Flunitrazepam abuse and personality characteristics in male forensic psychiatric patients

Psychiatry Research 103 Ž2001. 27᎐42

Flunitrazepam abuse and personality characteristics in male forensic psychiatric patients a,b,U Anna Maria Daderman , Gunnar Edmanc ˚ a

Department of Clinical Neuroscience, Occupational Therapy and Elderly Care Research, Di¨ ision of Forensic Psychiatry, Karolinska Institute, Huddinge, Sweden b Department of Psychology, Di¨ ision of Biological Psychology, Stockholm Uni¨ ersity, Stockholm, Sweden c Department of Psychiatry, Research and De¨ elopment, Danderyd’s Hospital, Danderyd, Sweden Received 3 April 2000; received in revised form 28 December 2000; accepted 14 May 2001

Abstract Sixty male non-psychotic forensic psychiatric patients Žaged 16᎐35 years. were studied after they completed their ordinary forensic psychiatric assessment ŽFPA.. The prevalence of flunitrazepam ŽFZ. abuse was investigated by using both structured and in-depth interviews with the objective of studying the relationship between the abuse and personality traits. The patient’s characteristics, DSM-IV disorders, and actual sentences were obtained by studying their files. In order to obtain measures on their personality traits, self-report inventories were administered to the patients. Eighteen out of 60 patients were FZ abusers, but only 4 of them received a diagnosis related to the FZ abuse during the ordinary FPA. In almost all cases, however, indications of the FZ abuse were found in the files. No differences in personality traits were found between the groups. The frequency of previous admissions to an FPA and actual sentences of robbery, weapons offenses, narcotic-related offenses, and other crimes Žsuch as theft. among the FZ abusers deviated significantly from forensic non-FZ abusers. Therefore, the FZ abuse per se might be more responsible for their tendency to commit crimes characterized by danger and thrill-seeking Žsuch as robbery, weapons offences, and theft. than personality. The most important conclusion is that assessment of FZ abuse is needed in forensic psychiatry. 䊚 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Flunitrazepam abuse; Forensic psychiatry; Robbery and weapons offences; Personality traits; Risk assessment

U

Corresponding author. Department of Clinical Neuroscience, Occupational Therapy and Elderly Care Research, Division of Forensic Psychiatry, Karolinska Institute, P.O. Box 4044, SE-141 04 Huddinge, Sweden. Tel.: q46-70-491-1413; fax: q46-8-711-71-41. .. E-mail address: [email protected] ŽA.M. Daderman ˚ 0165-1781r01r$ - see front matter 䊚 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 1 7 8 1 Ž 0 1 . 0 0 2 6 6 - 9

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A.M. Daderman, G. Edman r Psychiatry Research 103 (2001) 27᎐42 ˚

1. Introduction 1.1. Abuse of flunitrazepam Flunitrazepam ŽFZ. is a sedative᎐hypnotic benzodiazepine and is prescribed for the treatment of insomnia ŽFASS, 2000.. It also has special clinical uses for the induction of anaesthesia and for sedation prior to surgery ŽMattila and Larni, 1980.. FZ has been receiving increased attention from law enforcement agencies in a number of countries. Teo et al. Ž1979. reported FZ abuse in Singapore 20 years ago. FZ is abused also in Australia ŽRoss et al., 1995; Dobbin, 1997., in Brazil ŽInciardi and Surratt, 1998., in Europe ŽBarratini et al., 1987; Keup, 1993; San et al., 1993; Daderman and Lidberg, 1999a., in the ˚ Caribbean and in Chile ŽMaddaleno et al., 1988., in Hong Kong ŽUN Consultative Meeting, 1995., in Malaysia ŽNavaratnam and Foong, 1990., in New Zealand ŽDobson, 1987, 1989; Crawford, 1989., and in the United States ŽCalhoum et al., 1996; Saum and Inciardi, 1997; Simmons and Cupp, 1998.. Recently, Gambi et al. Ž1999. reviewed the reasons why some populations of drug abusers prefer FZ to the other benzodiazepines. One such reason is enhancement of feelings of power and self-esteem, reduction of fear and insecurity, and stimulation of the belief that nothing is impossible Žsee Daderman and Lidberg, 1999a.. ˚ FZ abusers are a high-risk group for committing severe violent crimes ŽTeo et al., 1979; Hermansson, 1998; van der Laan, 1988; Anglin et al., 1997; Dobbin, 1997; Elmgren, 1998; Rickert and Wiemann, 1998; Daderman and Lidberg, 1999a,b; ˚ Daderman et al., 2000a., for deviant driving be˚ haviour ŽDruid and Holmgren, 1997., and for deaths by intoxication ŽDrummer et al., 1993; Druid and Holmgren, 1997.. The most common adverse effect of FZ is complete or partial amnesia, particularly if it is taken with alcohol. It is known that many of those who take FZ display hostile behaviour, grandiosity and become careless. Thus, forensic psychiatric assessment ŽFPA. after a serious crime, especially in cases of bizarre, unexpected aggression followed by amnesia, should include an appropriate diagnosis, which

can be the basis for treatment planning, and for the reaction of society to prevent such abuse in the future. In sum, studies have shown that FZ is abused throughout the world and in many cases FZ is associated with violent behaviour, but the abuse by forensic psychiatric patients has so far not been studied. 1.2. A biological ¨ ulnerability model of de¨ iant beha¨ iour No behaviour can occur without an underlying mechanism and none operates in a vacuum. We behave in response to our environment ᎏ for example, in response to cultural or social rules, or stress. Buchsbaum et al. Ž1976. formulated the biological vulnerability hypothesis. Some personality traits are associated with a predisposition to psychiatric or psychological vulnerability ŽOreland and Shaskan, 1983.. Such constitutional vulnerability predisposes us to breakdown in the presence of stress or somatic disease. Support for this hypothesis was provided by the findings of Coursey et al. Ž1982. and Virkkunen et al. Ž1994.. 1.3. Personality traits and the abuse of alcohol and drugs Studies investigating the relationship between serotonergic and dopaminergic transmission and personality traits suggest that the transmitter system is involved Žfor overview, see Oreland, 1993.. Sensation-seeking Ž‘the willingness to take the risk’, see Zuckerman, 1994. is, for example, predictive of early drug use ŽNewcomb and McGee, 1991.. Early studies on criminal men showed that the criminals scored higher than non-criminals on all sensation-seeking subscales, with one exception ŽHaapasalo, 1990; Daderman, 1999.. The ex˚ ception is the thrill and adventure-seeking scale Žsee Section 2., on which criminals scored significantly lower than non-criminals. These results indicate that men involved in criminal acts have a willingness to take social and legal risks, but not a desire to take part in physically risky activities or sports. One Swedish study used the Karolinska

