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Neuropsychological Functioning of Inmates Referred for Psychiatric Treatment
Archives of Clinical Neuropsychology, Vol. 13, No. 3, pp. 303–318, 1998 Copyright 1998 National Academy of Neuropsychology Printed in the USA. All rights reserved 0887-6177/98 $19.00 1 .00
PII S0887-6177(97)00032-2
Neuropsychological Functioning of Inmates Referred for Psychiatric Treatment Myla H. Young and Jerald Justice California Department of Mental Health, Correctional Medical Facility, Psychiatric Program—Vacaville
This article describes the Neuropsychological (NP) functioning of 71 psychiatrically hospitalized male prisoners. Demographic description, patterns of drug use, patterns of violence, psychiatric diagnosis, and performance on the Halstead-Reitan Neuropsychological Battery (HRNB) are described. Using age and education adjusted norms (Heaton, Grant, & Matthews, 1991), 84% of this sample demonstrated impairment on the Halstead Impairment Index. Sensory Exam-Left, Tapping Dominant and Non-Dominant, Speech Perception, Tactual Performance Test Times/Memory/and Location, Trailmaking A and B, and Category Test were all impaired. Multivariate Analyses (MANOVAS) demonstrated significantly impaired performance on tasks of Motor, Psychomotor, and Reasoning, with FTT-Dominant, TPT-Total, and Category Test contributing the most meaningful contribution to the multivariate effect. Varimax Rotated Principle Components Analysis revealed a five-factor model (Motor, Learning, Attention, Abstraction, and Processing Speed), which accounted for 69.9% of the total variance. Need for further research, and implications for the use of this information in developing treatment programs for psychiatrically disturbed prisoners are discussed. 1998 National Academy of Neuropsychology. Published by Elsevier Science Ltd
Over the past several years, investigators have reported a wide range in incidence of both mental and neurocognitive disorders among prison inmates. Depending upon the geographic location and measurement instrument used, the incidence of mental disorder is reported as ranging from 16% to 67%, and incidence of neurocognitive disorder is reported as ranging from as low as 8% to as high as 94%. For example, Hartsone, Steadman, Robbins, and Monahan (1984) interviewed correctional staff in five states, and reported that these officials identified 37.5% of inmates as ‘‘suffering from psychological problems’’ and in need of psychiatric treatment. Guy, Platt, Zwerling, and Bullock (1985) interviewed 486 inmates admitted to Philadelphia prisons and identified 67% of inmates as being ‘‘psychiatrically disturbed and in need of specific mental health treatment,’’ and 11% in need of ‘‘immediate psychiatric hospital care.’’ Steadman, Holohean, and Dvoskin (1991) interviewed New York State prisoners and concluded that 16% experienced mental disabilities that required periodic services, and 8% experienced severe psychiatric disorders. Swetz, Salive, Stough, and Brewer (1989) interviewed Maryland State prisoners and found that 23% of inmates had at least one psychiatric hospitalization prior to prison, Address correspondence to Myla H. Young, PhD, California Department of Mental Health, Psychiatric ProgramVacaville, P.O. Box 2297, Vacaville, CA 95696-2297.
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and 12% required acute psychiatric hospitalization while in prison. More recently, Edwards, Faulkner, and Morgan (1994) found that 15% of South Carolina inmates had a history of psychiatric hospitalization prior to prison, and Teplin (1994) reported prevalence rates of more than 30% among urban male jail detainees. High incidence of mental disorder within the prison system is reported not only in the United States, but also in other countries. Bland, Newman, Dyck, and Orn (1990) compared mental disorder prevalence rates of Canadian community members with Canadian prisoners and concluded that, for all categories evaluated (Substance Abuse, Affective Disorders, Anxiety Disorders, Schizophrenic Disorders, and Cognitive Impairment), there was a significantly higher incidence of mental disorder among prisoners as compared to community members. Not only is there a higher incidence of mental disorder among prisoners as compared to community members, investigations suggest that severely mentally disordered prisoners frequently are placed in special housing units, rather than in prison psychiatric treatment facilities. Uhlig (1976) evaluated inmates who were designated as special management problems and were housed in special housing units (SHU). He reported that 53% of those inmates in SHU placements had a current severe mental disorder. More recently, a similar finding is reported by Hodgins and Cote (1991), who evaluated inmates in the Quebec region of the Correctional Service of Canada who were housed in either the Special Handling Unit (SHU) or the Long-Term Segregation Unit (LTSU). They reported that 29% of these inmates experienced a severe mental disorder (schizophrenia, major depression, bipolar disorder); 61% experienced alcohol abuse/dependence disorder; and 50% experienced other drug abuse/dependence disorders. Of those inmates who were identified as experiencing a major mental disorder, there was indication that for 86% of those inmates, the mental disorder was present prior to prison. They further reported that 33% of those inmates had a suicide gesture either prior to or in prison. The incidence of mental disorder among prisoners is increasingly documented. The incidence of neurocognitive impairment among prisoners is also increasingly documented. Utilizing the Diagnostic Interview Schedule (DIS) and the Structured Clinical Interview for DSMIII-R (SCID), and interviewing 1000 randomly selected prisoners, Neighbors (1987) reported that 8.2% of the sample met research diagnostic criteria for organic brain disorder. Utilizing a far more sensitive measure of neurocognitive functioning than structured interview, Yeudal, Fedora, and Fromm (1977) reported an extraordinarily high incidence of neurocognitive impairment on the Halstead Reitan Neuropsychological Battery (HRNB), with 94% of those prisoners evaluated demonstrating abnormal findings on the HRNB. More specifically, he reported that 100% of rapists, 94% of homicide offenders, and 87% of assaulters had abnormal findings on this battery. Although Yeudal et al.’s report appears to be extraordinarily high, others report lower, but similar results. Martel (1992) evaluated 50 randomly selected inmates who were hospitalized at a maximum security state hospital for mentally disordered offenders in New York City. Neurological examinations and chart reviews were completed for these inmates. Martel considered DSM-III-R diagnosis of organic brain impairment, incident of head injury with loss of consciousness, evidence of seizure disorder, IQ in the subaverage range, and abnormal neurological findings. Utilizing a criteria of two or more of the previously identified indicators. Martel reported that 64% of these randomly selected inmates would be classified as brain impaired. Although addressing adolescent rather than adult functioning, Lewis et al. (1988) described the characteristics of 14 juveniles sentenced to death in the United States. These juveniles ranged in age from 15 years, 10 months to 17 years, 10 months and included six African American, seven Caucasian, and one Latino juvenile. Psychiatric, neurological, psychological, neuropsychological, and educational evaluations were completed. Lewis et al. reported extensive neurological and psychiatric disorders among this sample, with 9 juveniles
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TABLE 1 Reasons for Incomplete Participation in Study Reason
n
Percent
Delusional Manic Suicidal Malingering Unknown Total Incomplete/Refused
9 4 3 2 2 20
11 4 3 2 2 22
Note. Total number of participants approached for testing 5 91; Total number completing testing 5 71.
(64%) experiencing serious neurological abnormality and 11 juveniles (79%) experiencing major mental disorder. Lewis further reported that 12 juveniles (86%) had experienced ‘‘brutal physical abuse.’’ Considering the high incidence of mental and cognitive disorders among general prison populations, it is anticipated that a number of these inmates would require psychiatric hospitalization and treatment while incarcerated. It is also anticipated that those inmates who require psychiatric treatment while incarcerated would demonstrate substantial neuropsychological impairment, as well as psychiatric disorder. The purpose of this study was to describe the neuropsychological functioning of a group of inmates who, while incarcerated in California, required hospitalization because of psychiatric symptoms that prevented them from adequately functioning within the general prison population. Demographic description, patterns of drug use, patterns of violence, psychiatric diagnosis, and performance on a series of neuropsychological tests is described. METHOD Participants Ninety-one males who were receiving psychiatric treatment in a mental health facility located within a California State Prison were randomly selected for participation in this study. Of the 91 males who were selected, 71 males (78%) completed the study. Reasons for incompletion included delusional thinking, manic episode, suicidal behavior, possible malingering of psychiatric symptoms, and unknown reasons. Table 1 describes reasons for incompletion. Table 2 describes age and education for this group. All subjects were male. Ages ranged from 19 to 65 years, with a mean age of 34.2 years. Education ranged from completion of 5th grade to completion of 16 years (bachelor degree), with a mean education of 10.8 years. Table 3 further describes this group. Caucasians (44%) and African Americans (35%) comprised the largest ethnic groups, followed by Latino (17%), and Other (Asian, Native
TABLE 2 Age and Education of Sample
Age (Years) Education (Years)
M
SD
n
Minimum
Maximum
34.19 10.81
8.86 2.43
71 70
19 5
65 16
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TABLE 3A Ethnic, SES, Psychiatric Descriptions Descriptor Ethnic Group Caucasian African American Latino Other Total Social Services I II III IV V Total DSM-III-R Axis I Diagnosis Psychotic Depressive Organic Other Total
n
Percent
31 25 12 3 71
44 35 17 4
1 1 5 14 24 45
2 2 12 31 53
31 17 12 9 69
45 25 17 13
TABLE 3B Prior Treatment, Medication, Neurological Descriptions Descriptor Prior Psychiatric Treatment Received Treatment Not Received Treatment Total Primary Medication Type at Testing Antipsychotic Antidepressant Lithium Anticonvulsant Other None Total Neurological Injury Head Trauma Seizure Loss of Consciousness More than One Type Total
n
Percent
38 24 62
61 39
38 8 4 2 10 9 71
54 11 6 3 14 12
10 3 15 9 37
27 8 41 24
American) (4%). Utilizing a two factor index of social position (Myers & Bean, 1968), most subjects were in the two lowest classifications of social position (IV 5 31% and V 5 54%). In addition to demographic description, information regarding psychiatric diagnosis, psychiatric treatment prior to prison, medication at time of assessment, history of neurological injury, drug use history, and violence history prior to and in prison were obtained. Table 3 also provides this information. As is apparent from Table 3 (3A, 3B, 3C, 3D), psychiatric factors played a major role in describing this sample. Forty-five percent had a psychotic diagnosis; 25% had a depression
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TABLE 3C Drug Use History Descriptor Drug Use History No Drug Use Drug Use Total Drug Abuse/Dependence Total Polysubstance Abuse Total Drug Used Most Alcohol Cocaine Opioid Inhalant Amphetamine Phencyclidine Hallucinogen Sedative Cannabis Total Drugs Preferred Alcohol Cocaine Opioid Inhalant Amphetamine Phencyclidine Hallucinogen Cannabis Total Drugs First Used Alcohol Opioid Inhalant Cannabis Total
n
Percent
4 63 67 57 67 57 67
6 94
26 2 4 1 1 3 2 1 15 55
47 4 7 2 2 5 4 2 27
16 8 7 1 1 2 1 17 53
30 15 13 2 2 4 2 32
27 1 5 22 55
49 2 9 40
85 85
diagnosis; and 17% had an organic diagnosis. Of those who completed the study, 13% did not have an Axis I Disorder that fell into one of the previously indicated categories. Additionally, 61% of this sample had been psychiatrically hospitalized prior to prison. As would be expected, considering the incidence and type of psychiatric diagnoses, a substantial proportion of this sample was taking psychotropic medication at the time of the assessment. Overall, 87% were taking some type of psychotropic medication, with the majority (53%) taking antipsychotic medication, and lesser percentages taking antidepressants (11%), lithium (6%), anticonvulsant (3%) and other (14%). A medical examination was not completed as a part of this study, but medical examination and history were taken at the time of hospitalization. Information regarding known neurological injury was obtained both from the patient and from the medical file. Twenty-seven percent of the entire sample had experienced a head trauma resulting in loss of consciousness, and 8% indicated that they had experienced at least one seizure. Another 41% indicated that they had experienced a loss of consciousness from an incident other than head trauma or seizure, and the length of unconsciousness was more than 30 minutes. The primary reason for this loss of consciousness was drug related. Twenty-four percent indicated that they had experienced more than one type of neurological injury.
