Risk and prediction of violent crime in forensic psychiatry

Objective: To test the predictive accuracy for violent recidivism of the age at onset of substance abuse, the platelet MAO-B activity, and various combinations of criminological and clinical risk factors among violent offenders in a prospective Swedish follow-up study. Subjects: One hundred violent offenders, consecutively admitted for forensic psychiatric investigations between 1998 and 2001 (baseline). Methods: Psychiatric and psychological data collection at baseline included age at onset of criminal behaviour and substance abuse and measures of platelet MAO-B activity. Known criminological and clinical risk factors were registered as well as ratings with the risk assessment instruments the Psychopathy Checklist-Revised (PCL-R), Historical, Clinical, Risk Management (HCR-20), and Life History of Aggression (LHA). After a mean follow-up time of almost five years, data on violent recidivism was obtained from official crime registers and analysed in relation to the clinical and criminological risk factors and to the results of the risk instruments. Results: Twenty subjects were reconvicted for violent crimes during follow-up. The age at onset of substance abuse, but not the MAO-B activity (regardless of smoking habits), correlated with risk factors for violence and predicted criminal recidivism. Most criminological and clinical risk factors, such as age at first conviction, number of convictions, history of conduct disorder, substance abuse, and scores on the PCL-R, HCR-20, and LHA, demonstrated modest correlations with violent recidivism and moderate predictive ability with areas under the Receiver Operating Characteristics (ROC) curves between 0.72 and 0.76. Only age at first conviction and a history of substance abuse among primary relatives remained significant predictors in multivariate models. The development and use of forensic psychiatric risk assessments were analysed from a clinical point of view, considering changes over time, ethical dilemmas, and risk for integrity violations and misunderstandings due to divergent expectations and interpretations of terminology. Conclusions: Early-onset substance abuse and age at first conviction are independent risk factors for recidivistic violence in forensic psychiatry. Simple historical risk factors describing behaviour have as good predictive accuracy as complex clinical risk assessment instruments

Violent Recidivism: A Long-Time Follow-Up Study of Mentally Disordered Offenders

Background: In this prospective study, mentally disordered perpetrators of severe violent and/or sexual crimes were followed through official registers for 59 (range 8 to 73) months. The relapse rate in criminality was assessed, compared between offenders sentenced to prison versus forensic psychiatric care, and the predictive ability of various risk factors (criminological, clinical, and of structured assessment instruments) was investigated. Method: One hundred perpetrators were consecutively assessed between 1998 and 2001 by a clinical battery of established instruments covering DSM-IV diagnoses, psychosocial background factors, and structured assessment instruments (HCR-20, PCL-R, and life-time aggression (LHA)). Follow-up data was collected from official registers for: (i) recidivistic crimes, (ii) crimes during ongoing sanction. Results: Twenty subjects relapsed in violent criminality during ongoing sanctions (n = 6) or after discharge/parole (n = 14). Individuals in forensic psychiatric care spent significantly more time at liberty after discharge compared to those in prison, but showed significantly fewer relapses. Criminological (age at first conviction), and clinical (conduct disorder and substance abuse/dependence) risk factors, as well as scores on structured assessment instruments, were moderately associated with violent recidivism. Logistic regression analyses showed that the predictive ability of criminological risk factors versus clinical risk factors combined with scores from assessment instruments was comparable, with each set of variables managing to correctly classify about 80% of all individuals, but the only predictors that remained significant in multiple models were criminological (age at first conviction, and a history of substance abuse among primary relatives). Conclusions: Only one in five relapsed into serious criminality, with significantly more relapses among subjects sentenced to prison as compared to forensic psychiatric care. Criminological risk factors tended to be the best predictors of violent relapses, while few synergies were seen when the risk factors were combined. Overall, the predictive validity of common risk factors for violent criminality was rather weak

Author Correction:Study of 300,486 individuals identifies 148 independent genetic loci influencing general cognitive function

Christina M. Lill, who contributed to analysis of data, was inadvertently omitted from the author list in the originally published version of this article. This has now been corrected in both the PDF and HTML versions of the article

The precarious practice of forensic psychiatric risk assessments

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. (C) 2009 Elsevier Ltd. All rights reserved

Age at onset of substance abuse: a crucial covariate of psychopathic traits and aggression in adult offenders

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

Platelet Monoamine Oxidase B Activity Did Not Predict Destructive Personality Traits or Violent Recidivism: A Prospective Study in Male Forensic Psychiatric Examinees.

Aims: 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. Methods: 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. Results: 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. Conclusions: 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

Correlation coefficients (Spearman's rho) between criminological risk factors and scores on structured assessment instruments in relation to violent recidivism during the follow-up period.

<p>*Correlation is significant at the 0.05 level (2-tailed).</p><p>**Correlation is significant at the 0.01 level (2-tailed).</p

Clinical risk factors and violent recidivism during the follow-up period.

<p>*All diagnoses in the table are based on the DSM-IV.</p

Basic descriptions concerning aspects of the follow-up period (months), violent criminal relapses, all criminal relapses, and psychiatric diagnoses at baseline for the total group, those in forensic psychiatric care, and those sentenced to prison.

<p>*Consisting of all violent reconvictions during the follow-up period (e.g. one murder, one arson, one case of exposing somebody to danger, two aggravated assaults, five assaults, three aggravated unlawful thefts/robberies, two cases of intimate partnership violence, and five violations of the legislation against carrying arms/knives in public places.</p><p>**Consisting of all reconvictions during the follow-up period (e.g. besides violent criminality also drug crimes, shoplifting, and traffic offences).</p