A.M. Daderman, G. Edman r Psychiatry Research 103 (2001) 27᎐42 ˚

Scales of Personality ŽKSP. Žsee Section 2. to study a group of young men abusing alcohol ŽRydelius, 1983.. Their personality patterns were characterized by higher scores than non-abusers on the impulsiveness, monotony-avoidance Žsensation-seeking ., and somatic anxiety scales; and lower scores on the socialisation scale Žwhich is based on a role-taking interaction theory of psychopathy.. Previous research indicates that male forensic psychiatric patients in Sweden with a disorder involving abuserdependence of alcohol in combination with other substances show high ratings for somatic anxiety, social desirability, monotony avoidance, irritability, and suspicion, and low ratings for socialisation, compared with male forensic psychiatric patients without the disorder ŽStalenheim and von Knorring, 1998.. ˚ It is possible that FZ abusers show the same personality pattern as alcohol abusers, since alcohol and FZ seem to have similar pharmacological properties. Both may promote the action of the synaptic transmitter gamma-aminobutyric acid ŽGABA., therefore inhibiting broad regions of the brain and ᎏ possibly ᎏ leading to lower serotonin concentrations in the brain. 1.4. Abuse of flunitrazepam in male ju¨ enile delinquents is related to some background factors and personality traits

abusers Ž42%., but only 1 out of 28 non-FZ abusers, had been in contact with psychological or psychiatric services during childhood, which may indicate earlier and more intense psychological dysfunctioning in FZ abusers than in non-FZ abusers. Moreover, FZ abusers had high scores on verbal aggression and sensation-seeking boredomsusceptibility scales, when compared with the criminal non-FZ abusers. In that study, we presented a psychopharmacological model that explained paradoxical rage reactions from acute abuse with FZ as resulting from a disinhibition phenomenon in the serotonergic mechanism and personality traits assumed to reflect this biological basis of personality. 1.5. The aim of the study The general aim of this study was to investigate the prevalence of FZ abuse in male forensic psychiatric patients and to study some background characteristics, actual crimes, and personality traits that could be related to FZ abuse. Specifically, the aims of the study were to examine the following issues: 䢇

䢇

Our study of young male FZ abusers in Swedish national correctional institutions for severe juvenile offenders, based on in-depth interviews, showed that FZ gives an increased feeling of power and self-esteem, reduces fear and insecurity, and stimulates the belief that nothing is impossible ŽDaderman and Lidberg, 1999a.. The ˚ results showed that, under the influence of FZ, the offenders become unpredictable, very aggressive, and frightening. Some interesting background factors are briefly described here. Seventeen out of 19 FZ abusers Ž89%. had been convicted of violent crimes two or more times prior to the assessments, in contrast to only 16 out of 28 non-FZ abusers. Moreover, 18 out of 19 FZ abusers Ž95%. had previously been sentenced to care in a correctional institution compared to 16 out of 28 non-FZ abusers. Eight out of 19 FZ

29

How prevalent is FZ abuse in male forensic psychiatric patients? Are there associations between FZ abuse and the patients’ background characteristics, especially a previous admission to an FPA, type of actual crime, and personality?

On the basis of a previous study ŽDaderman and ˚ Lidberg, 1999a., the hypothesis was tested that verbal aggression and boredom-susceptibility would be higher in FZ abusers than in non-FZ abusers.

2. Methods 2.1. Forensic psychiatric patients For a period of approximately 1 year ŽNovember 1997᎐November 1998., all male patients F 35 years of age who were in the final phase of their

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A.M. Daderman, G. Edman r Psychiatry Research 103 (2001) 27᎐42 ˚

FPA were asked by the first author ŽA.M.D.. to participate in a neuropsychological research project, including studies on dyslexia, personality, self-confidence, platelet monoamine oxidase ŽMAO. activity, executive functions, and substance abuse. Criteria for exclusion were need for an interpreter, obvious psychotic disorder, or mental retardation. Medication was not a reason for exclusion. Since the study took place after several weeks of incarceration in a high security ward, the patients were well out of any withdrawal stage from a previous abuse of alcohol or drugs. Sixty patients were recruited from male inpatient defendants from the Department of Forensic Psychiatry in Stockholm. Mean age was 27 years ŽS.D.s 5.7 years, range 16᎐35 years.. All patients were admitted for an FPA before being sentenced. 2.2. Forensic psychiatric assessment (FPA) An FPA in Sweden includes extensive reports from a team comprising a psychologist, a forensic psychiatrist, and a social worker. Thus, an FPA file is based on multi-disciplinary teamwork and includes a description of the patient’s life from childhood through adulthood, up to the day of the offence. The patients were diagnosed by using DSM-IV ŽAPA, 1994., which also comprises the Global Assessment of Functioning scale ŽDSMIV; APA, 1994.. The intellectual level of the patients was estimated either by means of the Wechsler Adult Intelligence Scale-Revised ŽWAIS; Wechsler, 1981. or a Swedish standard intelligence test ŽSRB. developed by Dureman Ž1959.. For all patients, the IQ was and Salde ¨ average or above average. In addition, ward observations by the nursing staff and interviews with relatives and other persons who know the patient supplemented the assessment ŽHolmberg, 1994.. 2.3. Procedure The first author ŽA.M.D.. interviewed all patients about FZ abuse. The interviews were