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TABLE 3D Offenses with Highest Violence Descriptor Violence History 1-Nonviolent 2-Ambiguous 3-Property Crimes 4-Threats to Person 5-Attack on Person 6-Loss of Life 7-Loss of Life with Exceptional Violence Total Lifetime Violence High Violence Low Violence Total Violence in Prison Discipline Charge-Assault Total
n
Percent
0 2 7 9 24 3
0 3 12 15 40 5
15 60
25
37 20 57
65 35
59 71
83
Note. Total: Totals differ because of missing data. Percents are based on known data rather than total sample size. SES: The higher the number the lower SES. Loss of Consciousness: For reasons other than head trauma or seizure. Psychotic Diagnosis: Psychosis includes DSM-III-R Schizophrenia, Schizo-affective, Psychosis NOS, Depressive and Bipolar Disorder with Psychotic Features. Depressive includes Major Depression and Bipolar Disorders without Psychotic Features, Depressive Disorder NOS. Organic includes Organic Psychosis, Organic Mood, Organic Disorder NOS. None includes NO Diagnosis, Malingering, Adjustment Disorder, Dysthymia. High Lifetime Violence: 21 offenses of physical attack, or 11 offenses of murder.
Drug use history was also particularly relevant in this sample. Ninety-four percent indicated that they had used some form of illegal drug, and 85% described drug use that met DSM-III-R criteria for drug abuse and/or dependence. Of those reporting drug abuse, 85% also indicated polysubstance abuse. The most abused drug was alcohol (47%), followed by marijuana (27%). Of interest, alcohol (30%) and marijuana (32%) were also indicated as drugs of preference, followed by cocaine (15%) and opioids (13%). When asked about drug first used, inhalants entered the picture (9%) along with alcohol (49%) and marijuana (40%). The average age for first drug use was 12.8 years, with most first using drugs at 12.0 years. The youngest age for drug use was 7 years, and the oldest age was 21 years. This sample was also characterized by a high level of violence. Using a 7-point Violence Rating Scale (see Appendix A), 71% had at least one convicted offense that involved violent physical attack. When describing lifetime patterns of violence as either high violence (two or more offenses that involved violent physical attack, or one offense that included murder or murder with particularly high violence), or low violence, 65% had lifetime patterns of high violence and 35% had lifetime patterns of low violence. Not only did this sample demonstrate a pattern of high violence that resulted in incarceration, a large number continued to be violent once in prison. Eighty-three percent had at least one disciplinary action as a result of violent behavior while in prison.
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TABLE 4 Age and Education Adjusted Means, Standard Deviations, and Percent of Subjects in Impaired Range for Theoretical Grouping of NP Tests into NP Functions Tests Summary Scores Halstead Impairment Index Sensory Scores Tactile Form Rec-Right Tactile Form Rec-Left Sensory Exam-Right Errors Sensory Exam-Left Errors Motor Scores Tapping-Dom Hand Tapping-Non-Dom Hand Grip Strength-Dom Hand Grip Strength-Non-Dom Hand Attention Scores Seashore Rhythm Test Speech Perception Test Learning Scores Tactual Perf Test-Memory Tactual Perf Test-Loc Verbal Scores Aphasia Screening Test Psychomotor Scores Tactual Perf Test-Dom Tactual Perf Test-Non-Dom Tactual Perf Test-Both Tactual Perf Test-Total Time/Block Trailmaking A Reasoning Scores Category Test Trailmaking B
M
SD
n
% Impaired
27.73
14.12
51
84.31
49.52 48.54 42.27 38.08
10.17 8.22 12.48 14.89
69 70 69 71
13.04 14.29 43.48 70.00
33.86 37.13 45.11 46.32
12.53 12.41 12.01 10.64
70 71 70 71
65.71 54.93 28.57 33.80
43.91 38.06
14.35 9.72
71 71
40.85 60.56
39.01 39.21
11.53 9.28
71 71
63.38 54.93
47.60
11.78
71
23.94
37.61 39.32 38.92
12.11 11.87 11.20
71 71 71
57.75 45.07 56.34
28.89 34.37
9.67 12.20
71 71
83.10 74.65
33.96 36.98
12.51 12.47
71 71
73.24 64.79
Note. Impairment Cutoff Score T 5 40.
MATERIALS Materials included a demographic data form, structured clinical interview, tests of neuropsychological functioning, and tests of psychiatric functioning. Demographic information was obtained through interview with the inmate and review of criminal and medical records. Any differences between inmate report and documentation were resolved by relying on documented information. Structured clinical interview was accomplished using the Structured Interview for DSM-III-R–Patient Edition (SCID-P). Neuropsychological testing included tests from the Halstead-Reitan Neuropsychological Battery (HRB) as listed in Table 4. Psychiatric diagnosis was established by utilizing demographic information, SCID-P and the Rorschach Test. PROCEDURES Subjects were randomly selected from weekly admission lists provided by the Health Information Services. Within 2 weeks of admission the inmate was approached to provide informed consent. There was a 22% refusal/incompletion rate as described in Table 1. A comprehensive review of medical and criminal records was completed; the inmate was interviewed; and all previously listed tests were administered. Record reviews and clinical inter-
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views were completed by a Licensed Clinical Social Worker, who has 15 years experience working in a forensic setting. Neuropsychological and Rorschach tests were administered by a Licensed Clinical Psychologist, who has specialized pre- and postdoctoral training in neuropsychology, and 7 years experience working in a prison. Neuropsychological tests were also administered by three predoctoral psychology interns who were trained and supervised by the principal author. Psychiatric diagnosis was established using all available information. Since Rorschach and SCID-P were independently and blindly administered by two individuals, reliability of psychiatric diagnosis was established by obtaining percent of agreement between the SCID-P and the Psychological Testing Report. There was 79% agreement between these two measures.
RESULTS Raw Neuropsychological (NP) testing scores were converted to age and education adjusted T-scores in accordance with normative data provided by Heaton et al. (1991). Individual NP tests were organized according to function, as indicated by Heaton et al. (1995). Table 4 provides description of this sample’s performance on these tests. Using an impairment cutoff score of T 5 40 (Heaton et al., 1991), Table 4 reveals that the overall mean performance for this population was impaired on Category Test (CAT), Trail Making A (TMTA), Trail Making B (TMTB), Tactual Performance Test-Total Time (TPT-T), Tactual Performance Test-Memory (TPT-M), Tactual Performance Test Localization (TPT-L), Speech Perception Test (SPPER), Finger Tapping Test Dominant (FTT-D) and Non-dominant (FTT-N), and Sensory Perception Left (SP-L). The overall mean performance for this population was not impaired on Seashore Rhythm (SEA), Grip Strength Dominant (GRIP-D) and Non-Dominant (GRIP-N), Sensory Perception Right (SP-R), Tactual Figure Recognition Right (TFR-R) and Left (TFR-L), and the Aphasia Test (APHASIA). Ninety-one individuals were randomly selected for participation, and 71 completed at least 85% of testing. Only data from participants whose performance was considered to be valid, and who completed at least 85% of all measures were included in analyses. Multivariate Analysis MANOVAS for each NP function were conducted to determine whether this sample’s performance was not only impaired, but significantly below the cutoff for impaired NP performance (T 5 40). Results for each function are as follows. Halstead Impairment Index (HII). The HII is composed of CAT, TPT-T, TPT-M, TPT-L, SEA, SPPER, and FTT-D. With the exception of SEA, performance on all these tests was impaired. MANOVA was significant with Wilk’s Lambda 5 .28, F(7, 63) 5 22.60, p , .001. Roy’s greatest characteristic root (GCR) revealed a strong effect (.72) with 72% of the variance in the covariance matrix accounted for by the difference between this group and Heaton et al.’s (1991) reference group. Post hoc canonical discriminant function analysis (DFA) indicated that all tests offered meaningful, unique contributions to the multivariate effect, with TPT-T (.99), CAT (.55), and TPT-M (.55) offering the greatest contributions, but with SEA (.44), SPPER (.22), FTT-D (.15), and TPT-L (.13) also offering meaningful contributions. Canonical structure coefficients (CSC) were consistent with DFA (TPT-T 5 .72; FTT-D 5 .31; CAT 5 .30; SEA 5 .18; SPPER 5 .13; TPT-M 5 .05). Univariate post hoc tests show that, using family-wide control for Type I error with Bonferroni adjusted p-values, CAT, TPT-T, SEA, SPPER, and FTT-D showed significant univariate differences,
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but TPT-M and TPT-L did not show significant univariate differences. Overall, compared to Heaton et al.’s (1991) sample, this sample was significantly impaired on the HII. Sensory. Sensory functioning was evaluated using SP-R, SP-L, TRF-R, and TFR-L. SP-L was in the impaired range, but all other measures were not impaired. Compared to Heaton et al.’s (1991) reference sample, sensory impairment did not significantly contribute to this sample’s impaired NP functioning. Motor. Motor functioning was evaluated using FTT-D, FTT-N, GRIP-D, and GRIP-N. Both FTT-D and FTT-N were impaired, but GRIP-D and GRIP-N were not impaired. MANOVA was significant with Wilk’s Lambda 5 .40, F(4, 66) 5 25.00, p , .001. Roy’s (GCR) revealed a strong effect (.60), indicating that 60% of the variance in the covariance matrix could be accounted for by the difference between this group and Heaton et al.’s (1991) reference group. Post hoc canonical (DFA) indicated that all tests offered meaningful, unique contributions to the multivariate effect, with FTT-D offering the strongest contribution (SDFC for FTT-D 5 1.39, FTT-N 5 .40, GRIP-D 5 .61, and GRIP-N 5 .64). CSC were consistent with the SDFC, with CSC-FTT-D 5 .40, CSC-FTT-N 5 .19, CSC-GRIP-D 5 .35, and CSC-GRIP-ND 5 0.48. Univariate post hoc T-tests for all measures were significant. Overall, FTT-D and -N contributed to the impaired performance of this sample, but GRIPD and -N were not impaired. Attention. Attention was evaluated using SEA and SPPR. SEA was not impaired, but SPPR was impaired. MANOVA was significant with Wilk’s Lambda 5 .85, F(2, 69) 5 6.10, p , .01. Roy’s GCR revealed a significant, but small effect (.15), indicating that 15% of the variance in the covariance matrix could be accounted for by the measures of attention. Post hoc canonical DFA indicated that both SEA and SPPR offered meaningful, unique contributions, but in opposite directions (SEA 5 0.94 and SPPR 5 2.81). CSC were consistent with SDFC, and in the same directions (SEA 5 0.65; SPPR 5 .48). Univariate post hoc T-tests demonstrated significant effects for SEA but did not indicate significant effects for SPPR. Overall, attention did not appear to significantly contribute to the impaired performance on this sample. Language. In this study, language was evaluated using the Aphasia Test. Overall performance on this test was within normal ranges (mean T-score 5 47.6). Univariate sample T-test demonstrates that this sample’s performance on this measure of language was significantly above the impairment cutoff score of T 5 240 (T 5 5.44, df 5 70, p , .001). Language did not significantly contribute to the impaired performance of this sample. Learning and memory. Learning and memory were evaluated using TPT-M and TPL-L. Although performance on both these measures was in the impaired range, MANOVA was not significant (Wilk’s Lambda 5 .99, F(2, 69) 5 .32, p . .05). Roy’s GCR did not reveal a meaningful effect (.01), indicating that less than 1% of the variance in the covariance matrix was accounted for by the difference between this group and Heaton et al.’s (1991) reference group. Post hoc canonical SDFC indicated a weak contribution of these tests to the multivariate effect (TPT-M 5 .57 and TPT-L 5 .55). CSC were consistent with SDFC (TMT-M 5 .89 and TPT-L 5 .89). Univariate post hoc T-tests were consistent with the multivariate results, with neither TPT-M or TPT-L showing significant effects. Learning and memory do not appear to account for the impairment demonstrated by this group.
