Female psychopathy: A descriptive national study of socially dangerous female NGRI offenders

International Journal of Law and Psychiatry 68 (2020) 101455

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Female psychopathy: A descriptive national study of socially dangerous female NGRI offenders☆

T

Felice Carabellesea, Alan R. Felthousb, , Donatella La Tegolaa,1, Ilaria Rossettoc,1, Filippo Franconic,1, G. Lucchinic,2, R. Catanesia ⁎

a

Section of Criminology and Forensic Psychiatry, Department of Internal Medicine, University of Bari Aldo Moro, Policlinico Universitario, p.za G. Cesare, 70124 Bari, Italy b Forensic Psychiatry Division, Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, 1438 South Grand Blvd, Saint Louis, MO 63104, USA c Sistema Polimodulare REMS Castiglione delle Stiviere ASL, MN, Mantova, Italy

ARTICLE INFO

ABSTRACT

Keywords: NGRI women offenders Psychopathy PCL-R Female psychopathy Borderline personality disorder

Understudied is psychopathy in females, particularly socially dangerous NGRI females, where the construct could be of forensic, clinical and criminologic significance. Italy's recent transformation of its mental health system created the context for studying such a population on a national level. Throughout the twentieth century until their closure in 2015, offenders found to be not guilty by reason of insanity (NGRI) and socially dangerous were placed in one of the the six high security hospitals in Italy (OPGs). Only one hospital, the Castiglione delle Stiviere maximum security hospital (OPG) in North Italy, treated female offenders, who came from all parts of Italy. The authors studied 66 of all 86 women in Castiglione delle Stiviere OPG. The aims of this study were to identify the prevalence of psychopathy in NGRI female offenders and eventually to identify any phenotypic gender-specific features of psychopathy. The SCID I and II interviews and other tests (MMPI-2, MCMI-III, R-Bans) were administered to all the women. Clinical historical information was obtained. Finally for all women who consented to participate in the study, the researchers administered the PCLR version validated for the Italian population. The final sample consisted of 66 women, who were deemed NGRI and socially dangerous. Here the authors present the final results as well as limitations of the research.

1. Introduction Psychopathy, an important construct for psychopathology, offender therapy, and criminal recidivism, has been little studied and therefore not well understood in female populations (Logan, 2009). Studies on the relationship between psychopathy and crime have focused mostly on males, not females (Nicholls, Odgers, & Cooke, 2007; Nicholls & Petrilla, 2006; Wynn, Hoiseth, & Pettersen, 2012. Verona and Vitale (2018), conclude that women show different manifestations of psychopathy in comparison with men. Psychopathic women tend to be less aggressive than men, at greater risk of suicide and more at risk of using drugs. They are also more seductive in their manipulative purposes (Verona, Sprague, & Sadeh, 2012). Several studies have reported a significant correlation, more often in women than in men, between

psychopathy and borderline personality disorder (BPD) (Carabellese et al., 2018; Verona & Vitale, 2018). Therefore BPD is thought to represent the phenotypical expression of psychopathy in females. The prevalence of psychopathy is also lower in women than in men due to several causes, which may interact with each other (Farrington, 2007; Jang, Stein, Taylor, Asmundson, & Livesley, 2003; Krischer, Sevecke, & Lehmkuhl, 2007; Wood & Eagly, 2002). Psychopathy is observed in 11–17.4% of women who commit violent acts, as compared to the 31% estimated among their male counterparts (Andershed, 2012), but women commit violent crimes less often than men with the same psychopathic traits (Kreis & Cooke, 2011), so it is possible that the role of the psychopathic dimension in the crime could be overlooked in female offenders or on the other hand that psychopathy in women is underestimated (Forouzan & Cooke, 2005). Even more so than threshold-

This study was carried out in the Sistema Polimodulare REMS Castiglione delle Stiviere ASL MN, Mantova during 2013. Corresponding author. E-mail address: [email protected] (A.R. Felthous). 1 For clinical data collection 2 For statistical data elaboration. ☆ ⁎

https://doi.org/10.1016/j.ijlp.2019.101455 Received 20 June 2018; Received in revised form 10 June 2019 0160-2527/ © 2019 Published by Elsevier Ltd.

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defined psychopathy, subthreshold psychopathic traits could be underrecognized in female offenders especially when the female offender has psychopathic traits. Psychopathic offenders indeed are usually considered legally responsible for the crimes they committed but psychopathy could be underrecognized in women who committed crimes (Carabellese et al., 2015) with related gender discrepancies in adjudication of criminal responsibility. In recent years the Italian national mental health system underwent transformational changes, creating a unique opportunity to study psychopathology in females found to be NGRI and socially dangerous. We begin the presentation of the study findings with a brief summary of the substantial changes that created the context and opportunity for conducting this descriptive study of psychopathy in female socially dangerous NGRI patients. The 1978 Mental Health Law Reform effectively established a clear separation between clinical psychiatry and forensic psychiatry in Italy. Clinical psychiatry was primarily focused on the treatment of the patient, whereas forensic psychiatry was mainly involved in the evaluation of patients, rather than their care (Catanesi, Carabellese, Candelli, Valerio, & Martinelli, 2009). Only the psychiatrists of the Maximum Security Hospitals (OPGs) incorporated both diagnostic and therapeutic tasks in their own practice, rather than having purely forensic duties. As a result, since the establishment of the National Healthcare System (SSN) in 1978, Italian psychiatrists have not taken responsibility for the management of the violent and illegal behavior of their patients (Carabellese, Punzi, La Tegola, Masiello, & Margari, 2010), although they understood its relevance (Catanesi, Carabellese, Candelli, et al., 2009), but rather they left this responsibility to the psychiatrists of the OPGs. Therefore, the issue about the relationship between mental illness and violent behavior has been widely neglected (Carabellese et al., 2014), despite the fact that psychiatrists in the public psychiatric services have themselves often been exposed to the violent behavior of their patients (Palumbo et al., 2016). After the closure of OPGs (Decree-Law Number 211, which became legally effective on February 17, 2012 (Art. Number 9)), one or more Residences for the Execution of Security Measures (REMS) (Decree-Law no. 81 of May 30, 2014), were established as replacements for OPGs in each region of the country. At that time, the responsibility for the treatment of mentally ill and socially dangerous NGRI offenders was transferred to the SSN and its community psychiatric services came under the auspices of the Departments of Mental Health (DSM) (Carabellese & Felthous, 2016). “Highly” dangerous patients, who were discharged from OPGs and continued to require security measures, were accommodated in REMS, each with a maximum of 20 beds. REMS are facilities established in each of Italy's 20 regions, which are responsible for keeping socially dangerous offenders within the proper level of security and for providing a clear therapeutic approach aimed at their social reintegration back into the community. The REMS represent a crucial component of a more comprehensive process of social reintegration, which has from time to time involved all community psychiatric services. On March 31, 2015 there were 16 active REMS. By November 2018 there were 689 inpatients in Italy's 30 active REMs. It was within this framework, which had undergone profound changes, that we decided to carry out our survey in collaboration with the previous OPG of Castiglione delle Stiviere. Among all six Italian OPGs, this was the only one that treated socially dangerous female NGRI offenders, from 1975 until its final closure in 2015. Besides being the only OPG that treated women, Castiglione delle Stiviere had another unique feature: it was the only OPG with a healthcare organization managed by only healthcare professionals and not prison officers. It had a unique and specific competence, with a strong therapeutic emphasis, and it provided a complete, national sample of socially dangerous mentally ill female offenders, who originated from all parts of Italy.

