پس زمینه عصبی شروع دوران کودکی تا صفات روانی و اختلالات شخصیتی بزرگسالی

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.

Introduction In a recent study of violent offenders, conduct disorder (CD) and psychopathic traits according to the Psychopathy Checklist Revised (PCL-R) [1], independently, were the closest psychiatric covariates to repeated violent crimes and high aggression scores [2]. The relevance of childhood-onset CD for adult social maladaptation has long been well known [3] as reflected by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) definition of antisocial personality disorder [4]. Psychopathy assessed by the 20-item PCL-R instrument has attracted interest mainly in the area of risk prediction, but studies addressing its neuropsychologic [5], neurologic [6], [7] and [8], and neurophysiologic [9], [10], [11], [12] and [13] basis indicate that psychopathy may be a specific childhood-onset disorder of empathy and social functioning [14]. Personality disorders are not diagnosed in child and adolescent psychiatry. Aberrations in empathy, communicative skills, and executive control are instead captured by diagnostic definitions for the autism spectrum disorders, attention-deficit/hyperactivity disorder (AD/HD), learning disabilities, and tic disorders (including Tourette's syndrome) [15] and [16]. In analogy with adult personality disorders having childhood precedents, these disorders have been found to carry an increased risk of adjustment problems and aggression in adulthood [2], [17], [18], [19] and [20]. Common to personality disorders, AD/HD, autistic traits, and learning disabilities is that they may be regarded as categorical disorders or as extreme constellations of normally distributed traits [15], [21], [22] and [23]. In the DSM-IV, personality disorders are defined as maladaptive patterns of cognitions, affects, interpersonal functioning, and impulse control that have caused psychosocial problems since adolescence. As indicated by the common features of these definitions, childhood-onset neuropsychiatric disorders and adult personality disorders may form a continuum describing the same underlying mechanisms in different terminologies. The erratic Cluster A personality disorders (paranoid, schizoid, and schizotypal) are thought to be related to psychotic disorders [24] or autism spectrum disorders [25] and [26] and the phobic Cluster C disorders (avoidant, dependent, and obsessive-compulsive) to anxiety disorders [27], whereas the dramatic Cluster B disorders (histrionic, narcissistic, borderline, and antisocial personality disorders) clearly share core features with AD/HD [28]. The DSM-IV definition of antisocial personality disorder is mainly based on behavioral characteristics noted before the age of 15 years (CD) and continued into adulthood, whereas psychopathy, as first defined by Cleckley [29], describes a specific constellation of personality traits, including dominance-seeking (through the instrumental use of manipulation, cruelty, and fear) and deficits in emotional reactivity, attachment, purposefulness, and consistency. To study the extent to which the features and problems assessed by the PCL-R correlate with DSM-IV diagnostic definitions of mental and personality disorders aiming at identifying possible unique features for psychopathy, we compared PCL-R ratings to independent ratings of childhood-onset neuropsychiatric disorders and adult psychiatric and personality disorders in perpetrators of severe crimes against other persons.