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Psychomotor. Psychomotor functioning was evaluated using TPT-T and TMT-A. Performance on both these tests was impaired. MANOVA was significant with Wilk’s Lambda 5 .40, F(2, 69) 5 52.31, p , .001. Roy’s GCR revealed a strong effect (.60), indicating that 60% of the variance in the covariance matrix could be accounted for by the difference between this group and Heaton et al.’s (1991) reference group. Post hoc canonical SDFC indicated that TPT-T offered the greatest meaningful contribution to the multivariate effect (TPT-T 5 .93), with TMT-A offering less meaningful contribution (TMT-A 5 .34). Univariate post hoc T-tests were but significant. Both TPT-T and TMT-A significantly contributed to impairment demonstrated by this group. Reasoning. Reasoning was evaluated using CAT and TMT-B. Performance on both tests was impaired. MANOVA was significant with Wilk’s Lambda 5 .81, F(2, 69) 5 8.32, p , .001. Roy’s GCR revealed a moderate effect (.19), indicating that 19% of the variance in the covariance matrix could be accounted for by the difference between this group and Heaton et al.’s (1991) reference group. Post hoc canonical SDFC indicated CAT offered the greatest meaningful, unique contribution to the multivariate effect (CAT 5 .93). TMT-B was less meaningful but also contributed to the effect (TMT-B 5 .15). CSC were consistent with SDFC, with CAT 5 .99 and TMT-B 5 .50. Although CAT had a greater effect than TMT-B, univariate post hoc T-tests were both significant (CAT 5 p , .001 and TMT-B 5 p , .05). Both CAT and TMB-B significantly account for the overall impaired NP performance of this sample, but performance on CAT accounts for the greater impairment. In summary, multivariate analyses revealed that the impaired performance of this sample was significantly affected by their performance on tasks of Motor, Psychomotor, and Reasoning. Of particular note, performance on FTT-D, TPT-T, and CAT had the greatest effect on this impaired performance. Factor scores. A principal components analysis with varimax rotation was performed on the age and education corrected T scores of test measures within the NP battery. Factor analyses were performed for three-, four-, and five-factor models. Although all analyses produced Eigenvalues .1, the five-factor model was selected because of its theoretical relevance. The five-factor model explained 69.9% of the total variance. For each factor, Table 5 lists the NP tests with the highest loading, in descending order. Only those tests that reached a criterion of ..50 were selected. All of the clinically derived tests that were entered into the factor analysis were represented in the factor scores. With the exception of Factor 5, these tests were represented in combinations that were similar to theoretical functional expectation. Factor 1 was a Motor Factor, and included FTT-D and N and GRIP-D and N. Interestingly, except for Memory and Location, TPT measures were a factor all to themselves, with Factor 2 including TPT Dominant, Non-Dominant, Both, and Total Time/Block. Factor 3 was a measure of Attention and Sensory Perception, and included SEA, SPPR, and SP-R and L. Factor 4 was a measure of abstraction and learning, and included TMT-B, CAT, TPT-L, and TPT-M. Factor 5 was the only theoretically unanticipated factor, and appears to be a measure of processing speed.
DISCUSSION In this study, 71 prison inmates were administered the HRNB. These inmates had been referred for psychiatric treatment after being incarcerated, and were referred because of being a danger to themselves, a danger to others, or gravely disabled. Reasons for referral included less severe incidences, such as threatening to hang or cut themselves, threatening to harm
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TABLE 5 Defining Variables from Varimax Rotated Principle Components Analysis of NP Test, (Five-Factor Solution) Factor 1—Motor Test GRIP-ND FTT-D GRIP-D FTT-ND Eigenvalue:
Structure
Factor 2—Overall Functioning Communality
.80 .80 .79 .71 3.22 Factor 3—Attention/Sensory
Test SP-L SEA SP-R APHASIA SSPER Eigenvalue: Test TFR-RTime TFR-LTime Eigenvalue:
Structure
.66 .79 .68 .60
Communality
.76 .75 .72 .63 .60 2.99 Factor 5—Processing Speed
.66 .48 .71 .60 .58
Test
Communality
.92 .92 2.01
.83 .88
Communality
TPT-Time .83 TPT-ND .78 TPT-Both .72 TPT-D .68 Eigenvalue: 3.00 Factor 4—Abstraction/Learning Test TMB-B CAT TPT-L TPT-M Eigenvalue:
Structure
Structure
.41 .79 .78 .74
Structure
Communality
.77 .62 .58 .52
.35 .52 .60 .56
2.78
D 5 Dominant Hand, N 5 Nondominant Hand, Grip 5 Strength of Grip, FTT 5 Finger Tapping Test, TPT-Tactual Perception Test, SP-Sensory Perceptual Errors, SPPR 5 Speech Sounds Perception, TMT 5 Trailmaking, CAT 5 Category, TFR 5 Tactile Form Recognition Time.
custody staff or other inmates, auditory/visual hallucinations, or refusing to eat/drink. Reasons for referral also included more severe incidents, such as hanging, serious self-mutilation by cutting arms, wrists or neck, attempting to cut off bodily organs, attempting to swallow dangerous objects, violent physical attacks on either custody staff or other inmates, and smearing or eating feces. All incidents were thought to have been related to psychiatric disorder, and inmates were referred for stabilization, evaluation, and treatment. Results of this study demonstrate that performance on NP testing for this group is quite severely compromised. Using Heaton et al’s (1991) reference group as a standard, and using the age- and education-adjusted NP impairment cutoff score of T 5 40, 84% of this sample were impaired on the Halstead Impairment Index (HII). Multivariate analyses revealed significantly impaired motor, psychomotor, and abstraction. Performance on attention, language, and learning/memory were low, but not significantly below impairment cutoff. SP-L, FTT-D and N, SPPR, TPT-T, TPT-M, TPT-L, CAT, and TMT-B were all significantly impaired. Although language, attention, and learning/memory were relative strengths in this group, mean performance on all measures was below the expected T 5 50. Although this study demonstrates impairment of NP functioning, the study does not provide reasons for this impairment. Review of demographic information provides some understanding. For example, this sample represents a group of men who are both prisoners and who have a psychiatric disorder, with 70% having a DSM-III-R Primary Axis I diagnosis of psychotic or depressive disorder, and 17% having a DSM-III-R organic disorder. Although there are some differing conclusions as to which NP functions are impaired in individuals with schizophrenia, most investigators agree that attention, motor, verbal memory, and ab-
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straction are generally impaired (Braff et al., 1994; Heaton, 1994; Levin, Yurgelun-Todd, & Craft, 1989). Investigations of individuals with depressive disorders have demonstrated less consistent NP results. Although most investigators report the existence of NP impairment in individuals with Depressive disorders (Cassens, Wolfe, & Zola, 1990; Goldberg et al., 1993), the exact nature of that impairment differs, leading Cassens et al. (1990) to conclude that depression can best be described as subtypes of depression. A substantial proportion of NP impairment in this group, therefore, is likely attributed to brain correlates of both psychotic and depressive disorders. One area of needed future research is to compare performance of participants in this study with performance of psychiatric, but nonprison, samples. In addition to psychiatric diagnosis, 87% of this sample was taking at least one psychotropic medication at the time of testing. A review of literature generally concludes that although motor and memory can be negatively affected by psychotropic medication, as a general finding other NP functions are not impaired, or may even be improved with appropriate psychotropic medication (Bilder, Turkel, Lipschutz-Broch, & Lieberman, 1992; Medalia, Gold, & Merriam, 1988). A review of demographic information also reveals that 85% of this sample have histories of severe polysubstance abuse. For many, drug use started early (mean age for first drug use was 12.8 years), and included substances that are known to be particularly harmful to brain structures, particularly inhalants and alcohol (Grant, Adams, Carlin, Rennick, Judd, Schooff, & Reed, 1978; Grant, Adams, Carlin, Rennick, Judd, Schooff, 1978; Grant, 1987; Hormes, Filley, & Rosenberg, 1986). Considering the ‘‘vulnerability hypothesis’’ as described by Davidson and Dobbing (1968) and Himwich (1970), the adolescent brain would be particularly vulnerable to damage from drugs known to primarily affect anterior brain areas. This population, therefore, would be at particular risk for NP impairment associated with early use of these drugs. Although neurological examinations were not completed as a formal part of this study, medical and neurological examinations were performed on all participants when they were admitted for treatment. This information indicates that 52% have known neurological injuries, which included head trauma with loss of consciousness, seizure disorder, or loss of consciousness due to factors other than head trauma. The incidence of undiagnosed medical disorder with known neuropsychiatric symptoms (lupus, endocrine, cardiovascular, etc.) is not known. There are multiple possible explanations for the pervasiveness and severity of impairment demonstrated by this sample of prisoners in psychiatric treatment. It is not our intention to minimize these factors. Of particular relevance, however, participants in this sample were also quite violent. When considering only those offenses for which they were formally charged (not including offenses that were reduced through plea bargaining, or which occurred but the individual was not formally charged), 71% of this sample had at least one crime that involved serious physical violence or murder, and 24% had crimes that not only resulted in loss of life, but were particularly heinous (torture, serial murder, etc.). Men in this sample not only had histories of severe violence prior to prison, but continued that violence once they were in prison. Eighty-three percent had received at least one documented prison offense for violence, and many had multiple violent offenses once in prison. Multiple studies have documented the relationships between violence and mental disorders (Graham, Thienhaus, & Somoza, 1990; Krakowski, 1994; Marzuk, 1996; Mulvey, 1994; Teplin, 1994; Torrey, 1994; Torrey, 1995); violence and drug use (Bradford, Greenberg, & Motayne, 1992; Buss, Abdu, & Walker, 1995; Miller, Gold, & Mahler, 1991; Moss & Tarter, 1993; Swanson, Morrisey, Goldstrom, & Laurence, 1993); and violence and NP impairment (Diaz, 1995; LaPierre, Braun, Hodgins, & Toupin, 1995; Mungas, 1988; Volavka, Martell, & Convit, 1992). Concurrent with the downsizing of both institutional and community-based mental health services, the penal system is, by default, becoming society’s largest provider of mental health
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services. The frequency of mentally ill individuals in prisons and forensic facilities continues to increase. The factors influencing this phenomena will not be discussed here, but the impact must be addressed not only as a penal system problem, but ultimately as a societal concern. Ironically this shift of responsibility is to a system that is least able, by design and focus, to address the needs of a mentally ill population. The services required by a mentally ill population are often inconsistent with the mission of a penal system. In addition to the system problems in providing mental health services to prisoners, the characteristics of this patient population warrant special concern. The experiences of clinicians treating these inmate-patients are that this population is unique, atypical, and not representative of psychiatric populations in state hospitals or even forensic treatment facilities. The relative degree of psychiatric impairment in conjunction with NP impairment, and the pervasive violence potential revealed in this study corroborate these perceptions. Regardless of the hypothesized reasons for the NP impairment and violence demonstrated by this sample, the realities of this situation must be addressed. Prisons and mental health facilities within prisons must provide a safe environment for inmates and staff. Further, they must provide treatment for inmates suffering from major mental disorders, the same as they do for inmates needing treatment for medical problems. The scope of this endeavor is formidable. In a recent publication, Keefe (1995) makes the point that treatment of the mentally ill is a complex and difficult task, but treatment of individuals who have both psychiatric disorder and NP impairment is even more complex and difficult, and treatment outcome is less effective. Keefe does not address treatment issues of psychiatric disorder, NP impairment, and violence. He does, however, point out that treatment is most effective when the cognitive strengths and weaknesses of these individuals are identified, and treatment plans are developed with these factors in mind. The primary purpose of this study was to provide a comprehensive description of this sample of psychiatrically hospitalized inmates in order to more effectively design treatment programs. Results revealed severe psychiatric disorder, severe cognitive impairment, and high violence histories and propensities in this sample of psychiatrically hospitalized prisoners. The severity of these problems, combined with the constraints and unique aspects of the environment in which they must be treated creates major challenges to treatment. The descriptive and comparative aspects of this study were utilized in designing a treatment program for these mentally ill prisoners. Treatment outcome measures are currently in progress. Beyond its immediate utility, this study raises many issues for further investigation. Relationships between NP impairment and various psychiatric disorders, and the impact of psychotropic medication on NP functioning continue to require greater exploration and understanding. More information is needed regarding the impact of drug use on NP functioning; the impact of early adolescent use of inhalants and alcohol; and the relationship between drug use and violence. The role of neurological injuries, which are not the focus of treatment, but which affect overall NP functioning, also needs to be explored. Most importantly, the relationships of these factors in understanding violence, and the impact of these factors on treatment outcomes need to be better understood.