independent of the ordinary FPA. All patients were interviewed individually in a room at the forensic psychiatric unit, located outside of Stockholm ŽHuddinge.. The FZ abusers in the present study include those who, according to an interview, based on the guidelines of the Swedish version of the Structured Clinical Interview for DSM-IV ᎏ Axis I Disorders ŽSCID-I., developed by First et al. Ž1997., fulfilled the criteria for Sedative, Hypnotic, or Anxiolytic Abuse Ž292.89., generally referred to as Substance Abuse, by the DSM-IV in the text ŽAPA, 1994, p. 182., as ‘a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances. They may be repeated failures to fulfil major role obligations, repeated use in situations in which it is physically hazardous, multiple legal problems, and recurrent social and interpersonal problems’. Two patients also showed signs of FZ dependence ŽTable 1.. Those patients were included in the FZ abusers group. In addition to the structured interviews, formal, unstructured interviews, based on interpersonal communication theory ŽBanaka, 1971., were held in order to conduct an in-depth study of the patients’ abuse of FZ. Thus, detailed data of FZ abuse in the form of direct quotations and careful descriptions of situations, events, people, interactions, and observed behaviour were also reported. The questions were open-ended to encourage patients to describe their subjective experiences. One of the questions was, for example, ‘Why do you abuse FZ?’ and another question was, ‘What does it mean to be intoxicated with FZ?’ Depending on how articulate the patient was, his age, and the duration and intensity of the abuse of FZ, the interviews lasted from approximately 30 min to 2 h. The patients also completed four self-report personality inventories. Items were read aloud to those five patients who showed severe difficulties in responding to the inventories; one of them was an illiterate Žonly two of the inventories, the EPQ and the SSS, containing easy items were read for this patient., and the remaining four patients were severe dyslexics. Eight patients did not com-

A.M. Daderman, G. Edman r Psychiatry Research 103 (2001) 27᎐42 ˚

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Table 1 Age, diagnostic ŽDSM-IV and forensic files., and anamnestic data of a group of male forensic psychiatric patients who in the present study showed DSM-IV criteria for Sedative, Hypnotic, or Anxiolytic AbuserDependence Ž‘FZ abusers’; n s 18. Age

Axis I diagnosis

Axis II diagnosis

1

GAFFPA

16

301.83

15

No diagnosis

19

311, 312.8, 305.20, 305.70 314.9, 299.80, 312.8 No diagnosis

20

26

1

GAFLY

Indications of FZ abuse in forensic files

Previous FPA

40

No indications

No

60

55

No indications

No

301.7, 301.83

35

35

No

No diagnosis

No diagnosis

55

55

305.20, 305.70 304.80 304.80 304.10, 304.00, 304.30, 304.40, 305.00, 311 304.00, 305.40 305.00, 305.90 299.80, 300.15, 303.90, 304.10, 304.80 No diagnosis 305.00

301.7

65

65

Intoxicated Žtwice. with tablets against insomnia Žsuicide attempts.; anti-insomnia tablets; Rohypnol, taken in connection with the actual offence No indications

301.7 301.7 301.7, 301.0, 294.9

60 45 49

60 50 49

No diagnosis 301.9 No diagnosis

68 70 30

68 70 30

301.9 301.7

65 58

65 51

301.7

55

55

33

305.70, 305.20, 305.00 304.80

No diagnosis

65

60

33

304.80

301.9

65

50

34

296.04, 304.40, 305.20, 315.9 303.90, 305.40, 305.70

No diagnosis

24

301.9

70

17

26 27 27

30 30 30

31 31

32

35

No

No

Rohypnol Tablets, benzodiazepines Rohypnol, taken in connection with the actual offence Rohypnol No indications Rohypnol

Yes Yes No

Yes No

38

Tablets A medication classified as narcotics; anti-anxiety medication Anti-anxiety medication, and tablets; benzodiazepines Tablets against insomnia Anti-anxiety medication, especially benzodiazepines Benzodiazepines

70

Rohypnol

Yes

No Yes No

Yes

No No

No

The reporting of overall functioning on Axis V is done using the Global Assessment of Functioning ŽGAF. Scale, on a hypothetical continuum from a value of 100 Žsuperior. to 0 Žno information.. GAF considers psychological, social, and occupational functioning, not impairment in functioning due to physical or environmental limitations. 1 GAF FP A , ratings on the GAF Scale at the time of the forensic psychiatric assessment; GAF LY , the highest level of GAF during the past year; 294.9, Cognitive Disorder NOS; 296.04, Bipolar I Disorder, Single Manic Episode, Severe with Psychotic Features; 299.80, Asperger’s Disorder; 300.15, Dissociative Disorder NOS; 301.0, Paranoid Personality Disorder; 301.7, Antisocial Personality Disorder; 301.83, Borderline Personality Disorder; 301.9, Personality Disorder NOS; 303.90, Alcohol Dependence; 304.00, Opioid Dependence; 304.10, Sedative, Hypnotic, or Anxiolytic Dependence; 304.30, Cannabis Dependence; 304.40, Amphetamine Dependence; 304.80, Polysubstance Dependence; 305.00, Alcohol Abuse; 305.20, Cannabis Abuse; 305.40, Sedative, Hypnotic, or Anxiolytic Abuse; 305.70, Amphetamine Abuse; 305.90, Other Žor Unknown. Substance Abuse; 311, Depressive Disorder NOS; 312.8, Conduct Disorder; 314.9, Attention-DeficitrHyperactivity Disorder NOS; 315.9, Learning Disorder NOS.