2. The study aims The aims of this study were to: 1) identify the prevalence of psychopathy in socially dangerous female offenders, both those committed violent crimes and those who did not; 2) identify how and if the psychopathic dimension coexists with mental pathology of NGRI socially dangerous female offenders 3) evaluate the reliability of the PCL-R (Hare, 2003) for the clinical and prognostic assessment of psychopathy, especially psychopathic traits in socially dangerous women in Italy; 4) identify any phenotypic gender-specific features of psychopathy and finally 5), to seek effective treatment options for women with a psychopathic profile. Once the total PCL-R score was obtained, the level of psychopathy of the subject under consideration could be established. Those who obtained a total score equal to or > 30 were considered to be psychopathic subjects. Average scores of the general population are about 8–10 points, whereas criminals obtain average scores of about 18–20 points (Hare, 2003). However, studies of European populations have used 25 as the threshold for psychopathy, rather than 30 which is applied in North American populations (Hicks, Vaidyawathan, & Patrick, 2010; Strand & Belfrage, 2005). The lower cut off in European countries was set to reflect the distribution of PCL-R scores in these countries. See Hare (2007) for further discussion of cut scores. 3. The study This study was carried out in compliance with the rules and recommendations of the hospital's ethics committee. The female patients were informed about the purpose of the research and provided written informed consent in order to participate. The data were processed anonymously. 3.1. Instruments and data collection Among the different tools used for the assessment of psychopathy were the Structured Clinical Interview for DSM Axis II disorders (SCIDII); the Levenson Psychopathy Scales (LPS Primary and Secondary Psychopathy); the Psychopathic Personality Inventory-Revised (PPI-R) (Lilienfeld & Widows, 2005); and the Comprehensive Assessment of Psychopathic Personality (CAPP) (Cooke, Michie, Hart, & Clark, 2005). For this study, we chose the Psychopathy Checklist Revised (PCL-R) designed by Hare (2003), which is considered the gold standard. The PCL-R measures psychopathy through the description and the assessment of a constellation of interpersonal, emotional and behavioral features (Hare, 2007). It makes use of a) consultations with officials who documented on the subjects under evaluation and their possible related crimes as well as the investigative and criminal reports; b) the collection of other collateral information in order to obtain further descriptions of the subject; c) the analysis of a semi-structured interview, performed by a trained interviewer for the investigation of specific interpersonal and emotional characteristics of the subject, his/ her lifestyle and any antisocial behaviors. The PCL-R consists of 20 items. Each item is given a score (0, 1, 2). The items are divided into four components that converge in two factors: Factor 1 or the Interpersonal/Affective factor includes interpersonal and affective traits that affect social interactions and relationships. Factor 1 is divided into an interpersonal component (Component 1) and an affective component (Component 2). Factor 2, the Social Deviance factor, explores the lifestyle of the subject, especially the subject's antisocial, impulsive, irresponsible and unscrupulous behavior. Factor 2 is divided into the following components: Lifestyle (Component 3) and Antisocial (Component 4). The OPG's researchers (two general psychiatrists and two psychologists with expertise in the selected tests) involved in this study had four preliminary meetings with the other researchers in order to adapt the research with respect to the OPG's ethical rules and to standardize 2

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F. Carabellese, et al.

contextual environment, intervention with the family, or a combination). The questionnaire consisted mostly of dichotomous items (yes/no), but with several non-exclusive multiple choice items. An open-ended form was chosen for several questions which required a descriptive response. The questionnaire was filled out by the researchers, and the responses were subsequently recoded for analysis. The resulting data were organized in a dedicated database.

the collection method. The research was approved by OPG's ethical commission. The researchers met regularly once a month during the patient recruitment phase. Every patient enrolled into the OPG was assessed using the SCID I and II, MMPI-II, MCMI-III, and R-Bans. Two psychiatrists administered the SCID I and II; two psychologists the MMPI-II, MCMI-III and R-Bans. The researchers also interviewed the healthcare providers to collect clinical and historical information. All researchers had been trained to use the PCL-R by an official licensed trainer before the research was initiated (Prof. Vincenzo Caretti). Also used was an instrument for gathering useful data which organized the data into three sections: Section 1: The first section included personal data (age, sex, place of birth and residence, schooling, and work history), family structure and the quality of relationship between the family and the mentally ill relative, as well as information regarding violent behavior, psychiatric records and substance abuse in the family. Section 2: The second section took into consideration the clinical data: 1) diagnosis (SCID I, SCID II, and tests); 2) onset and topology of the manifested disorders; 3) the manner in which first contact was made with the facility; 4) treatment initiated and treatment during the hospitalization; 5) compliance demonstrated before and during hospitalization in the OPG (good, satisfactory, unsatisfactory, inconsistent, resistive episodes, or disruptions; 6) psycho-social adaptability level exhibited by the patient before (good, satisfactory, unsatisfactory, poor, and none); 7) The quality of intra- and extra-familial relationships (in both cases rated as “good”, “satisfactory”, and “poor”); 8) history of prior mental hospital admissions, rehospitalizations, and whether admissions were involuntary (frequently, sporadically, or occasionally), the reason for admission and the average duration of hospitalization; 9) self- or other-directed aggressive behaviors during hospitalization in the OPG; 10) possible prior comorbid substance abuse; and 11) PCL-R scores (total, F1, and F2). Section 3: The third section included criminal and judicial data: 1) criminal record and security measures before admission into the OPG; 2) types of crimes committed against the person (e.g., homicide, attempted homicide, personal injuries, stalking, threats) and the manner of commission (with firearms or other weapons, injuries from blunt instruments, beatings, maltreatment); 3) types of crimes against persons and property and their frequency; 4) potentially motivating factors (e.g., stressful events, stressful events followed by an interruption of therapy, suspension of therapy, change of staff, no preceding event); 5) target (mother, father, siblings, relatives, significant others, others); and 6) court decision (i.e., NGRI, guilty with reduced responsibility). Other information that was obtained included: 1) type of intervention by the psychiatric facility after the admission into the OPG; 2) changes in the person's condition after the intervention (significant, modest, little, no change) and the source of the changes (psychopharmacological therapy, psychotherapy, interventions in the

