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The Correlates of Comorbid Antisocial Personality Disorder in Schizophrenia
The Correlates of Comorbid Antisocial Personality Disorder in Schizophrenia
791
Schizophrenia Bulletin, Vol. 30, No. 4, 2004 P. Moran and S. Hodgins
play a pattern of antisocial behavior both before and after orders and another set conferring a vulnerability for exter-
the onset of schizophrenia (Hodgins 2004). nalizing problems. Just as investigations of hereditary fac-
Comorbid APD amplifies the suffering of people with tors associated with schizophrenia have not taken account
schizophrenia. Among men with schizophrenia, comorbid of antisocial behavior patterns, studies of the role of
APD is associated with persistent criminality, much of it obstetric complications have not taken account, for exam-
nonviolent, that begins in adolescence and often leads to ple, of the damage that maternal antisocial behavior could
imprisonment (Hodgins and Cote 1993), with early-onset do to the developing fetus.
substance use, unemployment, and homelessness Some children with conduct disorder (Frick et al.
(Tengstrom and Hodgins 2002). Other studies suggest that 2003) and some adults with APD (Cooke and Michie
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Comorbid Antisocial Personality Disorder Schizophrenia Bulletin, Vol. 30, No. 4, 2004
state of Hessen in Germany; and southern Sweden). One childhood and adolescence (defined as birth to age 18)
hundred and forty-five (62.5%) of the men had been dis- was obtained from participants; family members; and
charged from a forensic psychiatric hospital, and 87 school, military, criminal, and medical files. A consensus
(37.5%) had been discharged from a general psychiatric decision about each variable was made by the research
hospital. The proportion of the total sample recruited in psychiatrist and research assistant after all information
each site was as follows: Canada, 39 percent (n - 90); had been extracted from files and interviews with patients
Finland, 25 percent (n = 57); Germany, 27 percent (n = and family members had been completed.
63); and Sweden, 9 percent (n = 22). The mean age of the Parents' characteristics. Information on parents
sample was 38 years (standard deviation [SD] = 11.3), and was obtained from the participants, family members, and
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Schizophrenia Bulletin, Vol. 30, No. 4, 2004 P. Moran and S. Hodgins
Procedure. Within each site, each participant with a APD, compared to those without APD, met criteria for
diagnosis of a major mental disorder being discharged alcohol and drug abuse or dependence. The history of
from the forensic hospital was approached and invited to treatment in psychiatric services, psychosocial function-
participate in the study. If the participant formally con- ing, and symptoms at discharge did not distinguish those
sented to participate, the SCID (Spitzer et al. 1992) was with APD. As would be expected because of the overlap
completed. If a diagnosis of a major mental disorder was between symptoms of APD and items on the PCL-R, the
confirmed, the participant was included in the study and participants with APD obtained higher mean total PCL-R
the other interviews and assessments were completed and scores and higher scores on the factor indicating an
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Comorbid Antisocial Personality Disorder Schizophrenia Bulletin, Vol. 30, No. 4, 2004
Table 1. Comparisons of the characteristics of men with schizophrenia and schizoaffective disorder with and
without comorbid APD
Variable APD No APD Test P
Sociodemographic characteristics
Mean age (yrs) 37.5 (SD= 11.7) 38.3 (SD= 11.2) 4230, n = 232) = 0.5 0.06
Father's occupation
White collar or professional 16% (7) 30% (47) X 2 (1,n= 199) = 3.6 0.06
Mother's occupation
X 2 (1,n=207) = 0.4
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Schizophrenia Bulletin, Vol. 30, No. 4, 2004 P. Moran and S. Hodgins
Table 1. Comparisons of the characteristics of men with schizophrenia and schizoaffective disorder with and
without comorbid APD—Continued
Variable APD No APD Test P
2
Substance abuse 82% (41) 4 1 % (73) X (1,n= 230) = 26.9 <0.001*
Mean age of onset (yrs) 13.7 (SD = 2.5) 14.9 (SD = 2.9) /(93, n = 95) = 2.0 0.05
Anxiety problems 35% (17) 34% (60) X 2 (1,n = 226) = 0.01 0.9
Mean age of onset (yrs) 9.8 (SD = 5.6) 9.7 (SD = 4.3) /(59, n = 61) = 0.03 0.9
model: attention/concentration problems, substance abuse, percent were characterized by all three variables; 40 per-
below-average performance at elementary school, and cent were characterized by two variables; 26 percent by
being placed in an institution before age 18. Likelihood one variable; and 2 percent by none of the three variables.
ratio tests indicated that the best model of childhood cor- The second model included variables that distin-
relates of APD included three variables: attention/concen- guished the participants with and without comorbid APD
tration problems before age 18 (adjusted odds ratio: 2.83; in adulthood. The analysis included 230 participants with
95% CI 1.34-5.94); substance abuse before age 18 complete data. Lifetime DSM-IV diagnoses of alcohol
(adjusted odds ratio: 5.44; 95% CI 2.41-12.28); and abuse or dependence and drug abuse or dependence were
below-average performance at elementary school entered as predictors because they had significantly distin-
(adjusted odds ratio: 2.91; 95% CI 1.39-6.11). This model guished the participants with and without comorbid APD
could not be improved upon to a statistically significant in univariate analyses. While the total PCL-R scores and
degree by the addition of further variables and yielded an the scores for impulsive and irresponsible behavioral style
overall likelihood ratio statistic of 46.96 (p < 0.001). The were significantly different for the participants with and
three significant variables often co-occur; therefore, we without APD, they were not entered into the model
examined the proportions of participants characterized by because they overlap with a diagnosis of APD. The score
these variables. Among the men with comorbid APD, 32 for deficient affective experience may be important in
796
Comorbid Antisocial Personality Disorder Schizophrenia Bulletin, Vol. 30, No. 4, 2004
understanding antisocial behavior among persons with bid APD, 14 percent were characterized by all five predic-
schizophrenia. It was therefore entered into the model tors, 44 percent by four, 22 percent by three, 18 percent
even though the univariate comparison was not significant by two, and 2 percent by one.