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A.M. Daderman, G. Edman r Psychiatry Research 103 (2001) 27᎐42 ˚

plete all inventories; two of these patients, although they said they did not need an interpreter, were not able to read Swedish sufficiently well. In addition, one patient had a major depressive episode Žlater, he completed two of the inventories., and three others become psychotic during the study. This left 47 patients for the KSP, 48 for the MNT, and 49 for the EPQ and SSS for the statistical analyses. Files from the Swedish National Board of Forensic Psychiatry were examined as well. These files included information from the Swedish National Police Register, the Hospital Discharge Register of the Swedish National Board of Health and Welfare, and documents from the courts. Approximately 2 years after the FPAs, the convictions were inspected. The project was approved by the ethics committee at the Karolinska University Hospital. The participation was voluntary and all patients gave their informed consent. 2.4. Personality in¨ entories The following four self-report personality inventories were administered to measure personality traits. When filling out the inventories, the patients were instructed to describe their usual, general ways of reacting and feelings, and not how they were feeling ‘right now’. 2.4.1. The Karolinska Scales of Personality (KSP) The KSP consists of 135 items, grouped into 15 scales Žfor a description of the scales, see Schalling et al., 1987.. The scales can be sub-divided into four groups ŽMindus et al., 1999. covering aspects of anxiety proneness ŽSomatic anxiety, Muscular tension, Psychic anxiety, Psychasthenia, and Inhibition of aggression., extraversion ŽImpulsiveness, Monotony avoidance, Detachment, Socialisation, and Social desirability., and aggressiveness᎐hostility ŽVerbal aggression, Indirect aggression, Irritability, Suspicion, and Guilt.. The construction of two different types of anxiety scales, Somatic anxiety Žautonomic disturbances, distress, and panic. and Psychic anxiety Žworry, anxiety, and anticipatory anxiety., is based on a two-factor theory of anxiety ŽBuss, 1962; Schalling et al.,

1975.. One of the 15 scales, a Socialisation scale, is based on items from the Gough Delinquency scale ŽGough, 1960.. Low scores on this scale are ᎏ among other things ᎏ related to low levels of social functioning, and reflect negative childhood experiences, poor school and family adjustment, and current general dissatisfaction. All aggressiveness and hostility scales are adapted from the Buss᎐Durkee Hostility Inventory ŽBuss, 1961. and it is assumed that they reflect diverse tendencies Žstrategies . for coping with aggressiveness-related situations: Indirect aggression reflects a tendency to react by, for example, slamming the door; Verbal aggression includes arguing, shouting, and being overly critical; Irritability reflects a tendency to irritation; Suspicion includes the projection of ill-will onto others; and Guilt reflects aggressiveness with feelings of guilt. The Detachment scale, assumed to be related to a separate syndrome within psychopathy, the schizoid or withdrawn type Žsee Schalling, 1978., is based on the Stability scale from the Marke᎐Nyman Temperament ŽMNT. inventory. The KSP also includes a modified version of the Marlow ᎐ Crowne Social Desirability Scale ŽCrowne and Marlow, 1964.. In a study on adolescents, Kampe et al. Ž1996., the KSP scales showed good stability or test᎐retest reliability over a 10-year period. Engstrom ¨ Ž1997. in a study on suicide attempters showed relatively good reliability values on the KSP aggressiveness-related scales, but low reliability on both hostility-related scales ŽGuilt and Suspicion.. The internal consistency, measured by Cronbach’s alpha, of all aggressiveness and hostility scales, with one exception show low reliability in the sample of male juvenile delinquents ŽDaderman ˚ et al., 2000b., as has been earlier shown in ‘normal’ subjects ŽGustavsson, 1997.. The exception is Ž1997. in a verbal aggression scale. Stalenheim ˚ study on male forensic psychiatric patients, who were re-assessed after approximately 2 years, showed good stability of all KSP scales. 2.4.2. The Eysenck Personality Questionnaire (EPQ) The EPQ-I version was used ŽEysenck and Eysenck, 1975.. It includes an impulsiveness scale from the Impulsiveness᎐Venturesomeness᎐Emp-

A.M. Daderman, G. Edman r Psychiatry Research 103 (2001) 27᎐42 ˚

athy ŽIVE. Inventory ŽEysenck and Eysenck, 1978.. The EPQ-I consists of 114 truerfalse items, and is classified into five scales: Extraversion, Neuroticism, Psychoticism, the Lie scale and the Impulsiveness scale. The Extraversion scale measures a higher order factor of extraversion, on which two of the most important components are sociability and impulsiveness. Subjects with high scores on the Neuroticism scale are nervous, anxious and have a pre-disposition for neurotic disorders. People with high values on the Psychoticism scale tend to be solitary, inhumane, insensitive, and hostile to others, and they enjoy upsetting and ‘making a fool of’ other people. The Lie scale is included as a validation check for socially desirable responding. Previous research on female and male samples from both a healthy and a criminal population shows that the scales from the EPQ-I have good validity and reliability Žfor a review, see Eysenck and Gudjonsson, 1989.. Engstrom ¨ Ž1997. showed that all scales are very reliable in terms of internal consistency. Cronbach’s alpha values ranged from 0.65 to 0.89. ŽCronbach’s alpha is a measure of reliability that ranges from 0 to 1, with values of 0.60᎐0.70 deemed the lower limit of acceptability.. 2.4.3. The Marke᎐Nyman Temperament (MNT) In¨ entory The MNT is a Swedish personality inventory, constructed by Marke and Nyman ŽNyman, 1956; Coppen, 1966; Barett, 1972. on the basis of a personality model of the Swedish psychiatrist Ž1958, 1973.. It consists of 60 Henrik Sjobring ¨ truerfalse items. Three scales are included: Validity, Stability, and Solidity, each consisting of 20 items. Subjects with low scores on the Validity scale are easily tired, tense, and meticulous, properties that are assumed to characterise psychasthenic-neurotic patients. High scorers on Stability are typically sophisticated, skilful and emotionally distanced towards other people, indicating low empathy. Low scores on Solidity indicate high impulsiveness ŽSchalling and Holmberg, 1970.. Impulsiveness is included in the concept of psychopathy used by Cleckley ŽHare and Cox, 1978..

