Testosterone as a biological marker in psychopathy and alcoholism
Introduction
Despite the vast literature on biological actions of testosterone, relatively little is known about the behavioral effects of androgens in man (Rubinow and Schmidt, 1996). In a study of alcoholic, violent criminals, Virkkunen et al. (1994)found that a high free testosterone level in the CSF was the best biological discriminator of violent offenders from non-violent, non-criminal control subjects. Also other studies of criminal populations (Kreuz and Rose, 1972; Ehrenkrantz et al., 1974; Rada et al., 1976; Mattsson et al., 1980; Dabbs Jr. et al., 1987, Dabbs Jr. et al., 1988) and of aggressive alcoholics (Lindman et al., 1987; Bergman and Brismar, 1994) have demonstrated a positive relationship between plasma or saliva testosterone levels and violence.
The search for biological markers of traits and behaviors in psychiatry has several aims, such as to understand pathophysiological mechanisms underlying disorders and behaviors and to find predictors of treatment outcome and crime relapse (Nurnberger Jr., 1992). However, there are so far few follow-up studies that might verify the predictive power of biological markers. A long-term follow-up study of young delinquents (Alm et al., 1996a, Alm et al., 1996b) showed that the calculated risk for late criminality was significantly augmented in subjects with low activity of platelet monoamine oxidase (MAO) and high levels of serum tri-iodothyronine (T3). These results are in accord with the Buchsbaum theory of a biochemical high risk paradigm (Buchsbaum et al., 1976) in which low platelet MAO activity is associated with psychopathy-related personality traits of impulsiveness, sensation-seeking and aggressiveness (von Knorring et al., 1984; Zuckerman, 1984; Schalling et al., 1987; Stålenheim and von Knorring, 1996a). Other studies have demonstrated a direct association between elevated levels of T3 and criminality (Levander et al., 1987; Stålenheim et al., 1996), post-traumatic stress disorders (Mason et al., 1994), and alcoholism (Sudha et al., 1995). Whether testosterone can serve as a biological marker in a way that is similar to platelet MAO activity and serum T3 has not yet been completely investigated.
The Karolinska Scales of Personality (KSP) (Schalling and Edman, 1993) provide a possibility to relate psychopathy to biological parameters (Schalling et al., 1987). Psychopathy is, however, more often assessed by means of the Psychopathy Checklist — Revised (PCL-R) (Hare et al., 1990). It defines a syndrome including affective, interpersonal and behavioral symptoms which has been described by Cleckley (1964)and Hare (1980). The PCL-R has been widely used for scientific and prospective purposes in criminal and forensic systems and is the strongest single predictor of criminal relapse (Hart and Hare, 1989; Hare et al., 1990). A diagnosis in the DSM system (American Psychiatric Association, 1987) corresponding to, but not consistent with, psychopathy is antisocial personality disorder which puts a strong emphasis on asocial behavior. It is mainly factor 2 of the PCL-R that is associated with criminality and a diagnosis of antisocial personality disorder within the DSM system.
The studies on testosterone mentioned above investigated subjects that were selected for violence. A review by Archer (1991)gives information about the influence of testosterone on human aggression in general. Archer summarizes evidence of a weak, but positive, relationship between testosterone levels and overall hostility inventory scores, and a slightly higher value for ratings of measures of direct and indirect forms of hostility. Archer finds problems in comparing studies of testosterone and aggression, because the hormonal measures vary between studies with measures of free and/or total testosterone in plasma versus in the CSF, and, furthermore, the definition and assessment methods of aggression vary. Only a few studies have measured free testosterone in men (Dabbs Jr. et al., 1987; Lindman et al., 1987; Virkkunen et al., 1994). They indicate that there is a positive relationship between free testosterone and aggression, except for one study of a large unselected sample (Christiansen and Knussman, 1987).
An alternative hypothesis has been put forward by Zuckerman (1991), namely that levels of testosterone in normal young men are related to sensation seeking, sexual experiences and sociability, but not to impulsivity or aggression (Daitzman and Zuckerman, 1980; Zuckerman, 1984; Zuckerman, 1991p. 1268). In accordance with this, a Swedish study of delinquents showed that testosterone levels were associated with traits of Monotony avoidance on the KSP (Mattsson et al., 1980).
The present study concerns males undergoing forensic psychiatric examinations in Sweden (see Stålenheim and von Knorring, 1996b). The aim is to clarify the relationships between testosterone and specific personality characteristics and behaviors.
The subjects gave their informed consent to the study, which had been approved by the Ethics Committee of the Medical Faculty of Uppsala University.
Section snippets
Research subjects
The subjects were 61 men, who were undergoing a major forensic investigation at the Department of Forensic Psychiatry in Uppsala during the period of 1992–1994. All subjects had committed serious criminal acts and the courts had found them guilty. The crimes were serious enough to require a more severe sentence than a fine. The violent crimes were assault (n=24), sexual offences (n=10), murder (n=9), robbery (n=5), kidnapping (n=3) and arson (n=3). All subjects had been detoxified from drugs
Results
As shown in Fig. 1, serum levels of TT and FT-DPC were strongly correlated, r=0.63, P<0.0001. A significant correlation was also found to exist between serum levels of TT and SHBG, r=0.39, P<0.01. No significant correlation was found between FT-DPC and SHBG serum levels.
The levels of FT-DPC, but not TT, decreased slightly with age (r=−0.26, P<0.05) while the levels of SHBG increased (r=0.34, P<0.01). Serum concentrations of SHBG were significantly correlated with measures of liver injury tests
Discussion
There are several methodological problems involved in the determination of testosterone levels. In the present study, free testosterone (FT-DPC), total testosterone and SHBG have all been regarded as different measures indicating high or low overall testosterone activity. One reason is that several studies, e.g. Longcope et al. (1990), have reported a significant positive correlation between total testosterone and SHBG.
Thus, the results of this study are very consistent: different measurements
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