REFERENCES Bland, R. C., Newman, S. C., Dyck, R. J., & Orn, H. (1990). Prevalence of Psychiatric Disorders and Suicide Attempts in a Prison Population. Canadian Journal of Psychiatry, 35, 407–413. Bilder, R. M., Turkel, E., Lipschutz-Broch, L., & Lieberman, J. A. (1992). Antipsychotic Medication Effects on Neuropsychological Functions. Psychopharmacology Bulletin, 28, 353–366.
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Bradford, J. M., Greenberg, D. M., & Motayne, G. G. (1992). Substance abuse an criminal behavior. Psychiatric Clinics of North America, 15, 605–622. Braff, D., Harris, M. J., Heaton, R., Jeste, D. V., Kuck, J., McAdams, L. A., Paulsen, J. S., & Zisook, S. (1994). Neuropsychological deficits in schizophrenias: Relationship to age, chronicity, and dementia. Archives of General Psychiatry, 51, 469–476. Buss, T., Abdu, R., & Walker, J. (1995). Alcohol, drugs, and urban violence in a small city trauma center. Journal of Substance Abuse Treatment, 12, 75–83. Cassens, G., Wolfe, L., & Zola, M. (1990). The neuropsychology of depressions. Journal of Neuropsychiatry, 2, 202–213. Davidson, A., & Dobbing, J. (1968). The developing brain. Philadelphia: F.A. Davis. Diaz, F. (1995). Traumatic brain injury and criminal behavior. Medicine & Law, 14, 131–140. Edwards, A. C., Faulkner, L. R., & Morgan, D. W. (1994). Prison inmates with a history of inpatient psychiatric treatment. Hospital and Community Psychiatry, 45, 172–174. Goldberg, T. E., Gold, J. M., Greenberg, R., Griffin, S., Schula, C., Pickar, D., Kleinman, J. E., & Weinberger, D. R. (1993). Contrasts between patients with affective disorders and patients with schizophrenia on a Neuropsychology Test Battery. American Journal of Psychiatry, 150, 1355–1362. Graham, L., Thienhaus, O., & Somoza, E. (1990). Violent behavior among schizophrenic patients. American Journal of Psychiatry, 147, 1383–1384. Grant, I., Mohns, L., Miller, M., & Reitan, R. M. (1976). A neuropsychological study of polydrug users. Archives of General Psychiatry, 33, 973–978. Grant, I., Adams, K. M., Carlin, A. S., Rennick, P. M., Judd, L. L., Schooff, K., & Reed, R. (1978). Organic impairment in polydrug users: Risk factors. American Journal of Psychiatry, 135, 178–184. Grant, I., Adams, K. M., Carlin, A. S., Rennick, P. M., Judd, L. L., & Schooff, K. (1978). The collaborative neuropsychological study of polydrug users. Archives of General Psychiatry, 35, 1063–1074. Grant, I. (1987). Alcohol and the brain: neuropsychological correlates. Journal of Consulting and Clinical Psychology, 55, 310–324. Guy, E., Platt, J., Zwerling, I., & Bullock, S. (1985). Mental health status of prisoners in an urban jail. Criminal Justice and Behavior, 2, 29–53. Hartsone, D., Steadman, H., Robbins, P., & Monahan, J. (1984). Identifying and treating the mentally disordered prison inmate. Mental Health and Criminal Justice, 8, 279–296. Heaton, R. K., Grant, I., & Matthews, C. G. (1991). Comprehensive norms for an expanded Halstead-Reitan Battery. Odessa, FL: Psychological Assessment Resources, Inc. Heaton, R. (1994). Neuropsychological deficits in schizophrenics: relationship to age, chronicity, and dementia. Archives of General Psychiatry, 54, 460–476. Heaton, R. K., Grant, I., Butters, N., & the HNRC Group (1995). The HNRC 500-Neuropsychology of hiv infection at different disease states. Journal of the International Neuropsychological Society, 1, 231–251. Himwich, W. (1970). Developmental neurobiology. Springfield, IL: Charles C Thomas. Hodgins, S., & Cote, G. (1991). The mental health of penitentiary inmates in isolation. Canadian Journal of Criminology, 183–192. Hormes, J. T., Filley, C. M., & Rosenberg, N. L. (1986). Neurologic sequelae of chronic solvent vapor abuse. Neurology, 36, 698–702. Keefe, R. (1995). The contribution of neuropsychology to psychiatry. American Journal of Psychiatry, 152(6), 6–15. Krakowski, M. (1994). Clinical symptoms, neurological impairment, and prediction of violence in psychiatric inpatients. Hospital and Community Psychiatry, 45, 700–705. Lapierre, D., Braun, C., Hodgins, S., & Toupin, J. (1995). Neuropsychological correlates of violence in schizophrenia. Schizophrenia Bulletin, 21, 252–262. Levin, S., Yurgelun-Todd, D., & Craft, S. (1989). Contributions of clinical neuropsychology to the study of schizophrenia. Journal of Abnormal Psychology, 98, 341–356. Lewis, D., Pincus, J., Bard, B., Richardson, E., Prichep, L., Feldman, M., & Yaeger, C. (1988). Neuropsychiatric, psychoeducational, and family characteristics of fourteen juveniles condemned to death in the United States. American Journal of Psychiatry, 145, 584–589. Martel, D. (1992). Estimating the prevalence of organic brain dysfunction in maximum-security forensic psychiatric patients. Journal of Forensic Sciences, 37, 878–893. Marzuk, P. (1996). Violence, crime, and mental illness: how strong a link? Archives of General Psychiatry, 53, 481–486. Medalia, A., Gold, J., & Merriam, A. (1988). The effects of neuroleptics on neuropsychological test results of schizophrenia. Archives of Clinical Neuropsychology, 3, 249–271. Miller, N. S., Gold, M. S., & Mahler, J. C. (1991). Violent behaviors associated with cocaine use: possible pharmacological mechanisms. International Journal of the Addictions, 26, 1077–1088.
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Moss, H., & Tarter, R. E. (1993). Substance abuse, aggression, and violence: What are the connections? American Journal on Addictions, 2, 149–160. Mulvey, E. (1994). Assessing the evidence of a link between mental illness and violence. Hospital and Community Psychiatry, 45, 663–668. Mungas, D. (1988). Psychometric correlates of episodic violent behavior: A multidimensional neuropsychological approach. British Journal of Psychiatry, 152, 180–187. Myers, J. K., & Bean, L. L. (1968). A decade later: a follow-up of social class and mental illness. New York: John Wiley & Sons. Neighbors, H. W. (1987). The prevalence of mental disorder in Michigan prisons. Diagnostic Interview Schedule Newsletter, 4(12), 8–11. Steadman, H., Holohean, E., & Dvoskin, J. (1991). Estimating mental health needs and service utilization among prison inmates. Bulletin of the American Academy of Psychiatry and the Law, 19, 297–307. Swanson, J., Morrissey, J., Goldstrom, I., & Laurence, R. (1993). Demographic and diagnostic characteristics of inmates receiving mental health services in state adult correctional facilities: United States. Mental Health Statistical Nore, 20, 209. Swetz, A., Salive, M. E., Stough, T., & Brewer, T. (1989). The prevalence of mental illness in a state correctional institution for men. Journal of Prison and Jail Health, 8, 3–15. Teplin, L. (1994). Psychiatric and substance abuse disorders among male urban jail detainees. American Journal of Public Health, 84, 290–293. Torrey, E. (1994). Violence behavior by individuals with serious mental illness. Psychiatric Services, 45, 653–662. Torrey, E. (1995). Violence and mental illness. Psychiatric Services, 46, 407–408. Uhlig, H. (1976). Hospitalization experience of mentally disturbed and disruptive, incarcerated offenders. Journal of Psychiatry and Law, 4, 49–59. Volavka, J., Martell, D., & Convit, A. (1992). Psychobiology of the violent offender. Journal of Forensic Sciences, 37, 237–251. Yeudal, L., Fedora, O., & Fromm, D. (1987). A Neuropsychological theory of persistent criminality: implications for assessment and treatment. Advances in Forensic Psychology and Psychiatry, 2, 119–191.
