Personality Traits as Predictors of Inpatient Aggression in a High-Security Forensic Psychiatric Setting: Prospective Evaluation of the PCL-R and IPDE Dimension Ratings
Restricted accessResearch articleFirst published online May, 2011
Personality Traits as Predictors of Inpatient Aggression in a High-Security Forensic Psychiatric Setting: Prospective Evaluation of the PCL-R and IPDE Dimension Ratings
The Dangerous and Severe Personality Disorder (DSPD) initiative in England and Wales provides specialized care to high-risk offenders with mental disorders. This study investigated the predictive utility of personality traits, assessed using the Psychopathy Checklist—Revised (PCL-R) and the International Personality Disorder Examination, with 44 consecutive admissions to the DSPD unit at a high-security forensic psychiatric hospital. Incidents of interpersonal physical aggression (IPA) were observed for 39% of the sample over an average 1.5-year period following admission. Histrionic personality disorder (PD) predicted IPA, and Histrionic, Borderline, and Antisocial PDs all predicted repetitive (2+ incidents of) IPA. PCL-R Factor 1 and Facets 1 and 2 were also significant predictors of IPA. PCL-R Factor 1 and Histrionic PD scores were significantly associated with imminence of IPA. Results were discussed in terms of the utility of personality traits in risk assessment and treatment of specially selected high-risk forensic psychiatric patients in secure settings.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
2.
Andrews, D.A., & Bonta, J. ( 2006). The psychology of criminal conduct (4th ed.). Newark, NJ: LexisNexis .
3.
Andrews, D.A., Dowden, C., & Rettinger, J.L. (2001). Special populations within corrections. In J. A. Winterdyk (Ed.), Corrections in Canada: Social reactions to crime (pp. 170-212). Toronto, Ontario, Canada: Prentice Hall.
4.
Blackburn, R. ( 2000). Treatment or incapacitation? Implications of research on personality disorders for the management of dangerous offenders. Legal and Criminological Psychology, 5, 1-21.
5.
Blackburn, R. ( 2007a). Personality disorder and antisocial deviance: Comments on the debate on the structure of the Psychopathy Checklist-Revised. Journal of Personality Disorders, 21, 142-159.
6.
Blackburn, R. ( 2007b). Personality disorder and psychopathy: Conceptual and empirical integration. Psychology, Crime & Law, 13, 7-18.
7.
Blackburn, R., Logan, C., Renwick, S., & Donnelly, J. ( 2005). Higher-order dimensions of personality disorder: Hierarchical structure and relationships with the five-factor model, the interpersonal circle, and psychopathy. Journal of Personality Disorders , 19, 597-623.
8.
Blagov, P.S., Fowler, K.A., & Lilienfeld, S.O. (2007). Histrionic personality disorder. In W. O’Donohue, K. A. Fowler, & S. O. Lilienfeld (Eds.), Personality disorders: Toward the DSM-V (pp. 203-232). Los Angeles, CA: Sage.
9.
Blashfield, R.K., & Intoccia, V. ( 2000). Growth of the literature on the topic of personality disorders. American Journal of Psychiatry, 157, 472-473.
10.
Bradley, R., Conklin, C.Z., & Westen, D. ( 2007). Borderline personality disorder. In W. O’Donohue, K. A. Fowler, & S. O. Lilienfeld (Eds.), Personality disorders: Toward the DSM-V (pp. 167-201). Los Angeles, CA: Sage.
11.
Coid, J., Kahtan, N., Gault, S., & Jarman, B. ( 1999). Patients with personality disorder admitted to secure forensic psychiatric services. British Journal of Psychiatry , 175, 528-536.
12.
Coid, J., Yang, M., Roberts, A., Ullrich, S., Moran, P., Bebbington, P., . . . Singleton, N. ( 2006a). Violence and psychiatric morbidity in a national household population-A report from the British Household Survey. American Journal of Epidemiology, 164, 1199-1208.
13.
Coid, J., Yang, M., Roberts, A., Ullrich, S., Moran, P., Bebbington, P., . . . Singleton, N. ( 2006b). Violence and psychiatric morbidity in a national household population of Britain: Public health implications. British Journal of Psychiatry, 189, 12-19.
14.
Coid, J., Yang, M., Ullrich, S., Tianqiang, Z., Roberts, A., Roberts, C., . . . Farrington, D. (2007). Predicting and understanding risk of re-offending: The Prisoner Cohort Study. Ministry of Justice Research Summary6. London: Ministry of Justice, Research, Development and Statistics Directorate.
15.