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Engstrom ¨ Ž1997. studied people who had attempted suicide, and showed good reliability in terms of internal consistency for all MNT scales. 2.4.4. The Zuckerman Sensation-seeking Scales (SSS) The SSS Žthe SSS-V was used; the ‘V’ is the version number. ŽZuckerman, 1994. consists of 40 forced-choice items Ž10 items for each scale.. SSS measures four specific factors of sensation-seeking behaviour: Thrill and Adventure-seeking, Experience-seeking, Disinhibition, and Boredom susceptibility. The sum of the four subscales is expressed in a total score. High scores on Thrill and Adventure-seeking indicate a need to do things that are a little frightening. These items express a desire to engage in physically risky activities or sports Žsuch as parachuting, scuba diving, or downhill skiing. that provide unusual sensations of speed or the defiance of gravity. Another scale is Experience-seeking, which indicates a tendency to seek novel sensations and experiences through the mind and senses. Typical examples are the sensations found in listening to arousing music, and through social non-conformity Žsocial non-conformity may be expressed by association with groups on the fringes of conventional society.. Disinhibition measures disinhibited behaviour in the social sphere, and boredom susceptibility reflects an aversion towards repetitive and predictable events, such as routine work and boring people, and restlessness in the absence of change. Cross-cultural reliability and validity studies show good results Žfor a review, see Zuckerman, 1994.. 2.5. Treatment of data and statistical analyses All variables were summarised using standard statistics Žmean and S.D... This study used normative Ž‘normal’ population. personality values ŽTscores for the KSP, EPQ-I, and SSS-V; and standard scores for the MNT. in order to compare the mean personality scale scores of the forensic group with the normal distribution of means. The T-scores were derived from the raw data following adjustment for age and sex. These calcula-

34

A.M. Daderman, G. Edman r Psychiatry Research 103 (2001) 27᎐42 ˚

tions were based on the means and standard deviations of a large group of randomly selected subjects from the greater Stockholm area ŽBergman et al., 1988.. Similar transformations were carried out on the MNT and SSS-V scales, using male groups as reference ŽNyman and Marke, 1962; Zuckerman, 1994.. Differences in frequencies Že.g. type of crime. were analysed with the ␹ 2-method ŽFisher’s exact test if the expected cell frequency in any cell was five or below.. Group differences in continuous variables were analysed by means of Student’s t-test provided that the distributions were not skewed or had outliers. In multiple analyses, the level of significance was corrected employing the Bonferroni method ŽHowell, 1992.. In the case of skewed distributions, non-parametric methods ŽMann᎐Whitney’s test. were applied.

3. Results 3.1. Pre¨ alence of FZ abuse In the present study, 18 out of 60 patients Ž30%. were found to be FZ abusers, according to DSM-IV ŽSedative, Hypnotic, or Anxiolytic Dependence, 304.10, or Sedative, Hypnotic, or Anxiolytic Abuse, 305.40; Table 1.. Only four of them received an FZ abuse-related diagnosis during the ordinary FPA, indicating that assessment of this abuse is not a focus of forensic psychiatrists at the Stockholm unit. In almost all cases, however, indications of FZ abuse were found in the files. During the unstructured interview, FZ abusers declared different reasons for their abuse and two main groups could be discerned. The largest group consisted of subjects who abused FZ to obtain an augmented feeling of power and self-esteem Ž‘to be able to do everything’; n s 8; mean age s 28.8; S.D.s 4.6 years.. The other group consisted of subjects who used FZ as an anxiolytic Ž n s 7; mean age s 26.0; S.D.s 6.5 years.. The remaining patients consisted of three subjects who became frightened by the unexpected properties of FZ and therefore ᎏ after severe consequences related to their crimes ᎏ decided to discontinue

their abuse. This decision was a response to the violent nature of their crimes committed under the influence of FZ, and to the fact that they had amnesia for their crimes. There were no indications that the FZ abusers abused FZ in order to augment or prolong the sedative effects of heroin or methadone, or to attenuate the withdrawal effects of stimulants such as amphetamine derivatives Žsee Woods and Winger, 1997.. It is interesting to note that some of the patients, those who abused FZ to reduce the level of anxiety, reported an increase of anxiety, insomnia, excitation, nightmares, and also suspicion and irritability. Almost all FZ abusers reported that they became violent and committed serious offences under the influence of the drug, later having no memory of their felony Žsee also Daderman et al., ˚ 2000a for a description of some cases.. They found this effect of FZ very inadequate and awkward in many situations. The actual offences for which they were charged Žsee Table 2. were only some of the offences they committed; often they had not been caught for a crime. Some patients reported that they obtained FZ from general practitioners, who prescribed the drug for other indications than insomnia, for example, anxiety or a diffuse pain. One subject reported that he could usually buy some empty prescription forms from his doctor for the low price of 300 SEK Ži.e. approx. US$30. per form. He could therefore make up his own prescription for a desired amount of FZ tablets. Of course, FZ was also available on the illegal market. 3.2. FZ abusers ¨ s. non-FZ abusers: background characteristics, pre¨ ious FPA, type of actual offences, and lack of diagnosis of sleep disorders Table 2 presents characteristics of the FZ abusers vs. non-FZ abusers, and results from statistical comparisons. Number of previous admissions to an FPA, actual sentences for robbery Žrobbery is not regarded as a violent crime according to Swedish law and was, thus, analysed separately., weapons offences, narcotics-related offences and other crimes, such as theft, among the FZ abusers

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Table 2 Sociodemographic, diagnostic ŽDSM-IV and forensic files., and anamnestic characteristics of a group of male forensic psychiatric patients who in the present study showed DSM-IV criteria for Sedative, Hypnotic, or Anxiolytic AbuserDependence Ž‘FZ abusers’; ns18., and a group of non-FZ abusers Ž n s 42. Variable

Pa

Group FZ abusers

Non-FZ abusers

Age wyears, mean ŽS.D.; range.x Biological parents foreign-born w n Ž%.x Previous FPA w n Ž%.x Indicators of medical needs of the FZ use Diagnosis of sleep disorders Ž n. GAFFP A wscores, mean ŽS.D.; range.x

27.4 Ž5.9; 16᎐35.