3.2. Research tools and methods When the research was performed in February 2013, there were 86 women in the OPG of Castiglione. A PCL-R was completed on all women, using the version that was validated for the Italian population (Caretti, Manzi, Schimmenti, & Seragusa, 2011). As part of their OPG assessment all women were evaluated with the PCL-R. The F1, F2 and the total scores were recorded. A score equal to or > 25 on the PCL-R (Strand & Belfrage, 2005) was considered the threshold score for identifying psychopathy, consistent with studies performed on European populations. SCID I and II interviews and other tests (MMPI-2, MCMI-III, RBANS) were administered to the entire sample. Of those who had given consent, data on 66 (76.7%) of them were analyzed (see in the comment AF4). Categories of information collected were clinical history (age, marital status, education level, family and psychiatric history), diagnoses that had been established by OPG clinicians in Castiglione (partial or complete mental disorders), type of offense (against the property or the person) and the pharmacotherapy received in the OPG. In order to also rate the traits of the psychopathic dimension, to identify the correlations with different crimes and finally to estimate the possible coexistence with mental pathology, the subjects were divided into three different subgroups, depending on their total scores on the PCL-R: PCL-R ≥ 25; PCL-R between 20 and 24; PCL-R ≤ 19 as it was performed in our previous research (Carabellese et al., 2018). Finally, all the data obtained were statistically processed. We used the STATA MP 12.1 software for data analysis. We used the t-test for continuous variables with normal distribution (Factors 1, 2, 3, PCL); alternatively, we used the Kruskal-Wallis test as a non-parametric method, and the Bartlett's test for the analysis of the distribution of variables. 4. Results 4.1. Sample description The main characteristics of the sample in question are summarized in Table 1. The sample included mainly young women (ranging from 25 to 44 years old in 56.6% of the cases) (< 24 = 9 = 13.6%;

Table 1 Main characteristics of the women in the sample. Main characteristics of the women in the sample Age 25–44 years Italian Unmarried, widowed, separated Low education Unemployed, retired, disabled Poor quality reports Uncensored Prev. Psychiatric Hospitalization Positive psychiatric history Unknown to local services

Main characteristics of the women in the sample 56,6% 81,6% 60% 51% 53% 50% 73% 44% 50% 50%

Substance abuse Diagnosis expert Diagnosis in OPG Drug compliance Adherence to the rehabilitation plans Insight disorder Insight of the crime Aggressive behavior towards others NGRI Crimes against the person

40% Personality disorder (39%) Schizophrenia (36%) Personality disorder (54%) 50% 44% 50% 57% 23& 74% 86%

Note: The sample included mainly young women (ranging from 25 to 44 years old in 56.6% of the cases) (< 24 = 9 = 13.6%; 25–44 = 37 = 56.6%; 45–64 = 15 = 22.7%; > 65 = 5 = 7.1%), of Italian nationality (81.6%). Most of the women were not psychosocially integrated, with poor family quality, of in both their primary and secondary families, and with poor social relationships. Nearly two fifths (39.4%) had a history of substance abuse. 3

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1. The first aim of the study, to identify the prevalence of psychopathy in socially dangerous female offenders hospitalized as NGRI or of diminished responsibility, was accomplished by finding the distribution of this sample in each of the three groups

25–44 = 37 = 56.6%; 45–64 = 15 = 22.7%; > 65 = 5 = 7.1%), of Italian nationality (81.6%). Most of the women were not psychosocially integrated, had poor family quality in both their primary and secondary families, and had poor social relationships. They lived alone (59.5% of them were unmarried, widowed or separated, and without children), were of a low education level (47% had an elementary or middle school certificate, while 4.5% were illiterate) and were in poor financial condition (unemployed or disabled). More than two-thirds of the sample had no criminal record (72.7%) and had not been subjected to any security measures before (78.8%). Almost half of the women under evaluation reported a history of previous psychiatric hospitalization and a third of them had been hospitalized involuntarily. Nearly two fifths (39.4%) had a history of substance abuse. More than half of the women in the sample did not have any family history of mental illness. Fifty percent of the women were unknown to the psychiatric services before entering the OPG. For all the subjects, the forensic assessments that were completed pursuant to a court order following the crime had identified a serious mental illness. However, the diagnostic conclusions of the OPG clinicians were different from those of the experts appointed by the judges. The latter showed a relatively high prevalence of personality disorders (39.3%) and schizophrenic spectrum disorders (36.4%) within the female sample. From clinical observations in the OPG and results of this psycho-diagnostic research, a high prevalence of personality disorders was found, especially those belonging to Cluster B of the DSM IV-TR classification (American Psychiatric Association, 2000) (54.5%). Almost half of the women in the sample did not properly comply with the treatment and rehabilitation plans recommended by the OPG professionals. Half (50%) of the women showed no insight into their mental disorder and 43.9% for the crime committed. During the observation period, 77% of women did not exhibit aggressive behavior against others and were not subjected to restraint measures. Finally, 74.2% of the women in the sample had been found not guilty by reason of insanity (NGRI), for the crimes they had committed. Most of their crimes were offenses against the person (34.8% murder, 12.1% attempted murder, 27.2% personal injury, 10.6% stalking and/or threats). It is important to note that the PCL-R provides a dimensional score: A higher score corresponds to a greater adherence to the psychopathy model described by Hare and a higher probability that the individual is psychopathic (Caretti et al., 2011). However, a significant degree of psychopathy is also present in lower scores as well. For this reason we decided to divide the total sample of 66 women who completed the survey into three groups based on their total PCL-R scores. As shown below, we compared their characteristics and tried to understand whether we would also find the same features of psychopathy in women with scores lower than the cut-off (Table 2):

- Group I constituted 15% of the total sample: Their average PCL-R scores were: total = 28.9 (sd 2.9), F1 = 11.5 (sd 2.3), and F2 = 15.6 (sd 3.5); - Group II PCL scores were between 20 and 24 showing some psychopathy but below the threshold. Corresponding to 12% of the samples, their average PCL-R scores were total = 21.9 (sd 1.4), F1 = 10.3 (sd 2.6), and F2 = 11.1 (sd 2.8); - Group III were the non psychopathic women with scores of 19 or lower. This group was comprised of 73% of the sample: Their average PCL-R scores were total = 10.5 (sd 5.7), F1 = 5.2 (sd 3.0), and F2 = 5.1 (sd 3.3). Compared to the general characteristics of the entire sample, women in Group I showed some striking features: 60% of these cases exhibited aggressive behavior against others even in the OPG, in 50% of the cases necessitating the use of physical and/or pharmacological restraint, even though 50% of Group I were taking both antipsychotics and mood stabilizers at the same time, compared to 22% of the overall sample who were not. As for the clinical diagnosis, 70% of the women in Group I suffered from a personality disorder (compared to 54.5% of the overall sample), almost exclusively represented by borderline personality disorder (BDP), co-occurring with substance abuse in 60% of the cases. Eighty six percent of the women in this group had committed crimes against the person which is comparable to the general sample. It is interesting to note that the total PCL-R score of our Group I sample is very close to the normal cut-off indicated in the international literature. About 50% of women in Group II (those with psychopathy levels below the threshold) had a family history of psychiatric disorder which was slightly lower than that of women in Group I. They also showed aggressive behavior against others in 12.5% of the cases. Moreover, 14% of the cases required measures of physical restraint and specific pharmacotherapy for emergency control of dangerous agitation and aggression. Also in this group was a similarly high prevalence of Cluster B personality disorders, almost exclusively BPD, co-occurring with a history of substance abuse in 75% of the cases. This group of women had committed both crimes against the person (50%) and against property (50%). Group III had a family history of psychiatric disorder in only 39% of the cases. Only 14% of the cases developed aggressive behavior against others, therefore the need for physical restraint and emergency pharmacological treatment was less frequent. Approximately 50% of subjects in this group were diagnosed with a personality disorder; the remainder of the diagnoses were distributed equally between mood disorders and schizophrenia spectrum disorders. Even though the

Table 2 Distribution of the women in the sample based on PCL-R scores.