APPENDIX A: VIOLENCE RATING SCALE 1. Nonviolent Offenses Drug Offenses Fraud Prostitution Disorderly Conduct Trespassing Begging Failure to Provide for Spouse 2. Ambiguous Violence Escape Driving Offenses Theft Possession of a Weapon Possession of Stolen Property Violation of Probation/Parole Contributing to Delinquency of Minor 3. Property Crimes Vandalism Burglary Grand Theft Auto Taking Vehicles w/o Owners Consent Malicious Mischief Grand Theft
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4. Threats to Person Indecent Exposure Robbery Lewd & Lascivious Acts Exhibiting a Deadly Weapon Intimidating a Witness 5. Attacks on Persons Car Jacking Assault Rape Incest Child Molestation Oral Copulation Kidnap Resisting Arrest Arson False Imprisonment 6. Attacks on Persons With Loss of Life or Special Circumstances Murder Manslaughter Sadistic Rape or Molestation Serial Rape Systemic Infliction of Pain Torture 7. Attacks on Person With Extreme Violence as Above but Resulting in Death of Victim
PII S0887-6177(97)00032-2
Neuropsychological Functioning of Inmates Referred for Psychiatric Treatment Myla H. Young and Jerald Justice California Department of Mental Health, Correctional Medical Facility, Psychiatric Program—Vacaville
This article describes the Neuropsychological (NP) functioning of 71 psychiatrically hospitalized male prisoners. Demographic description, patterns of drug use, patterns of violence, psychiatric diagnosis, and performance on the Halstead-Reitan Neuropsychological Battery (HRNB) are described. Using age and education adjusted norms (Heaton, Grant, & Matthews, 1991), 84% of this sample demonstrated impairment on the Halstead Impairment Index. Sensory Exam-Left, Tapping Dominant and Non-Dominant, Speech Perception, Tactual Performance Test Times/Memory/and Location, Trailmaking A and B, and Category Test were all impaired. Multivariate Analyses (MANOVAS) demonstrated significantly impaired performance on tasks of Motor, Psychomotor, and Reasoning, with FTT-Dominant, TPT-Total, and Category Test contributing the most meaningful contribution to the multivariate effect. Varimax Rotated Principle Components Analysis revealed a five-factor model (Motor, Learning, Attention, Abstraction, and Processing Speed), which accounted for 69.9% of the total variance. Need for further research, and implications for the use of this information in developing treatment programs for psychiatrically disturbed prisoners are discussed. 1998 National Academy of Neuropsychology. Published by Elsevier Science Ltd
Over the past several years, investigators have reported a wide range in incidence of both mental and neurocognitive disorders among prison inmates. Depending upon the geographic location and measurement instrument used, the incidence of mental disorder is reported as ranging from 16% to 67%, and incidence of neurocognitive disorder is reported as ranging from as low as 8% to as high as 94%. For example, Hartsone, Steadman, Robbins, and Monahan (1984) interviewed correctional staff in five states, and reported that these officials identified 37.5% of inmates as ‘‘suffering from psychological problems’’ and in need of psychiatric treatment. Guy, Platt, Zwerling, and Bullock (1985) interviewed 486 inmates admitted to Philadelphia prisons and identified 67% of inmates as being ‘‘psychiatrically disturbed and in need of specific mental health treatment,’’ and 11% in need of ‘‘immediate psychiatric hospital care.’’ Steadman, Holohean, and Dvoskin (1991) interviewed New York State prisoners and concluded that 16% experienced mental disabilities that required periodic services, and 8% experienced severe psychiatric disorders. Swetz, Salive, Stough, and Brewer (1989) interviewed Maryland State prisoners and found that 23% of inmates had at least one psychiatric hospitalization prior to prison, Address correspondence to Myla H. Young, PhD, California Department of Mental Health, Psychiatric ProgramVacaville, P.O. Box 2297, Vacaville, CA 95696-2297.
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and 12% required acute psychiatric hospitalization while in prison. More recently, Edwards, Faulkner, and Morgan (1994) found that 15% of South Carolina inmates had a history of psychiatric hospitalization prior to prison, and Teplin (1994) reported prevalence rates of more than 30% among urban male jail detainees. High incidence of mental disorder within the prison system is reported not only in the United States, but also in other countries. Bland, Newman, Dyck, and Orn (1990) compared mental disorder prevalence rates of Canadian community members with Canadian prisoners and concluded that, for all categories evaluated (Substance Abuse, Affective Disorders, Anxiety Disorders, Schizophrenic Disorders, and Cognitive Impairment), there was a significantly higher incidence of mental disorder among prisoners as compared to community members. Not only is there a higher incidence of mental disorder among prisoners as compared to community members, investigations suggest that severely mentally disordered prisoners frequently are placed in special housing units, rather than in prison psychiatric treatment facilities. Uhlig (1976) evaluated inmates who were designated as special management problems and were housed in special housing units (SHU). He reported that 53% of those inmates in SHU placements had a current severe mental disorder. More recently, a similar finding is reported by Hodgins and Cote (1991), who evaluated inmates in the Quebec region of the Correctional Service of Canada who were housed in either the Special Handling Unit (SHU) or the Long-Term Segregation Unit (LTSU). They reported that 29% of these inmates experienced a severe mental disorder (schizophrenia, major depression, bipolar disorder); 61% experienced alcohol abuse/dependence disorder; and 50% experienced other drug abuse/dependence disorders. Of those inmates who were identified as experiencing a major mental disorder, there was indication that for 86% of those inmates, the mental disorder was present prior to prison. They further reported that 33% of those inmates had a suicide gesture either prior to or in prison. The incidence of mental disorder among prisoners is increasingly documented. The incidence of neurocognitive impairment among prisoners is also increasingly documented. Utilizing the Diagnostic Interview Schedule (DIS) and the Structured Clinical Interview for DSMIII-R (SCID), and interviewing 1000 randomly selected prisoners, Neighbors (1987) reported that 8.2% of the sample met research diagnostic criteria for organic brain disorder. Utilizing a far more sensitive measure of neurocognitive functioning than structured interview, Yeudal, Fedora, and Fromm (1977) reported an extraordinarily high incidence of neurocognitive impairment on the Halstead Reitan Neuropsychological Battery (HRNB), with 94% of those prisoners evaluated demonstrating abnormal findings on the HRNB. More specifically, he reported that 100% of rapists, 94% of homicide offenders, and 87% of assaulters had abnormal findings on this battery. Although Yeudal et al.’s report appears to be extraordinarily high, others report lower, but similar results. Martel (1992) evaluated 50 randomly selected inmates who were hospitalized at a maximum security state hospital for mentally disordered offenders in New York City. Neurological examinations and chart reviews were completed for these inmates. Martel considered DSM-III-R diagnosis of organic brain impairment, incident of head injury with loss of consciousness, evidence of seizure disorder, IQ in the subaverage range, and abnormal neurological findings. Utilizing a criteria of two or more of the previously identified indicators. Martel reported that 64% of these randomly selected inmates would be classified as brain impaired. Although addressing adolescent rather than adult functioning, Lewis et al. (1988) described the characteristics of 14 juveniles sentenced to death in the United States. These juveniles ranged in age from 15 years, 10 months to 17 years, 10 months and included six African American, seven Caucasian, and one Latino juvenile. Psychiatric, neurological, psychological, neuropsychological, and educational evaluations were completed. Lewis et al. reported extensive neurological and psychiatric disorders among this sample, with 9 juveniles
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TABLE 1 Reasons for Incomplete Participation in Study Reason
n
Percent
Delusional Manic Suicidal Malingering Unknown Total Incomplete/Refused
9 4 3 2 2 20
11 4 3 2 2 22
Note. Total number of participants approached for testing 5 91; Total number completing testing 5 71.
(64%) experiencing serious neurological abnormality and 11 juveniles (79%) experiencing major mental disorder. Lewis further reported that 12 juveniles (86%) had experienced ‘‘brutal physical abuse.’’ Considering the high incidence of mental and cognitive disorders among general prison populations, it is anticipated that a number of these inmates would require psychiatric hospitalization and treatment while incarcerated. It is also anticipated that those inmates who require psychiatric treatment while incarcerated would demonstrate substantial neuropsychological impairment, as well as psychiatric disorder. The purpose of this study was to describe the neuropsychological functioning of a group of inmates who, while incarcerated in California, required hospitalization because of psychiatric symptoms that prevented them from adequately functioning within the general prison population. Demographic description, patterns of drug use, patterns of violence, psychiatric diagnosis, and performance on a series of neuropsychological tests is described. METHOD Participants Ninety-one males who were receiving psychiatric treatment in a mental health facility located within a California State Prison were randomly selected for participation in this study. Of the 91 males who were selected, 71 males (78%) completed the study. Reasons for incompletion included delusional thinking, manic episode, suicidal behavior, possible malingering of psychiatric symptoms, and unknown reasons. Table 1 describes reasons for incompletion. Table 2 describes age and education for this group. All subjects were male. Ages ranged from 19 to 65 years, with a mean age of 34.2 years. Education ranged from completion of 5th grade to completion of 16 years (bachelor degree), with a mean education of 10.8 years. Table 3 further describes this group. Caucasians (44%) and African Americans (35%) comprised the largest ethnic groups, followed by Latino (17%), and Other (Asian, Native
TABLE 2 Age and Education of Sample
Age (Years) Education (Years)
M
SD
n
Minimum
Maximum
34.19 10.81
8.86 2.43
71 70
19 5
65 16
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TABLE 3A Ethnic, SES, Psychiatric Descriptions Descriptor Ethnic Group Caucasian African American Latino Other Total Social Services I II III IV V Total DSM-III-R Axis I Diagnosis Psychotic Depressive Organic Other Total
n
Percent
31 25 12 3 71
44 35 17 4
1 1 5 14 24 45
2 2 12 31 53
31 17 12 9 69
45 25 17 13
TABLE 3B Prior Treatment, Medication, Neurological Descriptions Descriptor Prior Psychiatric Treatment Received Treatment Not Received Treatment Total Primary Medication Type at Testing Antipsychotic Antidepressant Lithium Anticonvulsant Other None Total Neurological Injury Head Trauma Seizure Loss of Consciousness More than One Type Total
n
Percent
38 24 62
61 39
38 8 4 2 10 9 71
54 11 6 3 14 12
10 3 15 9 37
27 8 41 24
American) (4%). Utilizing a two factor index of social position (Myers & Bean, 1968), most subjects were in the two lowest classifications of social position (IV 5 31% and V 5 54%). In addition to demographic description, information regarding psychiatric diagnosis, psychiatric treatment prior to prison, medication at time of assessment, history of neurological injury, drug use history, and violence history prior to and in prison were obtained. Table 3 also provides this information. As is apparent from Table 3 (3A, 3B, 3C, 3D), psychiatric factors played a major role in describing this sample. Forty-five percent had a psychotic diagnosis; 25% had a depression
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TABLE 3C Drug Use History Descriptor Drug Use History No Drug Use Drug Use Total Drug Abuse/Dependence Total Polysubstance Abuse Total Drug Used Most Alcohol Cocaine Opioid Inhalant Amphetamine Phencyclidine Hallucinogen Sedative Cannabis Total Drugs Preferred Alcohol Cocaine Opioid Inhalant Amphetamine Phencyclidine Hallucinogen Cannabis Total Drugs First Used Alcohol Opioid Inhalant Cannabis Total
n
Percent
4 63 67 57 67 57 67
6 94
26 2 4 1 1 3 2 1 15 55
47 4 7 2 2 5 4 2 27
16 8 7 1 1 2 1 17 53
30 15 13 2 2 4 2 32
27 1 5 22 55
49 2 9 40
85 85
diagnosis; and 17% had an organic diagnosis. Of those who completed the study, 13% did not have an Axis I Disorder that fell into one of the previously indicated categories. Additionally, 61% of this sample had been psychiatrically hospitalized prior to prison. As would be expected, considering the incidence and type of psychiatric diagnoses, a substantial proportion of this sample was taking psychotropic medication at the time of the assessment. Overall, 87% were taking some type of psychotropic medication, with the majority (53%) taking antipsychotic medication, and lesser percentages taking antidepressants (11%), lithium (6%), anticonvulsant (3%) and other (14%). A medical examination was not completed as a part of this study, but medical examination and history were taken at the time of hospitalization. Information regarding known neurological injury was obtained both from the patient and from the medical file. Twenty-seven percent of the entire sample had experienced a head trauma resulting in loss of consciousness, and 8% indicated that they had experienced at least one seizure. Another 41% indicated that they had experienced a loss of consciousness from an incident other than head trauma or seizure, and the length of unconsciousness was more than 30 minutes. The primary reason for this loss of consciousness was drug related. Twenty-four percent indicated that they had experienced more than one type of neurological injury.