27.4 Ž5.4; 18᎐35.

NS

6 Ž33%.

14 Ž33%.

NS

6 Ž33%.

3 Ž7%.

0

0

53.0 Ž16.7; 15᎐70.

53.4 Ž15.4; 28᎐80.

NS

GAFLY wscores, mean ŽS.D.; range.x Actual sentencesb Violent offences w n Ž%.xc Robbery w n Ž%.x Weapons offences w n Ž%.x Driving, influenced by alcohol or narcotics w n Ž%.x Inflicting damage and arson w n Ž%.x Narcotics-related offences w n Ž%.x Other crimes w n Ž%.x

53.7 Ž12.1; 30᎐70.

55.7 Ž16.3; 28᎐85.

NS

13 Ž72%. 5 Ž28%. 5 Ž28%. 2 Ž11%.

27 Ž64%. 2 Ž5%. 3 Ž7%. 1 Ž2%.

NS Ps 0.011 Ps 0.031 NS

1 Ž6%.

11 Ž26%.

NS

9 Ž50%.

6 Ž14%.

Ps 0.003

12 Ž67%.

12 Ž29%.

Ps 0.006

Ps 0.006

a Two-sided tests were used; t-test for continuous variables and ␹ 2 tests for nominal, categorical variables; GAF, ᎏ for abbreviation, see Table 1. b Only the presence or absence of the type of an actual sentence is reported Žthe majority of the subjects are sentenced for more than two types of crime.. c Murder, manslaughter, causing another’s death, assault, rape, unlawful threat, unlawful deprivation of liberty, kidnapping, and other sex crimes than rape; FPA, forensic psychiatric assessment; NOS, not otherwise specified; NS, not statistically significant.

Ž n s 18., was significantly more frequent among FZ abusers. There were, however, no significant differences between the groups regarding actual violent crime offences, such as murder, manslaughter, causing another’s death, assault, rape, unlawful threat, unlawful deprivation of liberty, kidnapping, and sex crimes other than rape. 3.3. Personality characteristics Many personality traits of the patients differed from those of subjects in the normal population,

suggesting vulnerability for mental disorders. The patients’ scores were significantly lower than those of normative males on the KSP Socialisation scale, while they were significantly higher than those of normative males on the KSP Impulsivness and IVE-Impulsiveness scales. As expected, the subjects obtained significantly higher scores on all anxiety proneness scales, with one exception, the Inhibition of aggression scale. Fig. 1 presents results regarding differences to mean personality scale T-scores in the KSP, EPQ-I, and SSS, for the group of patients, together with results from

36

A.M. Daderman, G. Edman r Psychiatry Research 103 (2001) 27᎐42 ˚

comparative analyses between results on the present group of forensic patients vs. normal males. Furthermore, the patients’ scores on the Validity Ži.e. psychasthenic traits. and Solidity Ži.e. impulsiveness. scales of the MNT were significantly lower than those of Swedish normative males, also indicating high anxiety proneness and impul-

sive behaviour. The mean standard score of the third scale, Stability, was within the normal range. Contrary to expectations, there were no significant differences in the personality variables between FZ abusers and non-FZ abusers ŽTable 3.. Some results were expected a priori for both

Fig. 1. Differences to mean personality scale T-score Ž50. in the Karolinska Scales of Personality ŽKSP; n s 47., the Eysenck Personality Questionnaire ŽEPQ; n s 49. including an impulsiveness scale from the Impulsiveness᎐Venturesomeness᎐Empathy ŽIVE. inventory, and the Zuckerman Sensation-seeking Scales ŽSSS; n s 49. for the group of forensic psychiatric patient in Sweden. An asterisk indicates statistical significance at the 5% level after Bonferroni correction Žcorresponding to a nominal significance level of 0.0018..

A.M. Daderman, G. Edman r Psychiatry Research 103 (2001) 27᎐42 ˚

37

Table 3 Comparison of mean scores and S.D. in personality scales from the KSP, the EPQ, including an impulsiveness scale from the IVE-I inventory, the MNT inventory, and the SSS, for the group of male forensic psychiatric patients at age 27 ŽS.D.s 5.7., subdivided into two subgroups: FZ and non-FZ abusers a Scales

Anxiety proneness Ža. Tension and distress KSP Somatic anxiety KSP Muscular tension Žb. Cognitive-social KSP Psychic anxiety KSP Psychasthenia MNT Validity KSP Inhibition of aggression EPQ Neuroticism

FZ

Non-FZ

Mean

S.D.

ŽTrS .

23.0 21.7

7.7 5.9

Ž67.4. Ž67.7.

22.7 21.4

6.7 6.4

Ž66.6. Ž67.1.

23.9 23.4 9.7 22.1

5.5 3.4 4.1 6.3

Ž60.6. Ž62.0. Ž1.7. Ž48.6.

23.5 23.1 11.8 23.4

6.0 4.6 4.6 6.1

Ž59.6. Ž58.4. Ž2.3. Ž52.0.

12.8

5.6

Ž65.2.

12.8

5.7

Ž65.0.

Ž64.2. Ž1.6. Ž54.1. Ž49.5. Ž54.5. Ž2.8. Ž20.1. Ž49.5. Ž67.2. Ž48.5.

27.8 9.1 27.3 13.5 23.5 11.3 45.6 6.9 14.2 6.3

5.0 4.0 6.2 5.7 5.1 18.9 10.3 3.0 5.2 3.1

Ž66.4. Ž1.9. Ž55.6. Ž50.4. Ž53.4. Ž3.1. Ž21.8. Ž51.3. Ž65.4. Ž42.7.

Ž59.5. Ž52.4. Ž50.6. Ž54.1.

5.5 5.2 3.8 20.8

1.9 2.1 2.3 7.5

Ž54.3. Ž48.9. Ž53.2. Ž51.9.