Family history Aggressive behavior towards others Personality disorders BDP Substance abuse Crimes against the person

Sample general (66 WOMEN)

1st GROUP PCL ≥ 25 (10 WOMEN)

2ndGROUP20 ≤ PCL ≤ 24 (8 WOMEN)

3rdGROUP PCL ≤ 19 (49 WOMEN)

35% 23%

60% 60%

50% 12,5%

39% 39%

54,5% 39% 39% 86%

70% 86% 60% 70%

75% 86% 75% 50%

47% 30% 27% 86%

Note: Group I constituted 15% of the total sample: Their average PCL-R scores were: total PCL = 28.9 (sd 2.9), F1 = 11.5 (sd 2.3), and F2 = 15.6 (sd 3.5); Group II PCL scores were between 20 and 24 showing some psychopathy but below the threshold. Corresponding to 12% of the samples: Their average PCL-R scores were total PCL = 21.9 (sd 1.4), F1 = 10.3 (sd 2.6), and F2 = 11.1 (sd 2.8); Group III were the non psychopathic women with scores of 19 or lower. This group was comprised of 73% of the sample: Their average PCL-R scores were total PCL = 10.5 (sd 5.7), F1 = 5.2 (sd 3.0), and F2 = 5.1 (sd 3.3). 4

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Table 3 Correlation among F1, F2, PCL-2 scores and psychiatric diagnosis (personality disorders generally and borderline personality disorders). Clinical diagnosis

F1

F2

Total PCL-R

Disorders of personality

Mean ± SD

95%

p value

Mean ± SD

95%

p value

Mean ± SD

95%

p value

Yes No

7.8 ± 3.4 5.4 ± 4.1

6.7–8.9 3.9–7.0

0.0065

8.7 ± 5.3 5.9 ± 4.6

6.9–10.4 4.1–7.6

0.0140

17.0 ± 8.2 11.6 ± 8.5

14.2–19.8 8.3–14.8

0.0057

Borderline personality disorder

Mean ± SD

95% CI

p value

Mean ± SD

95% CI

p value

Mean ± SD

95%

p value

Yes No

8.5 ± 2.5 6.3 ± 4.1

7.0–9.9 5.1–7.4

0.0301

10.4 ± 5.5 6.6 ± 4.7

7.2–13.6 5.2–7.9

0.0061

19.8 ± 1,9 13.1 ± 8.6

15.7–23.9 10.7–15.6

0.0049

Note: Statistical analysis (t-test for independent samples) showed a significantly positive correlation (p < 0.005) between BPD and higher scores for PCL, F1 and F2 for the women we examined (women with BPD showed significantly higher scores in all three groups, compared to those with other disorders).

majority were Cluster B, personality disorders in this group showed a wider variation: besides BPD (30%), there were antisocial (26%), histrionic (22%), paranoid (18%) and schizotypal (4%) personality disorders. The comorbidity with substance abuse was present in a minority of the group (27%). These women had committed mainly crimes against the person, which was comparable to the overall sample and the sample of psychopathic women. Statistical analysis (t-test for independent samples) showed a significantly positive correlation (p < 0.005) between BPD and higher scores for PCL, F1 and F2 for the women we examined (women with BPD showed significantly higher scores in all three groups, compared to those with other disorders, See Table 3). This finding is in line with previous surveys and observations, which have shown higher prevalence of BPD among female psychopathic subjects (Hicks et al., 2010; Nicholls et al., 2007) (while the incidence of ASPD is prevalent among male subjects (Giordano & Cernkovich, 1997; Mette, Kreis, & Cooke, 2011). Of the 10 psychopathic women in Group I (PCL-R ≥ 25), only three had committed crimes against the property. Albeit the size of this subgroup is small, these data would seem to be in contrast with the literature, which shows a prevalence of property crimes among psychopathic women and crimes against the person among men with a strong psychopathic component (Wynn et al., 2012). In addition, the statistical analysis of the PCL-R scores of all the women in the entire sample showed that those who committed robberies had significantly higher total scores on F2 and PCL-R compared to those responsible for murder (See Table 4). Women with higher F1 and F2 relationships (both within the family and outside the family, Tables 6, 7), showed a decreased ability to adjust psychosocially (Table 5), a stronger propensity for addictive behavior (Table 8) and little or no compliance to the various treatment approaches (pharmacological and psychological) within the community (Tables 9, 10). Regarding the behavior of the women in the sample, high scores appeared to be correlated with more frequent violent behavior against

others and a greater need for physical restraint (Table 11). Finally, the clinical re-evaluation of insight regarding both the illness and the committed crime, has once again shown a significant statistical correlation between the lack of conscience (on both) and higher score levels of F1, F2 and total PCL-R (Table 12) scores, as well as total PCL scores. 5. Discussion As for the evaluation of F1 and F2 scores (Table 13), there was no significant difference between women with sub-threshold score (F1 = 10.3 (sd 2.6), F2 = 11.1 (sd 2.8)) and the group of female psychopaths (F1 = 11.5 (sd 2.3), F2 = 15.6 (sd 3.5)), while the group of non-psychopathic women obtained substantially lower scores (F1 = 5.2 (sd 3.0), F2 = 5.1 (sd 3.3)). These data are consistent with the existence of a gray area in the spectrum of phenotypic features of the female psychopathy, which could remain underestimated with regard to certain aspects of psychopathic manifestation especially when the psychopathic dimension coexists with other psychopathology, especially personality disorders. So it is possible that psychopathy plays a role in crimes committed by female offenders that remains undiscovered. As in these cases in our sample it is also possible that such crimes are of a violent nature. Although the sample size is small, several considerations emerge when comparing the overall sample of socially dangerous women with the three subgroups identified based on the indicated values of PLC-R. Briefly: Discovering significant percentages of previous psychiatric issues within the families of psychopathic women, including those with a score below threshold, seems to support the hypothesis of hereditary factors of dysfunctional and psychopathic personality traits, which is consistent with some research data (Blonigen, Hicks, Krueger, Patrick, & Iacono, 2005; Goldman & Ducci, 2007). However, it could also indicate the existence of pathological relations, capable of promoting dysfunctional behavior which could develop into an actual personality disorder, a psychopathic disorder in particular, due to the impact of environmental factors not limited within the family. This was suggested by Farrington's seminal longitudinal studies of psychopathic men (Farrington, 2007). In this present study there was a positive correlation between higher scores of the PCL-R and diminished capacity to adapt to changing social situations, as well as deteriorated and inadequate interpersonal relationships, both within the family and outside of the family (Tables 5, 6, 7). This observation could strengthen the conceptual basis for the construct of secondary psychopathy, considered to be a disorder that is established and consolidated by the interaction of unfavorable social conditions (which can foment deviant behavioral patterns), in contrast to primary psychopathy with an inner world which is emotionally cold, distant, rigid and resource-poor in terms of the capacity for empathy (Hicks et al., 2012). With regard to the results of the clinical observation, the female

Table 4 Correlation between F2, PCL-R and crime committed. TYPE of crimE

F2

Total PCL-R

Mean

95%

p value

Mean value

95%

p value

Murder Yes No

4.6 8.9136.