Cooke, D.J., Michie, C., Hart, S.D., & Clark, D. ( 2005). Assessing psychopathy in the UK: Concerns about cross-cultural generalisability. British Journal of Psychiatry, 186, 335-341.
16.
Daffern, M., Howells, K., & Ogloff, J.R.P. (2006). What’s the point? Towards a methodology for assessing the function of psychiatric inpatient aggression. Behaviour Research and Therapy, 45, 101-111.
17.
de Brito, S.A., & Hodgins, S. ( 2009). Antisocial personality disorder. In M. McMurran & R. C. Howard (Eds.), Personality, personality disorder and violence (pp. 133-153). Chichester, UK: Wiley.
18.
de Vogel, V., & de Ruiter, C. ( 2005). The HCR-20 in personality disordered female offenders: A comparison with a matched sample of males. Clinical Psychology and Psychotherapy, 12, 226-240.
19.
Doren, D.M. ( 2002). Evaluating sex offenders: A manual for civil commitments and beyond. Thousand Oaks, CA: Sage.
20.
Douglas, K.S., & Skeem, J.L. ( 2005). Violence risk assessment: Getting specific about being dynamic. Psychology, Public Policy, and Law, 11, 347-383.
21.
Dspd Programme, Department of Health, Ministry of Justice, & HM Prison Service. (2008). Dangerous and Severe Personality Disorder (DSPD) High secure services for men: Planning and delivery guide. Retrieved from http://www.dspdprogramme.gov.uk/media/pdfs/High_Secure_Services_for_Men.pdf
22.
Duggan, C. ( 2004). Does personality change and, if so, what changes?Criminal Behaviour and Mental Health, 14, 5-16.
23.
Duggan, C. ( 2008). Why are programmes for offenders with personality disorder not informed by the relevant scientific findings? Philosophical Transactions of the Royal Society: Biological Sciences, 363, 2599-2612.
24.
Duggan, C., & Howard, R. ( 2009). The "functional link" between personality disorder and violence: A critical appraisal. In M. McMurran & R. C. Howard (Eds.), Personality, personality disorder and violence (pp. 19-37). Chichester , UK: Wiley.
25.
Eaves, D., Douglas, K.S., Webster, C.D., Ogloff, J.R.P., & Hart, S.D. ( 2000). Dangerous and long-term offenders: An assessment guide . Burnaby, BC: Simon Fraser University , Mental Health, Law, and Policy Institute.
26.
Edens, J.F. ( 2006). Unresolved controversies concerning psychopathy: Implications for clinical and forensic decision making. Professional Psychology: Research and Practice, 37, 59-65.
27.
Edens, J.F., & Petrila, J. ( 2006). Legal and ethical issues in the assessment and treatment of psychopathy. In C. Patrick (Ed.), Handbook of psychopathy (pp. 573-588). New York, NY: Guilford.
28.
First, M.B., Spitzer, R.L., Gibbon, M., & Williams, J.B.W. (1996). Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version (SCID-CV). Washington, DC: American Psychiatric Press.
29.
Fox, J.J., & Gable, R.A. ( 2004). Functional behavioral assessment. In R. B. Rutherford, M. M. Quinn, & S. R. Mathur (Eds.), Handbook of research in emotional and behavioral disorders (pp. 143-162). New York, NY: Guilford.
30.
Gadon, L., Johnstone, L., & Cooke, D. ( 2006). Situational variables and institutional violence: A systematic review of the literature. Clinical Psychology Review, 26, 515-534.
31.
Gendreau, P., Goggin, C., & Smith, P. ( 2002). Is the PCL-R really the "unparalleled" measure of offender risk? A lesson in knowledge cumulation. Criminal Justice and Behavior, 29, 397-426.
32.
Gray, N.S., McGleish, A., MacCulloch, M.J., Hill, C., Timmons, D., & Snowden, R.J. ( 2003). Prediction of violence and self-harm in mentally disordered offenders: A prospective study of the efficacy of HCR-20, PCL-R, and psychiatric symptomatology. Journal of Consulting and Clinical Psychology , 71, 443-451.
33.
Guy, L.S., Edens, J.F., Anthony, C., & Douglas, K.S. ( 2005). Does psychopathy predict institutional misconduct among adults? A meta-analytic investigation. Journal of Consulting and Clinical Psychology, 73, 1056-1064.
34.
Hanley, J.A., & McNeil, B.J. (1982). The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology, 143, 29-36.
Harris, G.T., Rice, M.E., Quinsey, V.L., Lalumière, M.L., Boer, D., & Lang, C. ( 2003). A multisite comparison of actuarial risk instruments for sex offenders. Psychological Assessment, 15, 413-425.
38.
