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PubMed2003

Moral responsibility and borderline personality disorder.

OBJECTIVE: To examine the concepts of free will and moral responsibility in a psychiatric context, and to consider whether those with borderline personality disorder (BPD) may be considered responsible for their actions. METHOD: A wide, but necessarily incomplete, range of literature was reviewed in the fields of psychiatry and philosophy. I offer a set of criteria for responsible action and examine some features of BPD in the light of these criteria. RESULTS: Impulsivity, acting out and the less severe forms of dissociation do not vitiate responsibility. Severe dissociative and psychotic symptoms may well render people with BPD less morally responsible for their actions. CONCLUSIONS: Comorbid conditions in BPD may also affect the ability to act responsibly.

Borderline Personality Disorder↗
PubMed2003

Antisocial constructs in predicting institutional violence among violent offenders and child molesters.

This study investigated the ability of self-reported antisocial constructs to predict serious institutional infractions among a correctional sample of child molesters (n = 69) and violent offenders (n = 138). Each group had significant predictors, but the predictors differed between the two groups. Interpersonal problems accounted for significant incremental variance after age in the relationship with institutional violence for child molesters. With the violent offender group, alienation and impulse expression showed significant incremental variance after accounting for age. Alienation and impulse expression also added to age in the relationship with the function of failure over time for the most institutionally disruptive. Implications for institutional classification and clinical use in an offender population are discussed.

Adolescent↗
PubMed2005

Psychiatric risk factors for motor vehicle fatalities in young men.

BACKGROUND: Motor vehicle accident (MVA) fatalities are an important cause of death in young men. Psychiatric disorders have been shown to be risk factors for MVA, but only a few studies have investigated MVA fatalities. METHOD: A case-control study was carried out comparing 61 young male MVA fatalities in which the subject was the driver with an equal number of living male subjects matched for age (case by case with no more than 1 year's difference between case subjects and control subjects) with the accident group. We assessed both groups, using structured interviews and psychological autopsies. RESULTS: Our results suggest that cluster B personality disorders (borderline and [or] antisocial) (OR 3.54; 95%CI, 1.38 to 16.01) and substance use disorders in the last 6 months (OR 4.33; 95%CI, 1.42 to 9.25) increased the risk of dying in MVAs. In addition, we observed an age effect, where differences in cluster B personality disorders and substance use disorders in the last 6 months were only significantly more prevalent in case subjects aged 26 years or over, compared with control subjects of the same age. Drivers under age 25 years appeared to be comparable with control subjects on all measures of psychopathology. Finally, this interaction between cluster B personality disorders and age over 26 years was the only significant predictor of car fatalities (adjusted OR 16.25; 95%CI, 1.67 to 158.10). CONCLUSION: Borderline and antisocial personality disorders in which impulsive-aggressive behaviours play a central role and substance use disorders appear to be risk factors for young male deaths in MVAs. Interestingly, this effect seems to be specific to MVA case subjects aged 26 years or over.

Accidents, Traffic↗
PubMed2006

A psychometric typology of U.K. domestic violence offenders.

A number of studies have described subtypes of domestically violent men, and the heterogeneity of domestically violent men is well established. The aim of the current study was to investigate the distribution of subtypes using psychometric measures in convicted domestically violent offenders in England. Four subtypes of offenders were identified: low pathology, borderline, narcissistic, and antisocial. These subtypes were broadly comparable with the family-only, dysphoric/borderline, and generally violent/antisocial types proposed by Holtzworth-Munroe and Stuart. The majority of the sample (60%) best fit the generally violent/antisocial profile. However, the reliance on psychometric measurement and lack of corroborative evidence from partners means that further research is necessary to test these findings.

Adult↗
PubMed2003

Underlying processes in the poor response inhibition of children with Attention-Deficit/Hyperactivity Disorder.

This study evaluated the effects of reward, punishment, and reward + punishment on the impulsive responses of ADHD children. The impulsive responses of ADHD and normal control boys (30 per group) were compared during performance of a go/no-go task, administered under reward-only, punishment-only, and reward + punishment conditions. When differences in aggression, anxiety, and IQ between these groups were controlled for, results indicated that the impulsivity levels of the ADHD group were higher than the control group in all three reinforcement conditions. Also, the ADHD group was more impulsive in the reward + punishment condition, compared to the reward-only and punishment-only conditions, and there was no difference between the reward-only and punishment-only conditions. The control groups showed no difference across the three reinforcement conditions. These findings raise the possibility that the poor response inhibition of ADHD children may be related to both a generalized inhibitory deficit and a response modulation deficit.

