Friday, March 4, 2011

More on Borderlines and Crime

In January I posted on Borderline Personality Disorder, Crime and Responsibility.  More recently, I came across an interesting literature review on the topic of BPD and its association with crime and incarceration.  “Borderline Personality and Criminality,” by Randy and Lori Sansone, was published in Psychiatry in 2009.

In this paper, the authors review multiple studies that have looked into the rates of Borderline Personality Disorder among the incarcerated and the criminal.  They acknowledge that it is not a comprehensive review and they did find a wide discrepancy in findings probably related to differences in methodology as well as peculiarities of different sample populations drawn on from penitentiaries.

Their overall conclusions:
According to the findings of the majority of studies in this area, compared to rates expected in the community, BPD is over-represented in prison populations.  This finding may be particularly evident among female prisoners.  Rates vary, depending on the methodology, but generally appear to be in the range of 25-50 percent.
This is a considerable difference from the rate in the general population that has been measured at between two and six percent. 

They continue:
Factors that may be associated with the presence of BPD among criminals include being female, having a history of childhood sexual abuse, committing an impulsive and violent crime (e.g., murder), having antisocial personality disorder traits, and perpetrating domestic violence.  given this association, clinicians in both mental health and primary care settings need to be aware of the possibilities of such histories in their patients with BPD.
It is well known that BPD has a higher rate among women than men.  This holds true in prison populations as well.  Rates among incarcerated men range around 5-6%, very similar, but maybe slightly higher than men in general.  Now where it gets interesting is with women.  Studies varied significantly in their findings.  On the low end, one study found 11.5% of incarcerated women to have BPD but another study found as many as 42.9%!  This last study was conducted in Germany using structured interviews.  Overall, not only do imprisoned  women have a higher rate of BPD than men, but also significantly higher than women in general.

It has often been speculated that the overall gender imbalance is due to biases in the formulation of the disorder criteria or biases in the act of diagnosing.  The authors mention this question in passing but do not offer any speculations.  (In my own, non-scientific, observations from the world of practice, I believe that because we expect to see BPD in women it leads to over-diagnosing among women where any kind of Axis II behavioral problems tend to result in a BPD label while, in contrast, BPD traits in men often go unnoted or misinterpreted as anti-social features.)

Childhood sexual abuse:
As with the general population, incarcerated people with BPD had a higher rate of childhood sexual abuse.  Not surprisingly, history of childhood sexual abuse was even higher for incarcerated women who were both sex offenders themselves and met the criteria for BPD.

Violent offenses:
Overall, data supports an association between BPD with higher rates of violence (toward others) when comparing prisoners with and without BPD.  One study found that women prisoners who had committed crimes related to major violence were four times more likely to meet criteria for BPD than women who had committed minimally violent crimes.  Another study of men in British prisons for murder found 49% of their subjects had BPD traits.

Some studies looked at violence in association to subtypes of BPD.  One study found serial murderers to be associated with a strongly manipulative subtype of BPD.  Another study relates rage-based murder with an “over-control” subtype of BPD.  The authors conclude that “the majority of current data and impressions indicate an association between BPD and the impulsive, rage-fueled murder."

Antisocial personality:
Both BPD and Antisocial Personality Disorder are associated with higher rates of violence.  Antisocial individuals tend to engage in more property crimes and are more calculating and planned.  Borderline individuals tend toward episodes of aggression and violence.

Where BPD and APD co-occur, there are significantly higher rates of anger, impulsivity and aggression resulting in a higher score of psychopathy.  (Personally, I've often felt there is a significant overlap between these two categories but the authors do not give any additional insight on the topic.)

Domestic Violence:
Multiple studies have found a very solid association between BPD and both male and female batterers.  Many batterers have a history of experiencing trauma themselves, and this, in turn, is also associated with development of BPD.  One study found that 27% of women arrested for domestic violence met the criteria for BPD.

Overall it seems there is a very clear link between BPD and both violence and criminality in general.  The strength of that link varies quite a bit from study to study, however.  The authors offer no causal speculations.  Make of it what you will.

Reference:  Sansone, Randy; Sansone, Lori (2009).  “Borderline Personality and Criminality.”  Psychiatry; 6(10):16-20.

Wednesday, March 2, 2011

Drug Money and Scientific Objectivity

A study published in the Canadian Medical Association Journal (CMAJ) confirms what we all suspected.  Drug money sullies the objectivity of medical journals.

Medical journals run the gambit from purely funded by subscription to those that are funded solely by advertising.  Some journals have both kinds of revenue.  The ad-supported journals get most of their business from pharmaceutical manufacturers.  These drug money supported journals are typically sent free to doctors around the world and have much larger circulation than the subscription supported journals.  These free journals are also less likely to be peer reviewed.

The CMAJ study examined 11 medical journals with distributions in Germany in 2007.  In addition they surveyed Canadian general practitioners to find what journals they rely on for up-to-date data.  The write-up states, “Our study shows that the tendency to positively recommend the use of a drug depends on the source of a journal’s funding . . . Free journals almost exclusively endorse the use of the selected drugs, whereas journals that rely exclusively on subscription fees for their revenue are more likely to recommend against the use the same drugs. . . . More than half of the doctors surveyed had used free journals as a source of information during the previous months.”

This kind of bias can be critical when adverse reaction to prescription medication is the sixth leading cause of the death, at least in the US (reported in JAMA several years ago).  This study was not specific to psychiatric drugs but it certainly has salience in the psychiatric field where many medicinal treatments have questionable benefit.  If the risk-benefit calculation is skewed, then neither doctors nor patients are making truly informed decisions.

We now know that people with severe mental illness have life spans that are 20 years shorter than the general population.  How much of that is a result of our pharmaceutical treatments?

Reference: Becker, Anette; et al.  Canadian Medical Association Journal (2011, March 1).  The influence of advertising on drug recommendations.