2.6–6.7 7.4–10.4

0.0005

11.4057 16.310.4

7.6–15.2 13.8–18.9

0.0136

Robbery Yes No

12.7 6.91082

8.2–17.1 5.6–8.2

0.0039

22.339.1 13.88.29

14.8–29.8 11.6–16.0

0.0108

Note: The statistical analysis of the PCL-R scores of all the women in the entire sample showed that those who committed robberies had significantly higher total scores on F2 and PCL-R compared to those responsible for murder. 5

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Table 5 Correlation between F1, F2, PCL scores and psychosocial adjustment. Psychosocial adaptation

Poor Good

F1

F2

Total PCL-R

Mean

95%

p value

Mean

95%

p value

Mean

95%

p value

8.3 3.6D001

7.1–9.5 1.7–5.5

0.0000 0.0012

9.50005 3.50125

7.6–11.4 1.2–5.8

0.0000 0.0044

18.400.4 7.40448

15.6–21.3 3.6–11.2

0.0000 0.0016

Note: Total PCL scores, more often showed a decreased ability to adjust psychosocially.

sample showed a significant prevalence of personality disorders of Cluster B. In particular, there was a positive correlation between high PCL-R, F1 and F2 scores and borderline personality disorder (Table 3). These findings are consistent with those described in the international literature (Verona, Sprague, & Shabnam, 2012) and suggest the existence of an overlapping area between the phenotypic features of the borderline personality disorder (See Mancke, Herpertz, & Bertsch, 2015 for a recent review and analysis of the aggressive behavior in BPD) and those of psychopathy in female subjects. In fact, typical borderline symptoms of emotional instability, anxiety and abusive behavior were frequently found among the latter (Mette, Kreis, & Cooke, 2011). The present sample showed the comorbidity of psychopathy and substance abuse (Table 8), with higher F1, F2 and PCL-R scores among women with substance abuse behavior compared to those without this behavior. This finding is also consistent with the comorbidity of BDP and substance abuse (particularly in Groups I and II). The coexistence of addictive behavior could be explained by considering both the specific characteristics of the borderline phenotype (which, indeed, include substance abusing behavior), and the recurrence of situations of sociorelational instability, marginalization and contiguity of criminal environments and situations. The psychopathic women in this study showed a tendency to exhibit aggressive behavior towards others (Table 11). This finding appears to be in contrast with the results of studies of females with psychopathy reported in the international literature (Andershed, 2012; Lehmann & Ittel, 2012), which describe instead a low profile of aggressiveness among women displaying the considered psychopathological dimension (especially if they are compared to psychopathic men). Regardless of the PCL-R scores, the present total sample showed a predominance (86%) of crimes committed against the person. This prevalence was also observed in the female sample with high psychopathy PCL-R levels (Group I), while the group of women under the threshold (Group II) showed an equal distribution of crimes against the person and crimes against the property. However, the statistical analysis showed that women who had committed crimes against property had higher F2 and PCL-R scores (Table 4). One could argue that in this case, a lower F1 score (which indicates a higher level of empathy) could compensate for the aggressive and impulsive tendencies which correlate with the F2 trait. Most likely this causes antisocial behavior in women that is characterized by manipulative behavior, a tendency towards deception and simulation, and a predominance of behaviors that are related to crimes against property (theft, drug dealing, fraud) (Wynn et al., 2012), even though we observed an absolute prevalence of crimes against the person rather than against the property among all the women hospitalized in the OPG, which suggests another possible

reading of the data: it should be easier for experts to formulate a forensic psychiatric judgement of mental illness and acquittal with hospitalization in the OPG for women who committed crimes against the person, rather than property crimes. It should be emphasized indeed that the diagnostic conclusions of the OPG clinicians were different from those of the experts appointed by the judges: the latter observed a high prevalence of personality disorders, especially BPD, than the former who found a higher prevalence of psychosis which was relevant to the criminal offense, typically a violent offense. However, it is important to point out that studies have shown an increased risk of aggressive behavior for psychopathic women against persons with whom they are close (family members, acquaintances and others) (Kreis & Cooke, 2011). Actually, even the present sample showed that most of the subjects' violent crimes were committed within the family (matricide, patricide, filicide). This figure indicates an obvious limitation of this study for generalizing the findings to psychopathic women in general. This study is limited to those hospitalized in an OPG and therefore, to women who are presumed by law to be clinically mentally ill, NGRI and socially dangerous. The need is patent to continue such research and to extend observations to other female samples undergoing security measures outside of prison, such as those on probation, or convicted women who are imprisoned. In addition, little or no compliance was shown by women with elevated PCL-R levels of psychopathy (and, in any case, by subjects with higher F1, F2 and PCL-R total scores, Tables 9, 10) to the therapeutic treatment and rehabilitation programs of the OPG in Castiglione delle Stiviere. In other words, this study demonstrates a significant correlation between failure to accept medical treatment or to attempt to become psychosocially reintegrated for women with higher levels of psychopathy. The results of this study would initially appear to be consistent with the common assumption that psychopathic disorders are not amenable to treatment and extend this assumption to women with psychopathy. This finding needs to be reconciled with recent literature that offers hope for the therapeutic efficacy where the target of treatment is impulsive aggression, conceptualized as a domain of psychopathic disorders. Research supports the efficacy of anti-impulsive aggression agents (AIAA) even where the character pathology is antisocial personality disorder (Felthous, 2015; Felthous, Lake, Rundle, & Stanford, 2013; Felthous & Stanford, 2015; Felthous, Stanford, & Saß, 2018). Study subjects with antisocial personality disorder not only cooperated with research protocol but their impulsive aggression diminished in frequency and intensity when treated with phenytoin (Barratt, Stanford, Felthous, & Kent, 1997; Barratt, Stanford, Kent, & Felthous, 1997).

Table 6 Correlation between F1, F2, PCL-R scores and quality of relationships within the family. Quality of relations in family

Poor Good

F1

F2

Total PCL-R

Mean

95%

p value

Mean

95%

p value

Mean

95%

p value

7.8 1.7D009

6.6–9.0 0.2–3.3

0.0001 0.0000

8.90010 2.70009

7.1–10.6 0.1–5.6

0.0000 0.0086

17.000.6 4.5086.