Impulsi¨ eness, extra¨ ersion, sensation-seeking, and withdrawal KSP Impulsiveness 27.5 4.2 MNT Solidity 7.7 2.8 KSP Monotony avoidance 27.7 4.8 EPQ Extraversion 13.3 3.6 KSP Detachment 23.8 4.6 MNT Stability 7.6 3.3 KSP Socialization 44.3 9.8 EPQ Psychoticism 6.3 3.9 IVE-Impulsiveness 14.9 4.4 SSS Thrill and 7.6 2.3 adventure-seeking SSS Experience-seeking 6.5 2.1 SSS Disinhibition 6.1 2.1 SSS Boredom susceptibility 3.3 1.8 SSS Total score 23.4 2.9

Mean

S.D.

ŽTrS .

Conformity KSP Social desirability EPQ Lie

25.8 7.3

3.6 3.8

Ž51.7. Ž48.0.

27.6 7.9

4.2 4.3

Ž56.2. Ž49.4.

Aggressi¨ eness KSP Indirect aggression KSP Verbal aggression KSP Irritability

13.5 13.9 12.5

2.3 3.6 2.3

Ž56.8. Ž53.4. Ž56.6.

13.6 13.8 12.3

3.3 3.7 2.7

Ž57.7. Ž53.1. Ž55.6.

Hostility KSP Guilt KSP Suspicion

13.1 12.6

2.7 3.0

Ž57.7. Ž59.5.

12.6 12.4

2.9 2.8

Ž56.0. Ž59.1.

For comparative purposes, mean scores on the KSP, EPQ, IVE, and SSS are also presented as T-scores ŽT ., and on the MNT as standard scores Ž S .. a Number of patients ŽFZ vs. non-FZ abusers . for specific inventory: 17 vs. 30 Žthe KSP.; 16 vs. 33 Žthe EPQ, IVE-I, and SSS.; 17 vs. 31 Žthe MNT..

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A.M. Daderman, G. Edman r Psychiatry Research 103 (2001) 27᎐42 ˚

theoretical and empirical reasons Žsee Section 1.. The mean scores on anxiety-related scales were, however, no higher than those of patients who were not FZ abusers, possibly indicating that the use of FZ was not for medical reasons. Neither was there any significant difference between the mean scores on KSP Verbal aggression nor on SSS Boredom-susceptibility for the FZ abusers and those of non-FZ abusers, in contrast with a previous study in juvenile delinquents who were FZ abusers ŽDaderman and Lidberg, 1999a.. ˚

4. Discussion 4.1. FZ abuse in male forensic patients In the present study, FZ abuse in a sample of male patients undergoing FPA at the largest Swedish department of forensic psychiatry was studied. It was found that a large proportion of the patients Ž30%. were FZ abusers, and also that the frequency of a previous FPA and conviction for offences such as robbery and weapons offences deviated significantly in FZ abusers from non-FZ abusers. It is intriguing that FZ abuse is not a topic of discussion among forensic psychiatrists, whereas it is a well-known problem in society. The complex, but psychiatrically meaningful, relationships between diagnoses, indications Žtraces. of FZ abuse in forensic files, actual sentences, and previous FPAs are clearly seen in Tables 1 and 2. It is remarkable that the patients did not have any diagnoses of sleep disorders, while notes in the forensic files indicate medication for such disorders. The fact that such traces exist indicates that it is often another member of the forensic team Žusually a social worker. who describes the FZ abuse, and not the one who is responsible for the DSM-IV diagnoses. It should be noted that other, more ‘established’ types of abuse, such as alcohol or amphetamine abuse, are reflected in the DSM-IV-diagnoses wsee, e.g. Wennberg and Ž1999, 2000. for some issues regarding Daderman ˚ alcohol abuse studied on this samplex, possibly due to better diagnostic procedures regarding other types of abuse than FZ. Thus, increased

insight into the importance of better diagnostic rules regarding FZ abuse, and also more of an effective control system that such a diagnosis is considered, are needed. The fact that all forensic authorities in Sweden are now included in one organisation, namely the National Swedish Board of Forensic Medicine, which is responsible for all forensic psychiatric and medical assessments, as well as for most of the forensic chemical and serological analyses in Sweden, offers an opportunity to use structural procedures in the assessment of all mental disorders which are related to violent and aggressive behaviour. Attempts to develop better instruments to assess FZ abuse in all Swedish forensic psychiatric units should soon be carried out. In addition, the above-discussed issue should be taken seriously in light of the present results regarding reassessment Ži.e. the higher frequency of previous admissions to a forensic psychiatric assessment of FZ abusers compared with non-FZ abusers .. Moreover, convictions for offences such as robbery and weapons offences deviate significantly in FZ abusers from non-FZ abusers, which is interesting in the light of recent national statistics ŽStatistics Sweden, 1999. showing a dramatically increasing proportion of crimes of robbery, especially in young men. An interesting point of this study is the lack of significant differences in the frequency of actual violent offences between those who are FZ abusers and those who are not. One should expect that those who abuse FZ are more involved in violent crimes due to the nature of the drug. This result may have something to do with the fact that many of the crimes remain undiscovered by official authorities. Sometimes, some of the FZ abusers found themselves in a hospital or a police station, and could not remember why they were there ŽDaderman et al., 2000a., as their episodic ˚ memory Žthat is, their memory for personal experiences . was impaired. 4.2. Personality in a group of male forensic patients This study shows a personality pattern, indicating high vulnerability Žsuch as high impulsiveness