Adolescent↗
PubMed2003

Neural substrates underlying impulsivity.

Attention deficit hyperactivity disorder (ADHD) is a neuropsychiatric disorder whose three main symptoms are impulsiveness, inattention, and hyperactivity. Although ADHD is an early developmental disorder, it may persist into adulthood, resulting in deficits associated with poor academic performance, frequent job changes, poor and unstable marriages, and increases in motor vehicle accidents. Of the three primary symptoms of ADHD, deficits in impulse control are the most challenging to the social network and the judicial system. While the etiology of ADHD remains unknown, recent work suggests that the central deficits in ADHD may be due to poor response inhibition that is linked to monoamine and prefrontal lobe deficiencies. In the past, preclinical studies designed to understand the lack of impulse control have generally been relegated to studies linked to aggression and drug abuse. With the use of innovative noninvasive techniques, like anatomical and functional magnetic resonance imaging, selective neurochemical and behavioral paradigms have converged with preclinical reports and lend support to the premise that monoaminergic neurotransmitter systems and the cortico-striatal circuitry are essential to impulse control. Furthermore, new emerging data on neural substrates underlying impulsivity have incorporated brain regions involved in reinforcement, reward, and decision making such as the nucleus accumbens, cerebellum, and amygdala. As noninvasive brain imaging, neurochemical, and behavioral approaches are combined, our knowledge of the neural networks underlying impulsivity will hopefully give rise to therapeutic approaches aimed at alleviating this disorder.

Animals↗
PubMed2004

The relationship between impulsivity, aggression, and impulsive-aggression in borderline personality disorder: an empirical analysis of self-report measures.

Impulsivity has been repeatedly identified as a key construct in BPD; however, its precise definition seems to vary especially regarding the overlap with aggression. The term impulsive-aggression , also generally seen as central to an understanding of BPD, seems to address itself to the interface between the two, but has itself been used inconsistently in the literature, sometimes having reference to a unitary phenotypic dimension, and at other times suggesting some combination of distinct traits. This study examined the relationship between multiple measures of impulsivity, aggression, and impulsive-aggression in a BPD sample ( N = 92) in order to clarify the relationship between these measured constructs in this clinical population. Results show little relationship between measures of aggression and impulsivity in BPD, with measures of impulsive-aggression correlating strongly with measures of aggression only. Implications of the present results for future research and clinical work with BPD are discussed.

Adolescent↗
PubMed1999

Recognition and treatment of DSM-IV intermittent explosive disorder.

Although models of impulsive aggression are often associated with psychiatric disorders, some individuals demonstrate violent outbursts of rage that are variously referred to in the field as rage attacks, anger attacks, episodic dyscontrol, and intermittent explosive disorder. According to DSM-IV, intermittent explosive disorder is characterized by discrete episodes of failure to resist aggressive impulses resulting in serious assaults or destruction of property. Virtually no research has been done on intermittent explosive disorder as defined by DSM-IV criteria, and this article discusses the phenomenology, comorbidity, and treatment response of 27 individuals who met the DSM-IV criteria for the disorder. The association of the explosive episodes in these subjects with maniclike affective symptoms, the high rate of lifetime comorbid bipolar disorder, and the favorable response of explosive episodes to mood-stabilizing drugs suggest that intermittent explosive disorder may be linked to bipolar disorder.

Adolescent↗
PubMed2006

Tourette's syndrome and the law.

Diminished legal responsibility and mental capacity have been used in defense of individuals with neurological disorders charged with legal misdemeanors, including criminal behavior. The purpose of this report is to 1) critically examine the mechanisms that may predispose patients with Tourette's syndrome (TS) to potentially, legally liable behaviors; 2) report the results of a nation-wide review of state, federal, and appellate cases involving TS; and 3) instigate awareness within the professional legal community regarding unrecognized organically-based behaviors that may predispose TS patients to unwanted legal disciplinary action. TS is a common neurological movement disorder of childhood onset associated with behavioral comorbidities, including impulse control problems, exhibition of obscene language or gestures, rage attacks, inappropriate obsessions, and other behaviors. To our knowledge, there are no studies (to date) addressing the potential impact of TS on the legal system. A comprehensive review of the neurobehavioral mechanisms underlying comorbid issues in TS is outlined. A comprehensive review of all cases tried in state and federal courts between 1985 and 2003, in which TS was somehow implicated, was conducted using the Westlaw database. As of October, 2003, TS was implicated in more than 150 cases found in the federal and state databases, 21 of which were criminal. Other cases are categorized as civil rights, criminal, education, family, labor, and social security cases. The authors conclude that TS rarely leads to criminal behavior, but patients with TS who have behavioral comorbidities are at risk of being involved with the legal system. The medical-legal community must learn to recognize the vulnerability of this patient population to potential mistreatment by the courts of justice.