14.2–19.9 0.3–8.7

0.0000 0.0006

Note: Total PCL scores, more often showed poor and deteriorated social relationships within the family. 6

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Table 7 Correlation between F1, F2, PCL scores and quality of relationships outside the family. Quality of reports out family

F1

POOR GOOD

F2

Total PCL-R

Mean total

95%

p value

Mean value

95%

p value

Mean value

95%

p value

8.0 1.8.000

6.7–9.3 0.5–4.2

0.0000 0.0003

9.10003 1.4003.

7.3–10.9 0.3–3.2

0.0000 0.0015

17.800.9 3.60152

14.9–20.6 0.2–6.9

0.0000 0.0004

Note: Total PCL scores, more often showed poor and deteriorated social relationships outside the family. Table 8 Correlation between F1, F2, PCL scores and addictive behavior. Addictional behaviour

F1

These Absent

F2

Total PCL-R

Mean total

95%

p value

Mean value

95%

p value

Mean value

95%

p value

8.7 6.0NT08

6.9–10.5 4.8–7.2

0.0151

130,151 5.7–7.2

9.8–16.1 4.4–7.0

0.0000

23.200.1 11.97.0.

18.2–28.1 9.6–14.3

0.0000

Note: Total PCL scores, more often showed a stronger propensity for addictive behavior. Table 9 Correlation between F1, F2, PCL-R scores and pharmacological compliance. Drug compliance

Yes No

F1

F2

Total PCL-R

Mean total

95%

p value

Mean value

95%

p value

Mean value

95%

p value

5.5alue 8.8006.

4.3–6.7 6.8–10.7

0.0028

5.50287 10.310.7

4.1–6.9 6.9–13.6

0.0012

11.2129 M 19.613.6

8.7–13.7 14.8–24.5

0.0006

Note: Total PCL scores, more often showed little or no compliance to the various treatment approaches (pharmacological) within the community. Table 10 Correlation between F1, F2, PCL-R scores and adherence to rehabilitative activities. Membership activities rehabilitation

Yes No

F1

F2

Total PCL-R

Mean Total

95%

p value

Mean value

95%

p value

Mean value

95%

p value

5.5 7.4026

3.9–7.1 6.0–8.7

0.0405

4.94051 9.0–8.7

3.0–6.7 7.0–10.9

0.0014

10.4147H 16.910.9

7.3–13.5 13.6–20.2

0.0026

Note: Total PCL scores, more often showed little or no compliance to the various treatment approaches (psychological) within the community. Table 11 Correlation between F1, F2, PCL-R scores and the need for restraint and aggressive behaviors against others. F1 Mean Need of restraints Yes 9.2 No 5.80000

F2

Total PCL-R

95%

p value

Mean value

95%

p value

Mean value

95%

p value

6.8–11.6 4.7–7.0

0.0081

14.181.6 5.2–7.0

10.5–17.7 4.0–6.4

0.0000

240,000 11.36.4.

17.9–30.1 9.1–13.5

0.0000

0.0048

11.748.3 4.8–6.8

8,7–14.6 3.7–6.1

0.0000

20.900.6 10.56.1.

16.2–25.7 8.3–12.7

0.0000

Aggressive behavior towards others Yes 8.5 ± 3.3 6.7–10.3 No 5.50005 4.3–6.8

Note: Regarding the behavior of the women in the sample, high scores appeared to be correlated with more frequent violent behavior against others and a greater need for physical restraint.

Impulsive aggression is no less responsive to AIAA treatment where it occurs within the context of a borderline personality disorder as demonstrated by Coccaro's drug trials with the AIAA fluoxetine (Coccaro, Lee, & Kavoussi, 2009). Hollander's multicenter study indicates that the diagnosis of borderline personality disorder is a favorable prognostic factor for the efficacy of valproate/divalproex in the treatment of impulsive aggression (Hollander et al., 2003, 2005). The positive results of dialectic behavioral therapy in the treatment of borderline personality disorder are well known (e.g., Linehan et al., 2006). Thus our finding that psychopathy among females is associated with borderline personality disorder may inform the clinician's therapeutic strategies.

Results of the present study raise the question of whether elevated psychopathy scores, in contrast to categorical personality disorders, worsen the prognosis for therapeutic compliance and efficacy even for AIAAs shown to be effective for antisocial personality disorder and borderline personality disorder. Thus it will be important for future research to address with similarly well designed and controlled studies the efficacy of AIAAs in treating impulsive aggression in individuals with high PCL-R scores. In as much as impulsive aggression responds to AIAAs, it may be that elevated F2 scores provide a target for pharmacotherapy (i.e., impulsive aggression), whereas elevated F1 scores and the callous-unemotional factor are so far unresponsive and contribute 7

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F. Carabellese, et al.

Table 12 Correlation between F1, F2, PCL-R scores and insights of the disorder and committed crime. F1 Mean

F2

Total PCL-R

95%

p value

Mean value

95%

p value

Mean value

95%

p value

Insight disorder Yes 5.2 No 7.1167

3.4–7.1 5.8–8.4

0.0433

5.24331 7.7–8.4

3.1–7.3 5.9–9.6

0.0379

10.3793 15.49.60

6.6–14.0 12.4–18.4

0.0167

Insight crime Yes 5.2 No 7.3118

3.6–6.8 5.9–8.7

0.0226

5.42268 7.9–8.7

3.5–7.4 5.9–9.9

0.0412

10.6124 15.99.98

7.3–13.8 12.6–19.1

0.0118

Note: The clinical re-evaluation of insight regarding both the illness and the committed crime, has once again shown a significant statistical correlation between the lack of conscience (on both) and higher score levels of F1, F2 and total PCL-R. Table 13 Distribution of average scores of F1, F2, PCL-R within the three groups.

PCL-R total F1 F2

1st Group (15%)Average values (ds)

2nd Group (12%)Average values (ds)

3rd Group (73%)average values (ds)

28.9 (2.9) 11.5 (2.3) 15.6 (3.5)

21.9 (1.4) 10.3 (2.6) 11.1 (2.8)

10.5 (5.7) 5.2 (3.0) 5.1 (3.3)

Note: As for the evaluation of F1 and F2 scores (Table 13), there was no significant difference between women with sub-threshold scores (F1 = 10.3 (sd 2.6), F2 = 11.1 (sd 2.8)) and the group of female psychopaths (F1 = 11.5 (sd 2.3), F2 = 15.6 (sd 3.5)), while the group of non-psychopathic women obtained substantially lower scores (F1 = 5.2 (sd 3.0), F2 = 5.1 (sd 3.3)).