Results The overall prevalence of mental disorders was high: 96% had one or several Axis I diagnoses, 43% fulfilled the criteria for mood disorders, 20% for psychotic disorders, 52% for substance abuse or dependence, and 26% for anxiety disorders. 4.1. Childhood-onset neuropsychiatric disorders Fifty-five percent fulfilled the diagnostic criteria for one or several childhood-onset neuropsychiatric disorders: autism in 5%, Asperger's syndrome in 3%, atypical autism in 10%, Tourette's syndrome in 5%, chronic tics in 13%, AD/HD in 39%, and mental retardation in 17%. Another 3 subjects had DCD (overall present in 23%), and 14 had CD as main childhood-onset diagnosis (overall present in 48%). 4.2. DSM-IV personality disorders The collapsed prevalence of personality disorders was 67%, including antisocial personality disorder in 43%, borderline in 31%, narcissistic in 16%, histrionic in 7%, paranoid in 22%, schizoid in 22%, schizotypal in 13%, avoidant in 17%, obsessive compulsive in 15%, and dependent personality disorder in 2%. 4.3. Psychopathy The PCL-R scores were generally low, ranging from 0 to 27 points (median, 8), with the upper quartile delineated by a score of 14. Four percent had 24 points or more and 9% had 20 points or more. Factor 1 ranged from 0 to 7 (median, 0), Factor 2 from 0 to 8 (median, 3), and Factor 3 from 0 to 8 (median, 2). 4.4. Psychopathy and personality disorders associated with violent crimes Correlations between PCL-R total and factor scores, antisocial personality disorder, CD, and other Axis 1 and II disorders are given in Table 1. Psychopathy Checklist Revised total scores correlated negatively with unipolar mood disorders and positively with bipolar mood disorder and passive-aggressive personality disorder. The strongest positive associations to the PCL-R were noted for substance abuse, AD/HD, CD, autistic features, and Cluster B personality disorders. The 1 PCL-R factor not linked to any of these conditions was the interpersonal Factor 1, including the superficial, vicious, and manipulative traits that correspond to the popular concept of a “true psychopath.” Table 1. Spearman's rank correlation coefficients (with 2-tailed P values within brackets) between PCL-R total and factor scores (n = 100), major mental disorders (n = 100), childhood-onset disorders (n = 100), and personality disorders (PD) (n = 74) PCL-R Total PCL Factor 1 PCL Factor 2 PCL Factor 3 Antisocial PD CD Unipolar mood disorder −0.235 −0.242 −0.092 −0.270 −0.120 0.007 (0.019) (0.015) (0.363) (0.007) (0.304) (0.946) Bipolar mood disorder 0.199 0.092 0.061 0.104 0.107 0.280 (0.047) (0.364) (0.548) (0.302) (0.361) (0.005) Psychotic disorders 0.053 −0.029 −0.010 0.180 0.166 −0.030 (0.601) (0.776) (0.924) (0.073) (0.156) (0.767) Substance abuse 0.312 −0.027 0.216 0.313 0.528 0.402 (0.002) (0.788) (0.031) (0.001) (<0.001) (<0.001) Anxiety disorder 0.062 −0.092 0.189 −0.007 0.207 0.263 (0.540) (0.365) (0.059) (0.947) (0.075) (0.008) Impulse control disorders 0.123 −0.024 0.184 0.008 0.080 0.143 (0.223) (0.812) (0.067) (0.936) (0.496) (0.154) Sexual disorders −0.196 0.047 −0.058 −0.378 −0.349 −0.157 (0.050) (0.640) (0.565) (<0.001) (0.002) (0.119) Attention deficit 0.373 0.088 0.355 0.331 0.518 0.484 (<0.001) (0.385) (<0.001) (0.001) (<0.001) (<0.001) Hyperactivity 0.435 0.149 0.320 0.427 0.539 0.540 (<0.001) (0.138) (0.001) (<0.001) (<0.001) (<0.001) Gillberg and Gillberg criteria 0.250 0.094 0.247 0.206 0.282 0.296 (0.012) (0.351) (0.013) (0.040) (0.014) (0.003) Mental retardation 0.002 −0.053 0.042 −0.015 −0.019 −0.062 (0.985) (0.599) (0.681) (0.883) (0.873) (0.541) DCD 0.040 0.009 0.019 0.058 0.055 0.046 (0.690) (0.926) (0.850) (0.567) (0.637) (0.652) Tics −0.045 −0.018 −0.088 −0.023 0.096 0.071 (0.659) (0.858) (0.383) (0.821) (0.411) (0.484) Avoidant PD −0.095 −0.319 0.041 −0.090 0.117 0.097 (0.422) (0.006) (0.730) (0.446) (0.322) (0.410) Dependent PD 0.071 −0.055 0.213 0.037 0.319 0.199 (0.548) (0.645) (0.062) (0.754) (0.006) (0.089) Compulsive PD 0.029 −0.014 0.121 0.020 0.211 0.194 (0.805) (0.904) (0.305) (0.864) (0.071) (0.098) Passive-aggressive PD 0.311 0.132 0.289 0.251 0.474 0.401 (0.007) (0.264) (0.013) (0.031) (<0.001) (<0.001) Depressive PD 0.065 −0.024 0.119 0.030 0.307 0.196 (0.584) (0.841) (0.313) (0.797) (0.008) (0.094) Paranoid PD 0.191 0.053 0.284 0.169 0.411 0.381 (0.103) (0.656) (0.014) (0.150) (<0.001) (0.001) Schizotypal PD 0.100 −0.055 0.165 0.093 0.356 0.321 (0.395) (0.643) (0.160) (0.431) (0.002) (0.005) Schizoid PD 0.023 −0.138 0.084 0.014 0.212 0.200 (0.848) (0.240) (0.477) (0.909) (0.069) (0.087) Histrionic PD 0.273 0.138 0.131 0.349 0.483 0.482 (0.019) (0.240) (0.265) (0.002) (<0.001) (<0.001) Narcissistic PD 0.322 0.081 0.280 0.364 0.476 0.367 (0.005) (0.492) (0.016) (0.001) (<0.001) (0.001) Borderline PD 0.422 0.172 0.352 0.376 0.526 0.473 (<0.001) (0.143) (0.002) (0.001) (<0.001) (<0.001) Table options To establish the strongest childhood precursors to psychopathy, all significant associations between childhood neuropsychiatric disorders and PCL-R scores were entered into multivariate models. Hyperactivity disorder criteria in childhood remained the only significant covariate to the total PCL-R scores (P < .001) and to the behavioral Factor 3 (P < .001), whereas the affective Factor 2 covaried with attention-deficit criteria in childhood (P < .001).