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TABLE 3D Offenses with Highest Violence Descriptor Violence History 1-Nonviolent 2-Ambiguous 3-Property Crimes 4-Threats to Person 5-Attack on Person 6-Loss of Life 7-Loss of Life with Exceptional Violence Total Lifetime Violence High Violence Low Violence Total Violence in Prison Discipline Charge-Assault Total
n
Percent
0 2 7 9 24 3
0 3 12 15 40 5
15 60
25
37 20 57
65 35
59 71
83
Note. Total: Totals differ because of missing data. Percents are based on known data rather than total sample size. SES: The higher the number the lower SES. Loss of Consciousness: For reasons other than head trauma or seizure. Psychotic Diagnosis: Psychosis includes DSM-III-R Schizophrenia, Schizo-affective, Psychosis NOS, Depressive and Bipolar Disorder with Psychotic Features. Depressive includes Major Depression and Bipolar Disorders without Psychotic Features, Depressive Disorder NOS. Organic includes Organic Psychosis, Organic Mood, Organic Disorder NOS. None includes NO Diagnosis, Malingering, Adjustment Disorder, Dysthymia. High Lifetime Violence: 21 offenses of physical attack, or 11 offenses of murder.
Drug use history was also particularly relevant in this sample. Ninety-four percent indicated that they had used some form of illegal drug, and 85% described drug use that met DSM-III-R criteria for drug abuse and/or dependence. Of those reporting drug abuse, 85% also indicated polysubstance abuse. The most abused drug was alcohol (47%), followed by marijuana (27%). Of interest, alcohol (30%) and marijuana (32%) were also indicated as drugs of preference, followed by cocaine (15%) and opioids (13%). When asked about drug first used, inhalants entered the picture (9%) along with alcohol (49%) and marijuana (40%). The average age for first drug use was 12.8 years, with most first using drugs at 12.0 years. The youngest age for drug use was 7 years, and the oldest age was 21 years. This sample was also characterized by a high level of violence. Using a 7-point Violence Rating Scale (see Appendix A), 71% had at least one convicted offense that involved violent physical attack. When describing lifetime patterns of violence as either high violence (two or more offenses that involved violent physical attack, or one offense that included murder or murder with particularly high violence), or low violence, 65% had lifetime patterns of high violence and 35% had lifetime patterns of low violence. Not only did this sample demonstrate a pattern of high violence that resulted in incarceration, a large number continued to be violent once in prison. Eighty-three percent had at least one disciplinary action as a result of violent behavior while in prison.
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TABLE 4 Age and Education Adjusted Means, Standard Deviations, and Percent of Subjects in Impaired Range for Theoretical Grouping of NP Tests into NP Functions Tests Summary Scores Halstead Impairment Index Sensory Scores Tactile Form Rec-Right Tactile Form Rec-Left Sensory Exam-Right Errors Sensory Exam-Left Errors Motor Scores Tapping-Dom Hand Tapping-Non-Dom Hand Grip Strength-Dom Hand Grip Strength-Non-Dom Hand Attention Scores Seashore Rhythm Test Speech Perception Test Learning Scores Tactual Perf Test-Memory Tactual Perf Test-Loc Verbal Scores Aphasia Screening Test Psychomotor Scores Tactual Perf Test-Dom Tactual Perf Test-Non-Dom Tactual Perf Test-Both Tactual Perf Test-Total Time/Block Trailmaking A Reasoning Scores Category Test Trailmaking B
M
SD
n
% Impaired
27.73
14.12
51
84.31
49.52 48.54 42.27 38.08
10.17 8.22 12.48 14.89
69 70 69 71
13.04 14.29 43.48 70.00
33.86 37.13 45.11 46.32
12.53 12.41 12.01 10.64
70 71 70 71
65.71 54.93 28.57 33.80
43.91 38.06
14.35 9.72
71 71
40.85 60.56
39.01 39.21
11.53 9.28
71 71
63.38 54.93
47.60
11.78
71
23.94
37.61 39.32 38.92
12.11 11.87 11.20
71 71 71
57.75 45.07 56.34
28.89 34.37
9.67 12.20
71 71
83.10 74.65
33.96 36.98
12.51 12.47
71 71
73.24 64.79
Note. Impairment Cutoff Score T 5 40.
MATERIALS Materials included a demographic data form, structured clinical interview, tests of neuropsychological functioning, and tests of psychiatric functioning. Demographic information was obtained through interview with the inmate and review of criminal and medical records. Any differences between inmate report and documentation were resolved by relying on documented information. Structured clinical interview was accomplished using the Structured Interview for DSM-III-R–Patient Edition (SCID-P). Neuropsychological testing included tests from the Halstead-Reitan Neuropsychological Battery (HRB) as listed in Table 4. Psychiatric diagnosis was established by utilizing demographic information, SCID-P and the Rorschach Test. PROCEDURES Subjects were randomly selected from weekly admission lists provided by the Health Information Services. Within 2 weeks of admission the inmate was approached to provide informed consent. There was a 22% refusal/incompletion rate as described in Table 1. A comprehensive review of medical and criminal records was completed; the inmate was interviewed; and all previously listed tests were administered. Record reviews and clinical inter-
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views were completed by a Licensed Clinical Social Worker, who has 15 years experience working in a forensic setting. Neuropsychological and Rorschach tests were administered by a Licensed Clinical Psychologist, who has specialized pre- and postdoctoral training in neuropsychology, and 7 years experience working in a prison. Neuropsychological tests were also administered by three predoctoral psychology interns who were trained and supervised by the principal author. Psychiatric diagnosis was established using all available information. Since Rorschach and SCID-P were independently and blindly administered by two individuals, reliability of psychiatric diagnosis was established by obtaining percent of agreement between the SCID-P and the Psychological Testing Report. There was 79% agreement between these two measures.
RESULTS Raw Neuropsychological (NP) testing scores were converted to age and education adjusted T-scores in accordance with normative data provided by Heaton et al. (1991). Individual NP tests were organized according to function, as indicated by Heaton et al. (1995). Table 4 provides description of this sample’s performance on these tests. Using an impairment cutoff score of T 5 40 (Heaton et al., 1991), Table 4 reveals that the overall mean performance for this population was impaired on Category Test (CAT), Trail Making A (TMTA), Trail Making B (TMTB), Tactual Performance Test-Total Time (TPT-T), Tactual Performance Test-Memory (TPT-M), Tactual Performance Test Localization (TPT-L), Speech Perception Test (SPPER), Finger Tapping Test Dominant (FTT-D) and Non-dominant (FTT-N), and Sensory Perception Left (SP-L). The overall mean performance for this population was not impaired on Seashore Rhythm (SEA), Grip Strength Dominant (GRIP-D) and Non-Dominant (GRIP-N), Sensory Perception Right (SP-R), Tactual Figure Recognition Right (TFR-R) and Left (TFR-L), and the Aphasia Test (APHASIA). Ninety-one individuals were randomly selected for participation, and 71 completed at least 85% of testing. Only data from participants whose performance was considered to be valid, and who completed at least 85% of all measures were included in analyses. Multivariate Analysis MANOVAS for each NP function were conducted to determine whether this sample’s performance was not only impaired, but significantly below the cutoff for impaired NP performance (T 5 40). Results for each function are as follows. Halstead Impairment Index (HII). The HII is composed of CAT, TPT-T, TPT-M, TPT-L, SEA, SPPER, and FTT-D. With the exception of SEA, performance on all these tests was impaired. MANOVA was significant with Wilk’s Lambda 5 .28, F(7, 63) 5 22.60, p , .001. Roy’s greatest characteristic root (GCR) revealed a strong effect (.72) with 72% of the variance in the covariance matrix accounted for by the difference between this group and Heaton et al.’s (1991) reference group. Post hoc canonical discriminant function analysis (DFA) indicated that all tests offered meaningful, unique contributions to the multivariate effect, with TPT-T (.99), CAT (.55), and TPT-M (.55) offering the greatest contributions, but with SEA (.44), SPPER (.22), FTT-D (.15), and TPT-L (.13) also offering meaningful contributions. Canonical structure coefficients (CSC) were consistent with DFA (TPT-T 5 .72; FTT-D 5 .31; CAT 5 .30; SEA 5 .18; SPPER 5 .13; TPT-M 5 .05). Univariate post hoc tests show that, using family-wide control for Type I error with Bonferroni adjusted p-values, CAT, TPT-T, SEA, SPPER, and FTT-D showed significant univariate differences,
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but TPT-M and TPT-L did not show significant univariate differences. Overall, compared to Heaton et al.’s (1991) sample, this sample was significantly impaired on the HII. Sensory. Sensory functioning was evaluated using SP-R, SP-L, TRF-R, and TFR-L. SP-L was in the impaired range, but all other measures were not impaired. Compared to Heaton et al.’s (1991) reference sample, sensory impairment did not significantly contribute to this sample’s impaired NP functioning. Motor. Motor functioning was evaluated using FTT-D, FTT-N, GRIP-D, and GRIP-N. Both FTT-D and FTT-N were impaired, but GRIP-D and GRIP-N were not impaired. MANOVA was significant with Wilk’s Lambda 5 .40, F(4, 66) 5 25.00, p , .001. Roy’s (GCR) revealed a strong effect (.60), indicating that 60% of the variance in the covariance matrix could be accounted for by the difference between this group and Heaton et al.’s (1991) reference group. Post hoc canonical (DFA) indicated that all tests offered meaningful, unique contributions to the multivariate effect, with FTT-D offering the strongest contribution (SDFC for FTT-D 5 1.39, FTT-N 5 .40, GRIP-D 5 .61, and GRIP-N 5 .64). CSC were consistent with the SDFC, with CSC-FTT-D 5 .40, CSC-FTT-N 5 .19, CSC-GRIP-D 5 .35, and CSC-GRIP-ND 5 0.48. Univariate post hoc T-tests for all measures were significant. Overall, FTT-D and -N contributed to the impaired performance of this sample, but GRIPD and -N were not impaired. Attention. Attention was evaluated using SEA and SPPR. SEA was not impaired, but SPPR was impaired. MANOVA was significant with Wilk’s Lambda 5 .85, F(2, 69) 5 6.10, p , .01. Roy’s GCR revealed a significant, but small effect (.15), indicating that 15% of the variance in the covariance matrix could be accounted for by the measures of attention. Post hoc canonical DFA indicated that both SEA and SPPR offered meaningful, unique contributions, but in opposite directions (SEA 5 0.94 and SPPR 5 2.81). CSC were consistent with SDFC, and in the same directions (SEA 5 0.65; SPPR 5 .48). Univariate post hoc T-tests demonstrated significant effects for SEA but did not indicate significant effects for SPPR. Overall, attention did not appear to significantly contribute to the impaired performance on this sample. Language. In this study, language was evaluated using the Aphasia Test. Overall performance on this test was within normal ranges (mean T-score 5 47.6). Univariate sample T-test demonstrates that this sample’s performance on this measure of language was significantly above the impairment cutoff score of T 5 240 (T 5 5.44, df 5 70, p , .001). Language did not significantly contribute to the impaired performance of this sample. Learning and memory. Learning and memory were evaluated using TPT-M and TPL-L. Although performance on both these measures was in the impaired range, MANOVA was not significant (Wilk’s Lambda 5 .99, F(2, 69) 5 .32, p . .05). Roy’s GCR did not reveal a meaningful effect (.01), indicating that less than 1% of the variance in the covariance matrix was accounted for by the difference between this group and Heaton et al.’s (1991) reference group. Post hoc canonical SDFC indicated a weak contribution of these tests to the multivariate effect (TPT-M 5 .57 and TPT-L 5 .55). CSC were consistent with SDFC (TMT-M 5 .89 and TPT-L 5 .89). Univariate post hoc T-tests were consistent with the multivariate results, with neither TPT-M or TPT-L showing significant effects. Learning and memory do not appear to account for the impairment demonstrated by this group.