1. The women committed crimes mainly against property. Their crimes against the person and violent behaviors were generally within the family. 2. Women with high PCL-R psychopathy scores were mainly affected by borderline personality disorder, whereas psychopathic men in the literature show antisocial PD features with similar comorbidity regarding drug addiction conditions. (Carabellese et al., 2018) 3. Treatment efficacy could not be assessed due to the poor (or complete lack of) compliance observed for both the pharmacological treatments and community rehabilitation strategies. 4. Because we have no data on the rates of criminal recidivism of the women in the study sample, we cannot provide information about the predictive value of PCL-R in this population. 5. The PCL-R appears to be a valuable tool to identify the construct of psychopathy in female subjects (as indicated by the consistency of the collected data and of the phenotypic characteristics of psychopathic women with findings in the international scientific literature) (Hicks et al., 2010; Verona & Vitale, 2018. Proper knowledge of the clinical characteristics of psychopathy may be useful for both forensic psychiatrists and clinical psychiatrists. The differential diagnosis between psychopathy and other personality disorders would allow a more valid and discerning forensic evaluation. Also, in a clinical setting it would provide appropriate treatment guidance, even if the possibility of successful treatment appears to be rather modest. This last consideration assumes greater consistency in light of recent changes regarding obviating OPGs with the opening of REMS. The present case study analysis performed on the indicated female sample confirms the resistance of psychopathic women to complying with hospital treatment. The correct differential diagnosis of psychopathy should reduce the number of judgments of partial or total absence of responsibility, therefore preventing the improper admission of psychopaths in REMS, the current therapeutic and rehabilitative facilities for NGRI acquittees. 6. The psychopathic dimension can coexist with other psychopathies especially with a personality disorder. In the study population elevated psychopathy was inversely associated with psychotic disorders. In our sample of female offenders the coexistence of psychopathic dimension with other mental pathology could play a role in violent crimes' commission.

to poor therapeutic insight and motivation. Although the poor adherence of psychopathic women to the therapeutic rehabilitation paths and their tendency towards aggressive and violent behavior empirically suggest a possible recurrence of antisocial behavior, this study lacks parameters that could statistically demonstrate a correlation between psychopathy and a higher probability of criminal recidivism. In fact, we observed a significant relationship between high F2 scores and the presence of criminal records (F2 = 10.1 ± 4.6, with CI = 7.2–13 and p = 0.0230), confirming the level of antisocial behavior expressed by this score. Because of the absence of information about the criminal relapse after the discharge from the OPG, we are unable to arrive at any conclusions about the predictive value of the PCL-R in this population. One last consideration is the comparison between the forensic psychiatric assessment results after entering the OPG (wherein 74.2% of all the women were NGRI) and the expert diagnosis made prior to OPG admission (with personality disorder diagnosed in nearly 40% of the cases). In fact, since personality disorders do not significantly alter the a defendants reality testing, forensic experts less frequently consider them to be so serious as to abolish or greatly diminish the defendant's ability to understand his or her own actions and consequences and ability to determine them freely. This finding that personality disordered females are acquitted based upon insanity is open to different interpretations: It could be a result of a generally more lenient attitude of the experts towards women and their tendency to attribute their criminal behavior (especially if violent) to a mental illness that affected their judgement of reality even when they are not clearly suffering from a psychotic disorder. In addition, it could depend on a psychopathological interpretation that underestimates the psychopathic component. The inherent limitation of this study is that it considers a numerically small sample of mentally ill female offenders. On the other hand, it is important to consider that, given the specific features of the OPG in Castiglione delle Stiviere already described, this research is actually focused on the entire Italian population of mentally ill female offenders who are in a security hospital at a given time in the Italian population. 6. Conclusions In summary: 8

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References

Felthous, & H. S. Saß (Eds.). The international handbook of psychopathic disorders and the law, volume I: Diagnosis and treatment (pp. 41–67). Chichester, England: John Wiley & Sons, Ltd. Hare, R. D. (2003). Manual for the hare psychopathy checklist (2nd ed.). Toronto, ON: Multi-Health Systems revised. Hicks, B. M., Carlson, M. D., Blonigen, D. M., Patrick, C. J., Iacono, W. G., & Mgue, M. (2012). Psychopathic personality traits and environmental contexts: Differential correlates, gender differences, and genetic mediation. Personality Disorder, 3(3), 209–227. Hicks, B. M., Vaidyawathan, U., & Patrick, C. J. (2010). Validating female psychopathy subtypes: Differences in personality, antisocial and violent behaviour, substance abuse, trauma, and mental health. Personal Dis, 1, 38–57. Hollander, E., Tracy, K. A., Swan, A. C., et al. (2003). Divalproex in the treatment of impulsive aggression: Efficacy in Cluster B personality disorders. Neuropsychopharmacology, 28, 1186–1197. Hollander, E., Swann, A. C., Coccaro, E., et al. (2005). Impact of trait impulsivity and state aggression on divalproex versus placebo response in borderline personality disorder. American Journal of Psychiatry, 162, 621–624. Jang, K. L., Stein, M. B., Taylor, S., Asmundson, G. J. G., & Livesley, W. J. (2003). Exposure to traumatic events and experiences: Aetiological relationships with personality function. Psychiatry Research, 120, 61–69. Kreis, M. K., & Cooke, D. J. (2011). Capturing the psychopathic female: A prototypicality analysis of the comprehensive assessment of psychopathic personality (CAPP) across gender. Behavioral Sciences & the Law, 29, 634–648. Krischer, M. K., Sevecke, K., & Lehmkuhl, G. (2007). Family upbringing: Family factors as predictors for the development of antisocial behavior and psychopathy dimensions. In A. R. Felthous, & H. Saß (Eds.). The international handbook of psychopathic disorders and the law, volume I, diagnosis and treatment (pp. 291–302). Chichester, England: John Wiley & Sons, Ltd. Lehmann, A., & Ittel, A. (2012). Aggressive behaviour and measurement of psychopathy in female inmates of German prisons: A preliminary study. International Journal of Law and Psychiatry, 35, 190–197. Lilienfeld, S. O., & Widows, M. R. (2005). Professional manual for the Psychopathic Personality Inventory-Revised (PPI-R). Lutz, FL: Psychological Assessment Resources. Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., ... Lindenboin, N. (2006). Two year randomized control trial and follow-up of dialectical behaviour therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63, 757–766. Logan, C. (2009). Psychopathy in women: Conceptual issues, clinical presentation and management. Neuropsychiatrie, 23(1), 1–9. Mancke, F., Herpertz, S. C., & Bertsch, K. (2015). Aggression in borderline personality disorder: A multidimensional model. Personality Disorders, Theory, Research, and Treatment, 6(3), 278–291. Mette, K., Kreis, F., & Cooke, D. J. (2011). Capturing the psychopathic female: A prototypicality analysis of the comprehensive assessment of psychopathic personality (CAPP) across gender. Behavioral Sciences & the Law, 29, 634–648. Nicholls, T. L., Odgers, C. L., & Cooke, D. J. (2007). Women and girls with psychopathic characteristics. In A. R. Felthous, & H. S. Saß (Eds.). The international handbook of psychopathic disorders and the law, volume I: Diagnosis and treatment (pp. 347–366). Chichester, England: John Wiley & Sons, Ltd. Nicholls, T. L., & Petrilla, J. (2006). Gender and psychopathy: An overview of important issues and introduction to the special issue. Behavioral Sciences & the Law, 23(6), 729–791. Palumbo, C., Distaso, S., Di Sciascio, G., Carabellese, F., Valerio, A., & Catanesi, R. (2016). Evaluation of safety at work in psychiatric setting. La Medicina del Lavoro, 107(4), 284–292. Strand, S., & Belfrage, H. (2005). Gender differences in psychopathy in a Swedish offenders sample. Behavioral Sciences & the Law, 23(6), 837–850. Verona, E., Sprague, J., & Sadeh, N. (2012). Inhibitory control and negative emotional processing in psychopathy and antisocial personality disorder. Journal of Abnormal Psychology, 121(2), 498–510. Verona, E., Sprague, J., & Shabnam, J. (2012). Gender as factor-level interactions in psychopathy: Implications for self-directed violence risk and borderline personality disorder symptoms. Personality Disorders, Theory, Research, and Treatment, 3, 247–262. Verona, E., & Vitale, J. E. (2018). Psychopathy in women: Assessment, manifestation, and etiology. In C. J. Patrick (Ed.). Handbook of psychopathy (second edition) (pp. 509– 528). New York: Guilford. Wood, W., & Eagly, A. H. (2002). A cross-cultural analysis of the behavior of women and men: Implications for the origins of sex differences. Psychological Bulletin, 128, 699–727. Wynn, R., Hoiseth, M. H., & Pettersen, G. (2012). Psychopathy in women: Theoretical and clinical perspectives. International Journal of Women's Health, 4, 257–263.