once the Bonferroni correction was applied. Site of Finally, a model was determined using variables
recruitment and hospital at discharge (forensic or general) descriptive of participants' criminal careers. The follow-
were also entered as covariates. The best model of adult ing variables were entered into this model: total number
clinical correlates of APD included three variables: adult of crimes, total number of violent crimes, total number of
alcohol abuse or dependence (adjusted odds ratio: 2.92; nonviolent crimes, having a criminal conviction before
797
Schizophrenia Bulletin, Vol. 30, No. 4, 2004 P. Moran and S. Hodgins
nor homicide was found to be associated with APD. This the risk of schizophrenia (Arseneault et al. 2002; Zammit
finding is consistent with the observation that there are et al. 2002), intervening to reduce conduct disorder
several distinct subgroups of offenders with schizophrenia among children with a family history of schizophrenia
(Hodgins 2004). spectrum disorders could reduce cannabis abuse and
The men who developed comorbid APD had experi- thereby lower their risk of developing schizophrenia. The
enced numerous difficulties in childhood and early ado- effective treatment of conduct disorder during childhood
lescence. In addition to presenting conduct disorder, a sig- would reduce antisocial behaviors and increase prosocial
nificantly greater proportion of those with APD, compared skills. If schizophrenia did develop, these skills might
798
Comorbid Antisocial Personality Disorder Schizophrenia Bulletin, Vol. 30, No. 4, 2004
bid APD were first admitted to the general psychiatric ser- Armstrong, T, and Costello, E.J. Community studies on
vice, they had a long history of antisocial behavior, sub- adolescent substance use, abuse, or dependence and psy-
stance abuse, poor academic failure, and an adverse fam- chiatric comorbidity. Journal of Consulting and Clinical
ily environment, and many already had a criminal record. Psychology, 70:1224-1239, 2002.
There was, therefore, ample evidence for general psychi- Arseneault, L.; Cannon, M.; Poulton, R.; Murray, R.;
atric services to identify needs for specific treatments and Caspi, A.; and Moffitt, T.E. Cannabis use in adolescence
services in addition to those traditionally provided to first and risk for adult psychosis: Longitudinal prospective
onset cases of schizophrenia. Ideally, such patients require study. British Medical Journal, 32:1212-1213, 2002.
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Schizophrenia Bulletin, Vol. 30, No. 4, 2004 P. Moran and S. Hodgins
Treatments and Management Strategies. Dordrecht, The Mathalon, D.H.; Pfefferbaum, A.; Lim, K.O.;
Netherlands: Kluwer Academic, 2000. pp. 89-116. Rosenbloom, M.J.; and Sullivan, E.V. Compounded brain
Hodgins, S. Criminal and antisocial behaviors and schizo- volume deficits in schizophrenia-alcoholism comorbidity.
phrenia: A neglected topic. In: Gattaz, W., and Hafner, H., Archives of General Psychiatry, 60:245-252, 2003.
eds. 5th Search for the Causes of Schizophrenia. McGuire, J., ed. What works: Reducing reoffending—
Darmstadt, Germany: Steinkopff Verlag, 2004. pp. Guidelines from research and practice. Chichester, U.K.:
315-341. Wiley, 1995.
Hodgins, S., and Cote, G. The criminality of mentally dis- Moffitt, T.E., and Caspi, A. Childhood predictors differen-
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Comorbid Antisocial Personality Disorder Schizophrenia Bulletin, Vol. 30, No. 4, 2004
Scott, S.; Spender, Q.; Doolan, M.; Jacobs, B.; Aspland, Sheilagh Hodgins, Ph.D., Institute of Psychiatry, King's
H.; and Webster-Stratton, C. Multicentre controlled trial College, London; Derek Eaves, M.D., Vancouver, Canada;
of parenting groups for childhood antisocial behaviour in Markku Eronen, M.D., Ph.D., Vanha Vaasa Hospital,
clinical practice. British Medical Journal, 323:194-198, Vaasa, and Niuvanniemi Hospital, Kuopio, Finland;
2001. Stephen Hart, Ph.D., Simon Fraser University, Burnaby,
Silver, E. Race, neighbourhood, disadvantage, and vio- Canada; Robert Kronstrand, Ph.D., Rattsmedicinalverket
lence among persons with mental disorders: The impor- and Linkoping University, Linkoping, Sweden; Sten
tance of contextual measurement. Law and Human Levander, M.D., Ph.D., University Hospital, MAS,
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Schizophrenia Bulletin, Vol. 30, No. 4, 2004 P. Moran and S. Hodgins
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