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Psychomotor. Psychomotor functioning was evaluated using TPT-T and TMT-A. Performance on both these tests was impaired. MANOVA was significant with Wilk’s Lambda 5 .40, F(2, 69) 5 52.31, p , .001. Roy’s GCR revealed a strong effect (.60), indicating that 60% of the variance in the covariance matrix could be accounted for by the difference between this group and Heaton et al.’s (1991) reference group. Post hoc canonical SDFC indicated that TPT-T offered the greatest meaningful contribution to the multivariate effect (TPT-T 5 .93), with TMT-A offering less meaningful contribution (TMT-A 5 .34). Univariate post hoc T-tests were but significant. Both TPT-T and TMT-A significantly contributed to impairment demonstrated by this group. Reasoning. Reasoning was evaluated using CAT and TMT-B. Performance on both tests was impaired. MANOVA was significant with Wilk’s Lambda 5 .81, F(2, 69) 5 8.32, p , .001. Roy’s GCR revealed a moderate effect (.19), indicating that 19% of the variance in the covariance matrix could be accounted for by the difference between this group and Heaton et al.’s (1991) reference group. Post hoc canonical SDFC indicated CAT offered the greatest meaningful, unique contribution to the multivariate effect (CAT 5 .93). TMT-B was less meaningful but also contributed to the effect (TMT-B 5 .15). CSC were consistent with SDFC, with CAT 5 .99 and TMT-B 5 .50. Although CAT had a greater effect than TMT-B, univariate post hoc T-tests were both significant (CAT 5 p , .001 and TMT-B 5 p , .05). Both CAT and TMB-B significantly account for the overall impaired NP performance of this sample, but performance on CAT accounts for the greater impairment. In summary, multivariate analyses revealed that the impaired performance of this sample was significantly affected by their performance on tasks of Motor, Psychomotor, and Reasoning. Of particular note, performance on FTT-D, TPT-T, and CAT had the greatest effect on this impaired performance. Factor scores. A principal components analysis with varimax rotation was performed on the age and education corrected T scores of test measures within the NP battery. Factor analyses were performed for three-, four-, and five-factor models. Although all analyses produced Eigenvalues .1, the five-factor model was selected because of its theoretical relevance. The five-factor model explained 69.9% of the total variance. For each factor, Table 5 lists the NP tests with the highest loading, in descending order. Only those tests that reached a criterion of ..50 were selected. All of the clinically derived tests that were entered into the factor analysis were represented in the factor scores. With the exception of Factor 5, these tests were represented in combinations that were similar to theoretical functional expectation. Factor 1 was a Motor Factor, and included FTT-D and N and GRIP-D and N. Interestingly, except for Memory and Location, TPT measures were a factor all to themselves, with Factor 2 including TPT Dominant, Non-Dominant, Both, and Total Time/Block. Factor 3 was a measure of Attention and Sensory Perception, and included SEA, SPPR, and SP-R and L. Factor 4 was a measure of abstraction and learning, and included TMT-B, CAT, TPT-L, and TPT-M. Factor 5 was the only theoretically unanticipated factor, and appears to be a measure of processing speed.
DISCUSSION In this study, 71 prison inmates were administered the HRNB. These inmates had been referred for psychiatric treatment after being incarcerated, and were referred because of being a danger to themselves, a danger to others, or gravely disabled. Reasons for referral included less severe incidences, such as threatening to hang or cut themselves, threatening to harm
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TABLE 5 Defining Variables from Varimax Rotated Principle Components Analysis of NP Test, (Five-Factor Solution) Factor 1—Motor Test GRIP-ND FTT-D GRIP-D FTT-ND Eigenvalue:
Structure
Factor 2—Overall Functioning Communality
.80 .80 .79 .71 3.22 Factor 3—Attention/Sensory
Test SP-L SEA SP-R APHASIA SSPER Eigenvalue: Test TFR-RTime TFR-LTime Eigenvalue:
Structure
.66 .79 .68 .60
Communality
.76 .75 .72 .63 .60 2.99 Factor 5—Processing Speed
.66 .48 .71 .60 .58
Test
Communality
.92 .92 2.01
.83 .88
Communality
TPT-Time .83 TPT-ND .78 TPT-Both .72 TPT-D .68 Eigenvalue: 3.00 Factor 4—Abstraction/Learning Test TMB-B CAT TPT-L TPT-M Eigenvalue:
Structure
Structure
.41 .79 .78 .74
Structure
Communality
.77 .62 .58 .52
.35 .52 .60 .56
2.78
D 5 Dominant Hand, N 5 Nondominant Hand, Grip 5 Strength of Grip, FTT 5 Finger Tapping Test, TPT-Tactual Perception Test, SP-Sensory Perceptual Errors, SPPR 5 Speech Sounds Perception, TMT 5 Trailmaking, CAT 5 Category, TFR 5 Tactile Form Recognition Time.
custody staff or other inmates, auditory/visual hallucinations, or refusing to eat/drink. Reasons for referral also included more severe incidents, such as hanging, serious self-mutilation by cutting arms, wrists or neck, attempting to cut off bodily organs, attempting to swallow dangerous objects, violent physical attacks on either custody staff or other inmates, and smearing or eating feces. All incidents were thought to have been related to psychiatric disorder, and inmates were referred for stabilization, evaluation, and treatment. Results of this study demonstrate that performance on NP testing for this group is quite severely compromised. Using Heaton et al’s (1991) reference group as a standard, and using the age- and education-adjusted NP impairment cutoff score of T 5 40, 84% of this sample were impaired on the Halstead Impairment Index (HII). Multivariate analyses revealed significantly impaired motor, psychomotor, and abstraction. Performance on attention, language, and learning/memory were low, but not significantly below impairment cutoff. SP-L, FTT-D and N, SPPR, TPT-T, TPT-M, TPT-L, CAT, and TMT-B were all significantly impaired. Although language, attention, and learning/memory were relative strengths in this group, mean performance on all measures was below the expected T 5 50. Although this study demonstrates impairment of NP functioning, the study does not provide reasons for this impairment. Review of demographic information provides some understanding. For example, this sample represents a group of men who are both prisoners and who have a psychiatric disorder, with 70% having a DSM-III-R Primary Axis I diagnosis of psychotic or depressive disorder, and 17% having a DSM-III-R organic disorder. Although there are some differing conclusions as to which NP functions are impaired in individuals with schizophrenia, most investigators agree that attention, motor, verbal memory, and ab-
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straction are generally impaired (Braff et al., 1994; Heaton, 1994; Levin, Yurgelun-Todd, & Craft, 1989). Investigations of individuals with depressive disorders have demonstrated less consistent NP results. Although most investigators report the existence of NP impairment in individuals with Depressive disorders (Cassens, Wolfe, & Zola, 1990; Goldberg et al., 1993), the exact nature of that impairment differs, leading Cassens et al. (1990) to conclude that depression can best be described as subtypes of depression. A substantial proportion of NP impairment in this group, therefore, is likely attributed to brain correlates of both psychotic and depressive disorders. One area of needed future research is to compare performance of participants in this study with performance of psychiatric, but nonprison, samples. In addition to psychiatric diagnosis, 87% of this sample was taking at least one psychotropic medication at the time of testing. A review of literature generally concludes that although motor and memory can be negatively affected by psychotropic medication, as a general finding other NP functions are not impaired, or may even be improved with appropriate psychotropic medication (Bilder, Turkel, Lipschutz-Broch, & Lieberman, 1992; Medalia, Gold, & Merriam, 1988). A review of demographic information also reveals that 85% of this sample have histories of severe polysubstance abuse. For many, drug use started early (mean age for first drug use was 12.8 years), and included substances that are known to be particularly harmful to brain structures, particularly inhalants and alcohol (Grant, Adams, Carlin, Rennick, Judd, Schooff, & Reed, 1978; Grant, Adams, Carlin, Rennick, Judd, Schooff, 1978; Grant, 1987; Hormes, Filley, & Rosenberg, 1986). Considering the ‘‘vulnerability hypothesis’’ as described by Davidson and Dobbing (1968) and Himwich (1970), the adolescent brain would be particularly vulnerable to damage from drugs known to primarily affect anterior brain areas. This population, therefore, would be at particular risk for NP impairment associated with early use of these drugs. Although neurological examinations were not completed as a formal part of this study, medical and neurological examinations were performed on all participants when they were admitted for treatment. This information indicates that 52% have known neurological injuries, which included head trauma with loss of consciousness, seizure disorder, or loss of consciousness due to factors other than head trauma. The incidence of undiagnosed medical disorder with known neuropsychiatric symptoms (lupus, endocrine, cardiovascular, etc.) is not known. There are multiple possible explanations for the pervasiveness and severity of impairment demonstrated by this sample of prisoners in psychiatric treatment. It is not our intention to minimize these factors. Of particular relevance, however, participants in this sample were also quite violent. When considering only those offenses for which they were formally charged (not including offenses that were reduced through plea bargaining, or which occurred but the individual was not formally charged), 71% of this sample had at least one crime that involved serious physical violence or murder, and 24% had crimes that not only resulted in loss of life, but were particularly heinous (torture, serial murder, etc.). Men in this sample not only had histories of severe violence prior to prison, but continued that violence once they were in prison. Eighty-three percent had received at least one documented prison offense for violence, and many had multiple violent offenses once in prison. Multiple studies have documented the relationships between violence and mental disorders (Graham, Thienhaus, & Somoza, 1990; Krakowski, 1994; Marzuk, 1996; Mulvey, 1994; Teplin, 1994; Torrey, 1994; Torrey, 1995); violence and drug use (Bradford, Greenberg, & Motayne, 1992; Buss, Abdu, & Walker, 1995; Miller, Gold, & Mahler, 1991; Moss & Tarter, 1993; Swanson, Morrisey, Goldstrom, & Laurence, 1993); and violence and NP impairment (Diaz, 1995; LaPierre, Braun, Hodgins, & Toupin, 1995; Mungas, 1988; Volavka, Martell, & Convit, 1992). Concurrent with the downsizing of both institutional and community-based mental health services, the penal system is, by default, becoming society’s largest provider of mental health
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services. The frequency of mentally ill individuals in prisons and forensic facilities continues to increase. The factors influencing this phenomena will not be discussed here, but the impact must be addressed not only as a penal system problem, but ultimately as a societal concern. Ironically this shift of responsibility is to a system that is least able, by design and focus, to address the needs of a mentally ill population. The services required by a mentally ill population are often inconsistent with the mission of a penal system. In addition to the system problems in providing mental health services to prisoners, the characteristics of this patient population warrant special concern. The experiences of clinicians treating these inmate-patients are that this population is unique, atypical, and not representative of psychiatric populations in state hospitals or even forensic treatment facilities. The relative degree of psychiatric impairment in conjunction with NP impairment, and the pervasive violence potential revealed in this study corroborate these perceptions. Regardless of the hypothesized reasons for the NP impairment and violence demonstrated by this sample, the realities of this situation must be addressed. Prisons and mental health facilities within prisons must provide a safe environment for inmates and staff. Further, they must provide treatment for inmates suffering from major mental disorders, the same as they do for inmates needing treatment for medical problems. The scope of this endeavor is formidable. In a recent publication, Keefe (1995) makes the point that treatment of the mentally ill is a complex and difficult task, but treatment of individuals who have both psychiatric disorder and NP impairment is even more complex and difficult, and treatment outcome is less effective. Keefe does not address treatment issues of psychiatric disorder, NP impairment, and violence. He does, however, point out that treatment is most effective when the cognitive strengths and weaknesses of these individuals are identified, and treatment plans are developed with these factors in mind. The primary purpose of this study was to provide a comprehensive description of this sample of psychiatrically hospitalized inmates in order to more effectively design treatment programs. Results revealed severe psychiatric disorder, severe cognitive impairment, and high violence histories and propensities in this sample of psychiatrically hospitalized prisoners. The severity of these problems, combined with the constraints and unique aspects of the environment in which they must be treated creates major challenges to treatment. The descriptive and comparative aspects of this study were utilized in designing a treatment program for these mentally ill prisoners. Treatment outcome measures are currently in progress. Beyond its immediate utility, this study raises many issues for further investigation. Relationships between NP impairment and various psychiatric disorders, and the impact of psychotropic medication on NP functioning continue to require greater exploration and understanding. More information is needed regarding the impact of drug use on NP functioning; the impact of early adolescent use of inhalants and alcohol; and the relationship between drug use and violence. The role of neurological injuries, which are not the focus of treatment, but which affect overall NP functioning, also needs to be explored. Most importantly, the relationships of these factors in understanding violence, and the impact of these factors on treatment outcomes need to be better understood.