Hart, S.D. ( 1998). The role of psychopathy in assessing risk for violence: Conceptual and methodological issues. Legal and Criminological Psychology, 3, 121-137.
39.
Hart, S.D., Forth, A.E., & Hare, R.D. ( 1991). The MCMI-II and psychopathy. Journal of Personality Disorders, 5, 318-327.
40.
Heilbrun, K., Hart, S.D., Hare, R.D., Gustafson, D., Nunez, C., & White, A.J. ( 1998). Inpatient and postdischarge aggression in mentally disordered offenders: The role of psychopathy. Journal of Interpersonal Violence, 13, 514-527.
41.
Hemphill, J.F., Hare, R.D., & Wong, S. ( 1998). Psychopathy and recidivism: A review. Legal and Criminological Psychology, 3, 139-170.
42.
Hildebrand, M., & de Ruiter, C. ( 2004). PCL-R psychopathy and its relation to DSM-IV Axis I and II disorders in a sample of male forensic psychiatric patients in the Netherlands . International Journal of Law and Psychiatry, 27, 233-248.
43.
Hogue, T.E., Jones, L., Talkes, K., & Tennant, A. ( 2007). The Peaks: A clinical service for those with dangerous and severe personality disorder. Psychology, Crime & Law , 13, 57-68.
44.
Home Office and Department of Health. (1999 ). Managing dangerous people with severe personality disorder: Proposals for policy development. London, UK: Department of Health.
45.
Howard, R.C., Huband, N., Duggan, C., & Mannion, A. ( 2008). Exploring the link between personality disorder and criminality in a community sample. Journal of Personality Disorders, 22, 589-603.
46.
Howells, K. ( 2009). Angry affect, aggression and personality disorder. In M. McMurran & R. C. Howard (Eds.), Personality, personality disorder and violence (pp. 191-211). Chichester, UK: Wiley.
47.
Howells, K., & Day, A. ( 2007). Readiness for treatment in high risk offenders with personality disorders. Psychology, Crime & Law, 13, 47-56.
48.
IMPALOX Group. (2007). Evaluation of the assessment procedure at two pilot sites in the DSPD programme (IMPALOX Study). Retrieved from http://www.dspdprogramme.gov.uk/media/pdfs/2007_06_02-IMPALOX%20Study.pdf
49.
Jackson, R.L., & Richards, H.J. (2007). Diagnostic and risk profiles among civilly committed sex offenders in Washington State. International Journal of Offender Therapy and Comparative Criminology, 51, 313-323.
50.
Johnson, J.G., Cohen, P., Smailes, E., Kasen, S., Oldham, J.M., Skodol, A.E., & Brook, J.S. ( 2000). Adolescent personality disorders associated with violence and criminal behavior during adolescence and early adulthood. American Journal of Psychiatry, 157, 1406-1412.
51.
Johnson, J.G., Rabkin, J.G., Williams, J.B.W., Remien, R.H., & Gorman, J.M. ( 2000). Difficulties in interpersonal relationships associated with personality disorders and axis I disorders: A community-based longitudinal investigation. Journal of Personality Disorders, 14, 42-56.
52.
Langton, C.M. ( 2007). Assessment implications of "What Works" research for Dangerous and Severe Personality Disorder (DSPD) service evaluation. Psychology, Crime & Law, 13, 97-111.
53.
Langton, C.M., Hogue, T.E., Daffern, M., Mannion, A., & Howells, K. ( 2009). Prediction of institutional aggression among personality disordered forensic patients using actuarial and structured clinical risk assessment tools: Prospective evaluation of the HCR-20, VRS, Static-99, and Risk Matrix 2000. Psychology, Crime & Law, 15, 635-659.
54.
Leistico, A.-M.R., Salekin, R.T., DeCoster, J., & Rogers, R. ( 2008). A large-scale meta-analysis relating the Hare measures of psychopathy to antisocial conduct. Law and Human Behavior , 32, 28-45.
55.
Levy, K.N., Reynoso, J.S., Wasserman, R.H., & Clarkin, J.F. ( 2007). Narcissistic personality disorder. In W. O’Donohue, K. A. Fowler, & S. O. Lilienfeld (Eds.), Personality disorders: Toward the DSM-V (pp. 233-277). Los Angeles, CA: Sage.
56.
Lilienfeld, S.O., VanValkenburg, C., Larntz, K., & Akiskal, H.S. ( 1986). The relationship of histrionic personality disorder to antisocial personality and somatization disorder. American Journal of Psychiatry, 143, 718-722.
57.
Livesley, W.J. ( 2001). Conceptual and taxonomic issues. In W. J. Livesley (Ed.), Handbook of personality disorders: Theory, research, and treatment (pp. 3-38). New York, NY: Guilford.