American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, 4th edition, text revision. Washington DC: American Psychiatric Association. Andershed, H. (2012). There are differences between men and women with psychopathic personality traits regarding sub-types of psychopathy, criminality, aggression and victimization. Sweden: Conference in Orebro University. Barratt, E. S., Stanford, M. S., Felthous, A. R., & Kent, T. A. (1997). The effects of phenytoin on impulsive and premeditated aggression: A controlled study. Journal of Clinical Psychopharmacology, 17(5), 341–349. https://doi.org/10.1097/00004714199710000-0002. Barratt, E. S., Stanford, M. S., Kent, T. A., & Felthous, A. R. (1997). Neurological and cognitive psychophysiological substrates of impulsive aggression. Biological Psychiatry, 41, 1045–1061. https://doi.org/10.1016/5006.3223(96)00175-8. Blonigen, D. M., Hicks, B. M., Krueger, R. F., Patrick, C. J., & Iacono, W. G. (2005). Psychopathic personality traits: Heritability and genetic overlap with internalizing and esternalizing psychopathology. Psychological Medicine, 35, 637–648. Carabellese, F., Candelli, C., La Tegola, D., Rocca, G., Catamo, A., Martinelli, D., & Catanesi, R. (2014). Violent behavior and the factors associated with the decision to report it: A retrospective study. Journal of Forensic Psychiatry and Psychology, 25(5), 574–583. Carabellese, F., & Felthous, A. (2016). Closing Italian forensic psychiatry hospitals in favor of treating insanity acquittees in the community. Behavioral Sciences & the Law, 34(2–3), 444–459. Carabellese, F., Felthous, A. R., Rossetto, I., La Tegola, D., Franconi, F., & Catanesi, R. (2018). Female psychopaths: A sample of Italian women in a high security hospital. The Journal of the American Academy of Psychiatry and the Law, 46(2), 171–178. Carabellese, F., Punzi, G., La Tegola, D., Masiello, M., & Margari, F. (2010). Il trattamento del reo malato di mente nei servizi psichiatrici della Regione Puglia. Rassegna Italiana di Criminologia, 1, 189–206. Carabellese, F., Straticò, E., Rossetto, I., Benazzi, C., Sartori, T., & Catanesi, R. (2015). La dimensione della psicopatia nell'universo femminile. Rassegna Italiana di Criminologia, 1, 58–68. Caretti, V., Manzi, G. S., Schimmenti, A., & Seragusa, L. (Eds.). (2011). PCL-R. Hare psychopathy checklist-revised di: Hare, R.D. Florence: Giunti O.S. Catanesi, R., Carabellese, F., Candelli, C., Valerio, A., & Martinelli, D. (2009). Violent patients: What Italian psychiatrists feel and how this could change their patient care. International Journal of Offender Therapy and Comparative Criminology, 54(3), 441–447. Coccaro, E. F., Lee, R. J., & Kavoussi, R. J. (2009). A double-blind, randomized, placebocontrolled trial of fluoxetine in patients with intermittent explosive disorder. Journal of Clinical Psychiatry, 70, 653–662. https://doi.org/10.4088/JPC.08m04150. Cooke, D. J., Michie, C., Hart, S. D., & Clark, D. (2005). Assessing psychopathy in the United Kingdom: Concerns about cross-cultural generalisability. British Journal of Psychiatry, 186, 335–341. Farrington, D. P. (2007). Social origins of psychopathy. In A. R. Felthous, & H. S. Saß (Eds.). The International Handbook of Psychopathic Disorders and the Law, Volume I: Diagnosis and Treatment (pp. 319–334). Chichester, England: John Wiley & Sons, Ltd. Felthous, A. R. (2015). The appropriateness of treating psychopathic disorders. CNS Spectrums, 20, 182–189. https://doi.org/10.1017/S1092852915000243. Felthous, A. R., Lake, S. L., Rundle, B. K., & Stanford, M. S. (2013). Pharmacotherapy of impulsive aggression: A quality comparison of controlled studies. International Journal of Law and Psychiatry, 36, 258–263. https://doi.org/10.1017/j.ijlp.2013.04. 017. Felthous, A. R., & Stanford, M. S. (2015). A proposed algorithm for the pharmacotherapy of impulsive aggression. The Journal of the American Academy of Psychiatry and the Law, 43(4), 456–467. Felthous, A. R., Stanford, M. S., & Saß, H. (2018). Zur pharmakotherapie impulsiver aggression bei antisozialen und psychopathischen störungen. (German: Pharmacotherapy of impulsive aggression in antisocial and psychopathic disorders). Forensische Psychiatrie Psychologie, Kriminologie, 12(3), 266–276. https://doi.org/10. 1007/s11757-018-0491-2. Forouzan, E., & Cooke, D. J. (2005). Figuring out la femme fatale: Conceptual and assessment issues concerning psychopathy in females. Behavioral Sciences & the Law, 23, 765–778. Giordano, P. C., & Cernkovich, S. A. (1997). Gender and antisocial behavior. In D. M. Stoff, J. Breiling, & J. D. Maser (Eds.). Handbook of antisocial behavior (pp. 496–510). New York: Wiley. Goldman, D., & Ducci, F. (2007). The genetics of psychopathic disorders. In A. R. Felthous, & H. S. Saß (Eds.). The International Handbook of Psychopathic Disorders and the Law, Volume I: Diagnosis and Treatment (pp. 149–169). Chichester, England: John Wiley & Sons, Ltd. Hare, R. (2007). Psychological instruments in the assessment of psychopathy. In A. R.

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