Adolescent↗
PubMed1987

Sexual relationships of patients with kleptomania.

Kleptomania, a disorder of impulse control in which the patients feel a compelling urge to steal objects of no value to them, has long been considered a disorder related in some fashion to sexual impulses. Recent advances in the clinical understanding of human sexual functioning have not been accompanied by an effort to refine our thinking about its relationship to kleptomania. Research is hampered by the relative rarity of the disorder and the propensity of patients to avoid seeking professional help. Consequently, the available literature is restricted to case studies or small series that fail to differentiate between kleptomania and other forms of shoplifting. This paper describes the six patients I have seen with the primary diagnosis of kleptomania; all had dysfunctional sexual relationships. The sole male patient was a homosexual, and compulsively promiscuous. Sexual counseling and/or therapy may provide an additional method for treating this difficult disorder.

Adult↗
PubMed2002

Understanding the abnormal by studying the normal.

OBJECTIVE: In the present paper we ask whether it is meaningful to study psychopathic traits in non-referred youths and whether this kind of research can be used to understand the development of criminal full-blown psychopathy. METHOD: We review studies that have investigated the utility of assessing psychopathic traits in non-referred samples of youths. RESULTS: Research shows that psychopathic traits in non-referred youths manifest similarly to how they are manifested among incarcerated offenders, as indicated by similarities in factor structures. Also, psychopathic traits relate similarly to frequent, violent antisocial behavior in non-referred youths as among adult and adolescent institutionalized criminal offenders. Thus, the differences between the non-referred conduct-problem youths exhibiting a psychopathic personality pattern and the incarcerated, criminal youths identified as psychopathic seem to be quantitative rather than qualitative. CONCLUSION: It is concluded that research on non-referred youth samples can provide important knowledge about the processes that underlie the development of psychopathic traits and how this development can be prevented. Implications for future research and intervention and prevention are discussed.

Adolescent↗
PubMed2002

Serotonin platelet-transporter measures in childhood attention-deficit/hyperactivity disorder (ADHD): clinical versus experimental measures of impulsivity.

Impulsivity in terms of aggression, suicide or poor cognitive control has been associated with low synaptic availability of serotonin (5-HT) in adults and children. However, characteristics of the 5-HT transporter have not been studied in children with attention-deficit/hyperactivity disorder (ADHD: combined type), where impulsivity is a core symptom. Here, we explored in 20 children with ADHD the relationship of the density (Bmax) and affinity (Kd) of the platelet 5-HT transporter measured with [3H]paroxetine to both clinical ratings of impulsivity (Conners' Parent Questionnaire), and an experimental measure of impulsivity (the ability to withhold a prepotent response in the "stop-signal" paradigm). Decreases of affinity (increased Kd) correlated with a low probability of response inhibition, but not with the clinical ratings of impulsivity. However, ratings of distractibility and impulsivity correlated with the experimental measure of response-inhibition. In contrast, increased transporter affinity (low Kd) correlated modestly with higher ratings of aggressive and externalising behaviour. Bmax was not associated with any behavioural score. We conclude that the synaptic availability of 5-HT is under the control of the 5-HT transporter binding site affinity and that low affinity may be related to cognitive impulsivity (distractibility). Increased affinity of the transporter may also be related to conduct disturbance.

Adolescent↗
PubMed1987

A family study of patients with temper outbursts.

To evaluate the heritability of a personality trait, "having temper outbursts," and of associated diagnoses, we obtained histories of first degree relatives on two groups: (1) patients with temper outbursts (N = 33), and (2) diverse psychiatric patients without temper outbursts (N = 12). Family interviews were conducted blind to patient (temper or not) status, using a modified version of the Family History RDC. Though Ns are relatively small, and results therefore require confirmation, the data indicate familial transmission of temper problems; an average of 18.2% of Group 1 relatives had temper problems, compared to 4.3% for Group 2. The trait of having temper outbursts was more strongly transmitted than were specific diagnoses (e.g. Intermittent Explosive Disorder, Antisocial Personality Disorder or Residual Attention Deficit Disorder) associated with temper outbursts. Patients with neurological conditions apparently related to their temper outbursts were less likely to have positive family histories.