58.
Livesley, W.J. ( 2007). The relevance of an integrated approach to the treatment of personality disordered offenders. Psychology, Crime & Law, 13, 27-46.
59.
Logan, C. (2009). Narcissism . In M. McMurran & R. C. Howard (Eds.), Personality, personality disorder and violence (pp. 85-112). Chichester, UK: Wiley.
60.
Loranger, A. W., Janca, A., & Sartorius, N. (Eds.). (1997). Assessment and diagnosis of personality disorders: The ICD-10 international personality disorder examination (IPDE). Cambridge, UK: Cambridge University Press.
61.
Loranger, A.W., Sartorius, N., Andreoli, A., Berger, P., Buchheim, P., Channabasavanna, S.M., . . . Regier, D. ( 1994). The international personality disorder examination: The World Health Organization/Alcohol, Drug Abuse, and Mental Health Administration International pilot study of personality disorders. Archives of General Psychiatry, 51, 215-224.
62.
Luisada, P.V., Peele, R., & Pittard, E.A. ( 1974). The hysterical personality in men. American Journal of Psychiatry, 131, 518-522.
63.
Maden, A. ( 2007). Dangerous and severe personality disorder: antecedents and origins. British Journal of Psychiatry, 190 (Suppl. 49), s8-s11.
64.
McDermott, B.E., Edens, J.F., Quanbeck, C.D., Busse, D., & Scott, C.L. ( 2008). Examining the role of static and dynamic risk factors in the prediction of inpatient violence: Variable-and person-focused analyses . Law and Human Behavior, 32, 325-338.
65.
McGrath, R.E., & Meyer, G.J. ( 2006). When effect sizes disagree: The case of r and d. Psychological Methods, 11, 386-401.
66.
McGuire, J. ( 2008). A review of effective interventions for reducing aggression and violence. Philosophical Transactions of the Royal Society: Biological Sciences, 363, 2577-2597.
67.
McMurran, M., & Howard, R. C. (Eds.). (2009). Personality, personality disorder and violence. Chichester, UK: Wiley.
68.
Miller, R.J., Zadolinnyi, K., & Haffner, R.J. ( 1993). Profiles and predictors of assaultive-ness for different psychiatric ward populations. American Journal of Psychiatry , 150, 1368-1373.
69.
Moran, P., Walsh, E., Tyrer, P., Burns, T., Creed, F., & Fahy, T. ( 2003). Impact of comorbid personality disorder on violence in psychosis: Report from the UK700 trial. British Journal of Psychiatry, 182, 129-134.
70.
Mossman, D. ( 1994). Assessing predictions of violence: Being accurate about accuracy. Journal of Consulting and Clinical Psychology, 62, 783-792.
71.
Nolan, K.A., Czobor, P., Roy, B.B., Platt, M.M., Shope, C.B., Citrome, L.L., & Volavka, J. ( 2003). Characteristics of assaultive behavior among psychiatric patients. Psychiatric Services, 54, 1012-1016.
72.
Rice, M.E., & Harris, G.T. ( 2005). Comparing effect sizes in follow-up studies: ROC area, Cohen’s d, and r. Law and Human Behavior, 29, 615-620.
73.
Ronningstam, E. ( 2005). Narcissistic personality disorder: A review. In M. Maj, H. S. Akiskal, J. E. Mezzich, & A. Okasha (Eds.), Personality disorders (pp. 277-327). New York, NY: John Wiley.
74.
Sanislow, C.A., & McGlashan, T.H. (1998). Treatment outcomes of personality disorders. Canadian Journal of Psychiatry, 43, 237-250.
75.
Shine, J., & Hobson, J. ( 1997). Construct validity of the Hare Psychopathy Checklist, revised, on a UK prison population. Journal of Forensic Psychiatry , 8, 546-561.
76.
Skeem, J.L., Mulvey, E.P., & Grisso, T. ( 2003). Applicability of traditional and revised models of psychopathy to the Psychopathy Checklist: Screening version. Psychological Assessment, 15, 41-55.
77.
Swets, J.A., Dawes, R.M., & Monahan, J. ( 2000). Psychological science can improve diagnostic decisions . Psychological Science in the Public Interest, 1, 1-26.
78.
Tardiff, K., Marzuk, P.M., Leon, A.C., & Portera, L. ( 1997). A prospective study of violence by psychiatric patients after hospital discharge. Psychiatric Services, 48, 678-681.
79.
Taylor, R. ( 2003). An assessment of violent incident rates in the Dangerous Severe Personality Disorder Unit at HMP Whitemoor (Findings 210). London, UK: Home Office, Research, Development and Statistics Directorate.
