51, p=0.018), indicating that increased activity in the brain MA systems, especially the dopaminergic, is associated with increased peripheral thyroid hormone activity.
    Journal of Neural Transmission 01/2004; 110(12):1369-73. · 3.05 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To replicate the relation between the CSF HVA:5-HIAA ratio and psychopathic traits previously reported in a pilot group of 22 perpetrators of violent crimes. CSF monoamine metabolite concentrations in another 28 violent and sexual offenders, aged 45 or below, referred to pretrial forensic psychiatric investigation, were compared to features of psychopathy according to the Psychopathy Checklist-Revised (PCL-R). Our previous finding was repeated in the new study group, where the HVA:5-HIAA ratio was strongly associated with psychopathic traits (r = 0.50, p = 0.010), particularly its behavioural aspects (r = 0.523, p = 0.004). In subsamples of individuals from both study groups who had no medication (n = 25) or no current axis I disorder, including a history of mood disorder or substance dependence (n = 21), the HVA:5-HIAA ratio remained strongly associated with all psychopathy factors but most closely with the behavioural features. Retrospective assessments of childhood disruptive symptomatology, such as attention deficit hyperactivity disorder or conduct disorder, analysed in relation to the monoamine metabolites, showed the same association with the HVA:5-HIAA ratio. Violent and aggressive behavioural traits with childhood onset and adult expression as psychopathic features are associated with changed activity in the brain dopaminergic system, possibly as a result of serotonergic dysregulation.
    Journal of Neurology Neurosurgery & Psychiatry 08/2003; 74(7):918-21. · 4.92 Impact Factor

6 Following View all

13 Followers View all