REFERENCES Bland, R. C., Newman, S. C., Dyck, R. J., & Orn, H. (1990). Prevalence of Psychiatric Disorders and Suicide Attempts in a Prison Population. Canadian Journal of Psychiatry, 35, 407–413. Bilder, R. M., Turkel, E., Lipschutz-Broch, L., & Lieberman, J. A. (1992). Antipsychotic Medication Effects on Neuropsychological Functions. Psychopharmacology Bulletin, 28, 353–366.
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Bradford, J. M., Greenberg, D. M., & Motayne, G. G. (1992). Substance abuse an criminal behavior. Psychiatric Clinics of North America, 15, 605–622. Braff, D., Harris, M. J., Heaton, R., Jeste, D. V., Kuck, J., McAdams, L. A., Paulsen, J. S., & Zisook, S. (1994). Neuropsychological deficits in schizophrenias: Relationship to age, chronicity, and dementia. Archives of General Psychiatry, 51, 469–476. Buss, T., Abdu, R., & Walker, J. (1995). Alcohol, drugs, and urban violence in a small city trauma center. Journal of Substance Abuse Treatment, 12, 75–83. Cassens, G., Wolfe, L., & Zola, M. (1990). The neuropsychology of depressions. Journal of Neuropsychiatry, 2, 202–213. Davidson, A., & Dobbing, J. (1968). The developing brain. Philadelphia: F.A. Davis. Diaz, F. (1995). Traumatic brain injury and criminal behavior. Medicine & Law, 14, 131–140. Edwards, A. C., Faulkner, L. R., & Morgan, D. W. (1994). Prison inmates with a history of inpatient psychiatric treatment. Hospital and Community Psychiatry, 45, 172–174. Goldberg, T. E., Gold, J. M., Greenberg, R., Griffin, S., Schula, C., Pickar, D., Kleinman, J. E., & Weinberger, D. R. (1993). Contrasts between patients with affective disorders and patients with schizophrenia on a Neuropsychology Test Battery. American Journal of Psychiatry, 150, 1355–1362. Graham, L., Thienhaus, O., & Somoza, E. (1990). Violent behavior among schizophrenic patients. American Journal of Psychiatry, 147, 1383–1384. Grant, I., Mohns, L., Miller, M., & Reitan, R. M. (1976). A neuropsychological study of polydrug users. Archives of General Psychiatry, 33, 973–978. Grant, I., Adams, K. M., Carlin, A. S., Rennick, P. M., Judd, L. L., Schooff, K., & Reed, R. (1978). Organic impairment in polydrug users: Risk factors. American Journal of Psychiatry, 135, 178–184. Grant, I., Adams, K. M., Carlin, A. S., Rennick, P. M., Judd, L. L., & Schooff, K. (1978). The collaborative neuropsychological study of polydrug users. Archives of General Psychiatry, 35, 1063–1074. Grant, I. (1987). Alcohol and the brain: neuropsychological correlates. Journal of Consulting and Clinical Psychology, 55, 310–324. Guy, E., Platt, J., Zwerling, I., & Bullock, S. (1985). Mental health status of prisoners in an urban jail. Criminal Justice and Behavior, 2, 29–53. Hartsone, D., Steadman, H., Robbins, P., & Monahan, J. (1984). Identifying and treating the mentally disordered prison inmate. Mental Health and Criminal Justice, 8, 279–296. Heaton, R. K., Grant, I., & Matthews, C. G. (1991). Comprehensive norms for an expanded Halstead-Reitan Battery. Odessa, FL: Psychological Assessment Resources, Inc. Heaton, R. (1994). Neuropsychological deficits in schizophrenics: relationship to age, chronicity, and dementia. Archives of General Psychiatry, 54, 460–476. Heaton, R. K., Grant, I., Butters, N., & the HNRC Group (1995). The HNRC 500-Neuropsychology of hiv infection at different disease states. Journal of the International Neuropsychological Society, 1, 231–251. Himwich, W. (1970). Developmental neurobiology. Springfield, IL: Charles C Thomas. Hodgins, S., & Cote, G. (1991). The mental health of penitentiary inmates in isolation. Canadian Journal of Criminology, 183–192. Hormes, J. T., Filley, C. M., & Rosenberg, N. L. (1986). Neurologic sequelae of chronic solvent vapor abuse. Neurology, 36, 698–702. Keefe, R. (1995). The contribution of neuropsychology to psychiatry. American Journal of Psychiatry, 152(6), 6–15. Krakowski, M. (1994). Clinical symptoms, neurological impairment, and prediction of violence in psychiatric inpatients. Hospital and Community Psychiatry, 45, 700–705. Lapierre, D., Braun, C., Hodgins, S., & Toupin, J. (1995). Neuropsychological correlates of violence in schizophrenia. Schizophrenia Bulletin, 21, 252–262. Levin, S., Yurgelun-Todd, D., & Craft, S. (1989). Contributions of clinical neuropsychology to the study of schizophrenia. Journal of Abnormal Psychology, 98, 341–356. Lewis, D., Pincus, J., Bard, B., Richardson, E., Prichep, L., Feldman, M., & Yaeger, C. (1988). Neuropsychiatric, psychoeducational, and family characteristics of fourteen juveniles condemned to death in the United States. American Journal of Psychiatry, 145, 584–589. Martel, D. (1992). Estimating the prevalence of organic brain dysfunction in maximum-security forensic psychiatric patients. Journal of Forensic Sciences, 37, 878–893. Marzuk, P. (1996). Violence, crime, and mental illness: how strong a link? Archives of General Psychiatry, 53, 481–486. Medalia, A., Gold, J., & Merriam, A. (1988). The effects of neuroleptics on neuropsychological test results of schizophrenia. Archives of Clinical Neuropsychology, 3, 249–271. Miller, N. S., Gold, M. S., & Mahler, J. C. (1991). Violent behaviors associated with cocaine use: possible pharmacological mechanisms. International Journal of the Addictions, 26, 1077–1088.
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Moss, H., & Tarter, R. E. (1993). Substance abuse, aggression, and violence: What are the connections? American Journal on Addictions, 2, 149–160. Mulvey, E. (1994). Assessing the evidence of a link between mental illness and violence. Hospital and Community Psychiatry, 45, 663–668. Mungas, D. (1988). Psychometric correlates of episodic violent behavior: A multidimensional neuropsychological approach. British Journal of Psychiatry, 152, 180–187. Myers, J. K., & Bean, L. L. (1968). A decade later: a follow-up of social class and mental illness. New York: John Wiley & Sons. Neighbors, H. W. (1987). The prevalence of mental disorder in Michigan prisons. Diagnostic Interview Schedule Newsletter, 4(12), 8–11. Steadman, H., Holohean, E., & Dvoskin, J. (1991). Estimating mental health needs and service utilization among prison inmates. Bulletin of the American Academy of Psychiatry and the Law, 19, 297–307. Swanson, J., Morrissey, J., Goldstrom, I., & Laurence, R. (1993). Demographic and diagnostic characteristics of inmates receiving mental health services in state adult correctional facilities: United States. Mental Health Statistical Nore, 20, 209. Swetz, A., Salive, M. E., Stough, T., & Brewer, T. (1989). The prevalence of mental illness in a state correctional institution for men. Journal of Prison and Jail Health, 8, 3–15. Teplin, L. (1994). Psychiatric and substance abuse disorders among male urban jail detainees. American Journal of Public Health, 84, 290–293. Torrey, E. (1994). Violence behavior by individuals with serious mental illness. Psychiatric Services, 45, 653–662. Torrey, E. (1995). Violence and mental illness. Psychiatric Services, 46, 407–408. Uhlig, H. (1976). Hospitalization experience of mentally disturbed and disruptive, incarcerated offenders. Journal of Psychiatry and Law, 4, 49–59. Volavka, J., Martell, D., & Convit, A. (1992). Psychobiology of the violent offender. Journal of Forensic Sciences, 37, 237–251. Yeudal, L., Fedora, O., & Fromm, D. (1987). A Neuropsychological theory of persistent criminality: implications for assessment and treatment. Advances in Forensic Psychology and Psychiatry, 2, 119–191.
APPENDIX A: VIOLENCE RATING SCALE 1. Nonviolent Offenses Drug Offenses Fraud Prostitution Disorderly Conduct Trespassing Begging Failure to Provide for Spouse 2. Ambiguous Violence Escape Driving Offenses Theft Possession of a Weapon Possession of Stolen Property Violation of Probation/Parole Contributing to Delinquency of Minor 3. Property Crimes Vandalism Burglary Grand Theft Auto Taking Vehicles w/o Owners Consent Malicious Mischief Grand Theft
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4. Threats to Person Indecent Exposure Robbery Lewd & Lascivious Acts Exhibiting a Deadly Weapon Intimidating a Witness 5. Attacks on Persons Car Jacking Assault Rape Incest Child Molestation Oral Copulation Kidnap Resisting Arrest Arson False Imprisonment 6. Attacks on Persons With Loss of Life or Special Circumstances Murder Manslaughter Sadistic Rape or Molestation Serial Rape Systemic Infliction of Pain Torture 7. Attacks on Person With Extreme Violence as Above but Resulting in Death of Victim