Adult↗
PubMed2001

[The anxiety-phobic disorder classification in children].

The study on development regularities and psychopathological structure of anxiety phobic disorders has been conducted in 92 patients, aged 5-15 years. The structure of anxiety-phobic complex is represented. A level of anxiety affect development (primary or secondary, presence and direction of affect cognitive component) and negative effectiveness were emerged in the children as common obligate anxiety-phobic characteristics, which contributed to complex structure stability. Three anxiety-phobic disorder types--situation-dependent, personality-dependent and vital--were distinguished. The first one is characterized by the combination of secondary anxiety with cognitive vector expression, the vector being outside directed, and emotionally unstable negative effectiveness variant (particular sensitivity to negative situations with disability for negative emotion control). The second type is distinguished by secondary anxiety manifestations, the anxiety vector being directed towards the self-ego. In these cases, personality component--rigid variant of negative effectiveness (higher sensitivity to negative events, along with disability for negative emotion modulation) dominates. The third type is defined by the combination of primary anxiety (with vital disturbance, diffusion, psychic activity disorganization in the absence of cognitive component) with rigid variant of negative effectiveness. The types of manifesting anxiety-phobic disorders described correspond to reactive (situation-dependent type), endoreactive (personality-dependent type) and autochthonous (vital type) variants of the disease course.

Adolescent↗
PubMed2006

One session of high frequency repetitive transcranial magnetic stimulation (rTMS) to the right prefrontal cortex transiently reduces cocaine craving.

BACKGROUND: Cocaine dependence is a public health problem affecting 2 million individuals in USA. Craving is a predictor of subsequent cocaine use and is related to changes in brain activity in networks involving the prefrontal cortex. METHODS: We investigated the efficacy of one session of high frequency repetitive transcranial magnetic stimulation (rTMS) to reduce craving in cocaine addicted subjects. Six patients underwent two sessions of 10Hz rTMS over left or right dorsolateral prefrontal cortex (DLPFC). Before, immediately after and 4h after rTMS we measured craving using visual analogue scales. RESULTS: Right, but not left, DLPFC stimulation significantly reduced craving over time (F(2,10)=11.07, p=0.0029). The reduction was 19% (13.4-24.6%) from baseline and disappeared after 4h. The interaction of time by site of stimulation for craving was also significant (F(2,25)=6.13, p=0.0068). CONCLUSION: One session of 10Hz rTMS over right, but not left, DLPFC transiently reduces craving in cocaine dependent individuals. These results highlight the potential of non-invasive neuromodulation as a therapeutic tool for cocaine addiction.

Adult↗
PubMed2006

Cell phones for ecological momentary assessment with cocaine-addicted homeless patients in treatment.

This is the first study to examine whether cell phones could be used to collect ecological momentary assessment (EMA) data with homeless crack cocaine-addicted adults in treatment. The study adapted an EMA method to examine behavior in real time using cell phones and computer-automated telephone interviewing. Participants treated in an intensive outpatient treatment program were given cell phones for a 2-week period to record current states of cocaine craving and using episodes. Results showed cell phone technology could reliably deliver a computerized survey; this homeless population would use a cell phone to report craving and using episodes, and drug use reported via EMA was in agreement with urine toxicology results for 73% of participants. Of 30 participants, 24 (80%) completed the full 2-week protocol. Participants indicated the survey made them more aware of phenomena leading to cravings and use, suggesting the usefulness of EMA as a potential intervention.

Adult↗
PubMed1994

Determinants of early alcohol and drug use among young women in alcoholism treatment.

Substance abuse experimentation may be one of several types of problem behaviors. Data from 99 Caucasian women interviewed in alcoholism treatment (19-29 years old) were used to test a developmental model of substance experimentation. Respondents were classified into three groups based on their use prior to age 15: nonusers, users of alcohol only, and users of alcohol and other drugs. Family history of alcoholism was not related to childhood anxiety and impulse control problems. Childhood anxiety and impulse control problems predicted adolescent emotional and impulse control problems but did not differentiate early experimenters. Whereas adolescent emotional problems were not related to early experimentation, early drug and alcohol users were significantly more likely to have engaged in other impulsive behaviors (e.g., running away from home, trouble with school authorities) than were nonusers or users of alcohol only. Alcoholism prevention programs, therefore, would do well to target youth who exhibit acting-out behaviors as a high-risk group for early alcohol and drug use.

Acting Out↗