A.M. Daderman, G. Edman r Psychiatry Research 103 (2001) 27᎐42 ˚

and anxiety proneness. for mental disorders as determined by four reliable and validated personality inventories, based on forensic male psychiatric patients. The simultaneous use of four personality inventories, has not previously been reported in a forensic sample in Sweden. In particular, the SSS has never been used to study forensic psychiatric patients, nor has the present version of the EPQ. Stalenheim and von Knorring Ž1998. ˚ presented results on the KSP on a group of males from the same population, assessed during 1992᎐1994. The present study confirmed their results on the KSP with some exceptions. The few exceptions were on scales that measure impulsiveness, monotony avoidance and also indirect and verbal aggression, on which the present patients scored slightly higher. The MNT was used in the 1970s in a sample of male forensic psychiatric patients, and studied in relation to some biological correlates ŽLidberg et al., 1978; Levander et al., 1980.. Personality patterns on the MNT for the present group of patients are somewhat different from those studied by Lidberg et al. Ž1978. and Levander et al. Ž1980.. One example is the present result on the Stability scale Žclose to mean compared to a normative population.. A pattern of high scores on stability and low scores on solidity were assumed in early studies to indicate psychopathy ŽSchalling and Holmberg, 1970; Lidberg et al., 1978.. The present results Žstability close to mean and solidity lower as compared to the normative sample. may indicate a low or moderate degree of psychopathy in the present group of patients, which may be due to some legal issues; according to Swedish law, psychopathy is no longer seen as a ‘severe mental disorder’ Žsee Holmberg, 1994.. A psychopathic offender will not receive forensic psychiatric treatment since such offenders are now regarded as legally responsible for their crimes and, thus, are sentenced to prison. It is possible, that Swedish courts are reluctant to refer persons with signs of psychopathic disorders to an FPA, since the change of Swedish law in 1992 ŽSocialstyrelsen, 1996.. This is consistent with preliminary data regarding psychopathy from the present sample Ždata not shown..

39

4.3. Personality and FZ abuse The moderate Žor low. degree of psychopathy may also be one explanation why no differences between FZ abusers and non-FZ abusers in any personality traits were found in this study. The hypothesis regarding personality differences tested in this study was namely based on results on the previously studied juvenile delinquent sample ŽDaderman and Lidberg, 1999a., which ˚ comprises a large proportion of psychopaths ŽDaderman and Kristiansson, 2001.. It is possible ˚ that FZ abuse is rather related to psychopathy than to a particular personality trait. The lack of a significant difference could also be an effect of the low power of the statistical analyses. However, an examination of Table 3 reveals that except for the MNT scales, most of the differences were negligible. The MNT scales indicate that the FZ abuser might be more psychasthenic Žlower Validity scores., more dependent Žlower Stability scores., and more impulsive Žlower Solidity scores.. However, these differences are not supported by other scales assumed to measure the same personality variables and, thus, have to be confirmed by studies on samples of greater sizes. The lack of personality differences between FZ abusers and non-FZ abusers might indicate that certain personality traits does not make a person more prone to abuse FZ. Furthermore, the FZ abuse per se might be more responsible for their tendency to commit crimes characterized by danger and thrill-seeking Žsuch a robbery, weapons offences, and theft. than personality. Thus, the most important conclusion of this report might be that a more systematic assessment of FZ abuse is needed in forensic psychiatry. To reveal a FZ abuse and to treat it poses a serious economic and security challenge to the community.

Acknowledgements We are grateful to the staff of the Department of Forensic Psychiatry in Stockholm for their cooperation and patience, and to the forensic male patients for the time they volunteered. Prepara-

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A.M. Daderman, G. Edman r Psychiatry Research 103 (2001) 27᎐42 ˚

tion of this article was supported by a doctoral fellowship from the Swedish Foundation for Care Sciences and Allergy Research Žto Anna M. .. The Swedish National Board of Daderman ˚ Forensic Medicine, Karolinska Institute, the Soderstrom-Konigska Foundation, the Swedish ¨ ¨ ¨ Carnegie Institute, and the Swedish Medical Society of Addiction Medicine also supported this study by grants. We thank Dr George Farrants, and also two anonymous reviewers, for their helpful critical comments on an earlier version of this article. Anna M. Daderman presented some of ˚ the results from this study to the Annual Meeting of the Swedish Medical Association, 30 November᎐2 December 1999, Stockholm, Sweden. References Anglin, D., Spears, K.I., Hutson, H.R., 1997. Flunitrazepam and its involvement in date or acquaintance rape. Academy of Emergency and Medicine 4, 323᎐326. APA ŽAmerican Psychiatric Association., 1994. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. ŽDSMIV.. Authors, Washington, DC. Banaka, W.H., 1971. Training in Depth Interviewing. Harper & Row, New York. Barett Jr., J.E., 1972. Use of the M᎐N᎐T Inventory ŽSjobring’s ¨ personality dimensions. on an American population. Acta Psychiatrica Scandinavica 7, 501᎐509. Barratini, M., Fantozzi, R., Masini, E., Mannaioni, P.F., 1987. Abuse of licit drugs in heroin addicts. Clinical Therapy 120, 183᎐198. Bergman, H., Bergman, I., Engelbrektson, K., Holm, L., Johannesson, K., Lindberg, S., 1988. Psykologhandboken ŽThe Psychologist Handbook.. Karolinska Hospital, Stockholm. Buchsbaum, M.S., Coursey, R.D., Murphy, D.L., 1976. The biochemical high-risk paradigm: behavioural and familiar correlates of low platelet monoamine oxidase activity. Science 194, 339᎐341. Buss, A.H. ŽEd.., 1961. The Psychology of Aggression. John Wiley, New York. Buss, A.H., 1962. Two anxiety factors in psychiatric patients. Journal of Abnormal and Social Psychology 65, 426᎐427. Calhoum, S.R., Wesson, D.R., Galloway, G.P., Smith, D.E., 1996. Abuse of flunitrazepam ŽRohypnol. and other benzodiazepines in Austin and South Texas. Journal of Psychoactive Drugs 28, 183᎐189. Coppen, A., 1966. The Marke᎐Nyman temperament scale: an English translation. British Journal of Medical Psychology 39, 55᎐59. Coursey, R.D., Buchsbaum, M.S., Murphy, D.L., 1982. Twoyear follow-up of subjects at risk for psychopathology on

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