80.
Trevethan, S., Crutcher, N., & Moore, J.-P. ( 2002). A profile of federal offenders designated as dangerous offenders or serving long-term supervision orders (R-125). Ottawa, Ontario, Canada: Research Branch, Correctional Service of Canada. Retrieved from http://www.cscscc.gc.ca/text/rsrch/reports/r125/r125_e.pdf
81.
Turner, R.M., & Dudek, P. ( 1997). Outcome evaluation of psychosocial treatment for personality disorders: Functions, obstacles, goals, and strategies. In H. H. Strupp, L. M. Horowitz , & M. J. Lambert (Eds.), Measuring patient change in mood, anxiety, and personality disorders: Toward a core battery (pp. 433-460). Washington, DC: American Psychological Association.
82.
Tyrer, P. ( 2004). Editorial: Getting to grips with severe personality disorder . Criminal Behaviour and Mental Health, 14, 1-4.
83.
Tyrer, P., Coombs, N., Ibrahimi, F., Mathilakath, A., Bajaj, P., Ranger, M., . . . Din, R. ( 2007). Critical developments in the assessment of personality disorder. British Journal of Psychiatry, 190(Suppl. 49), s51-s59.
84.
Tyrer, P., Mitchard, S., Methuen, C., & Ranger, M. ( 2003). Treatment rejecting and treatment seeking personality disorders: Type R and Type S. Journal of Personality Disorders , 17, 263-268.
85.
Ullrich, S., & Marneros, A. ( 2004). Dimensions of personality disorders in offenders. Criminal Behaviour and Mental Health, 14, 202-213.
86.
Ullrich, S., & Marneros, A. ( 2007). Underlying dimensions if ICD-10 personality disorders: Risk factors, childhood antecedents, and adverse outcomes in adulthood. Journal of Forensic Psychiatry and Psychology, 18, 44-58.
87.
Vitacco, M.J., Van Rybroek, G.J., Rogstad, J.E., Yahr, L.E., Tomony, J.D., & Saewert, E. ( 2009). Predicting short-term institutional aggression in forensic patients: A multi-trait method for understanding subtypes of aggression. Law and Human Behavior, 33, 308-319.
88.
Walters, G.D. ( 2003). Predicting institutional adjustment and recidivism with the Psychopathy Checklist factor scores: A meta-analysis. Law and Human Behavior, 27, 541-558.
89.
Walters, G.D., Knight, R.A., Grann, M., & Dahle, K.-P. ( 2008). Incremental validity of the Psychopathy Checklist facet scores: Predicting release outcome in six samples. Journal of Abnormal Psychology, 117, 396-405.
90.
Warner, M.B., Morey, L.C., Finch, J.F., Gunderson, J.G., Skodol, A.E., Sanislow, C., . . . Grilo, C.M. ( 2004). The longitudinal relationship of personality traits and disorders. Journal of Abnormal Psychology, 113, 217-227.
91.
Widiger, T.A., & Frances, A.J. ( 2002). Toward a dimensional model for the personality disorders . In P. T. Costa & T. A. Widiger (Eds.), Personality disorders and the five-factor model of personality (2nd ed., pp. 23-44). Washington, DC: American Psychological Association .
92.
Widiger, T.A., & Trull, T.J. ( 1994). Personality disorders and violence. In J. Monahan & H. J. Steadman (Eds.), Violence and mental disorder: Developments in risk assessment (pp. 203-226). Chicago, IL: University of Chicago Press.
93.
Wong, S.C.P., Gordon, A., & Gu, D. ( 2007). Assessment and treatment of violence-prone forensic clients: An integrated approach. British Journal of Psychiatry, 190(Suppl. 49), s66-s74.
94.
Wong, S.C.P., & Hare, R.D. ( 2005). Guidelines for a Psychopathy Treatment Program. Toronto, Ontario, Canada: Multi-Health Systems.
95.
Wormith, J.S., & Olver, M.E. ( 2002). Offender treatment attrition and its relationship with risk, responsivity and recidivism. Criminal Justice and Behavior , 29, 447-471.
96.
Wormith, J.S., Olver, M.E., Stevenson, H.E., & Girard, L. ( 2007). The long-term prediction of offender recidivism using diagnostic, personality, and risk/need approaches to offender assessment. Psychological Services, 4, 287-305.
97.
Yudofsky, S.C., Silver, J.M., Jackson, W., Endicott, J., & Williams, D. ( 1986). The Overt Aggression Scale for the objective rating of verbal and physical aggression. American Journal of Psychiatry , 143, 35-39.
