Personality traits as predictors of occupational

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Nordic Journal of Psychiatry

ISSN: 0803-9488 (Print) 1502-4725 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsc20

Personality traits as predictors of occupational performance and life satisfaction among mentally disordered offenders Helena Lindstedt doctoral candidate ROT M.Sc., Anne Söderlund Ph.D. RPT, Gunilla Stålenheim M.D. & Per-Olow Sjödén Ph.D. To cite this article: Helena Lindstedt doctoral candidate ROT M.Sc., Anne Söderlund Ph.D. RPT, Gunilla Stålenheim M.D. & Per-Olow Sjödén Ph.D. (2005) Personality traits as predictors of occupational performance and life satisfaction among mentally disordered offenders, Nordic Journal of Psychiatry, 59:5, 357-364, DOI: 10.1080/08039480500320082 To link to this article: http://dx.doi.org/10.1080/08039480500320082

Published online: 12 Jul 2009.

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Personality traits as predictors of occupational performance and life satisfaction among mentally disordered offenders

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˚ LENHEIM, PER-OLOW ¨ DERLUND, GUNILLA STA HELENA LINDSTEDT, ANNE SO ¨ DE´N SJO

Lindstedt H, So¨derlund A, Sta˚lenheim G, Sjo¨de´n P-O. Personality traits as predictors of occupational performance and life satisfaction among mentally disordered offenders. Nord J Psychiatry 2005;59:357 /364. Oslo. ISSN 0803-9488. The study investigated to what extent personality traits, e.g. socialization, proneness for anxiety, aggression and hostility were associated with and predictive of self-reported and observed occupational performance and perceived life satisfaction among male mentally disordered offenders (MDOs). Also, subjects with psychopathic-related personality traits were compared with subjects without such traits regarding demographic data and dependent variables. The MDOs were included from the Swedish National Board of Forensic Medicine. A total of 55 subjects were visited at their hospital ward for data collection with the Karolinska Scales of Personality (KSP), Capability to Perform Daily Occupation (CPDO), Allen Cognitive Level Screen (ACLS) and the Manchester Quality of Life Scale (MANSA). Seven KSP scales and two KSP factors correlated significantly with the dependent variables. Regression analyses revealed that the KSP Socialization scale, the KSP Anxiety-proneness and Psychopathy factors were the most important predictors. Subjects with psychopathy differed from remaining groups by having more conduct disorders before 15 years, being more often brought up in outcasted families and less subjected to measures of pupil welfare activities. The life history was concluded to be important influencing occupational performance and life satisfaction. Subjects with high anxiety proneness should be given attention in treatment planning. ’ Forensic occupational therapy, Life satisfaction, Mentally disordered offenders, Occupational performance, Personality traits. Helena Lindstedt, Department of Public Health and Caring Sciences, Section of Caring Sciences, Uppsala Science Park, Dag Hammarskjo¨ldsva¨g 10 B, SE-751 83 Uppsala, Sweden, E-mail: [email protected]; Accepted 2 June 2004.

entally disordered offenders (MDOs) constitute a heterogeneous group with a diversity of social, psychological and biological problems. Such problems cause obstacles in everyday occupations as well as in social life (1). Improvements of their ability to perform occupations and perceptions of life satisfaction are important goals in forensic occupational therapy and indirectly related to the risk of offending behavior among MDOs (2). Previous studies searching for predictors of everyday functioning, social functioning and life satisfaction have been performed among subjects with severe mental disorders. It seems that neurocognitive performance is a major predictor of everyday functioning (3, 4). In one study (5), long-term (12-year) good social function was predicted by little

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or no personality disturbances, single marital status and self-rated depression. Eklund et al. (6) found that personality characteristics were predictors of good functioning. Their results showed that character and temperamental factors were strongly associated with good functioning (6). In another study by Eklund et al. (7), factors predicting perceived life satisfaction were determined by trait-like personality properties and self-variables. In the same study (7), severe mental disorders explained a substantial part of life satisfaction. Materialistic, objective life circumstances explained only a minor part (7). These predictive studies of everyday and social functioning as well as life satisfaction have often been performed in community settings with outpatients, whereas MDOs are confined to hospitals after DOI: 10.1080/08039480500320082

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committing a serious and often violent crime. An important objective of studies of occupational performance and life satisfaction among MDOs is to get a view of their ability to live a safe life in the community. Personality traits, i.e. individual characteristics consisting of dispositions to react in a predictable manner (8, 9), have been shown to be stable over time and across situations (10, 11). Earlier studies of personality traits have investigated the importance of biological markers among MDOs with psychopathy (12) and in criminal populations (13). The common result of these two studies were high anxiety, low socialization and normal aggression. This might be important as personality traits of MDOs are assumed to influence their occupational performance and how satisfied they are with life. Occupational performance will be focused in the present study as ‘‘the actions of the individual elicited and guided by the occupational form’’ according to Creek (14, p. 587). Creek refers to the occupational form as ‘‘the sociocultural and physical characteristics of an occupation that exist independent of the person engaging in the occupation and that influence the occupational performance of the individual’’ (14, p. 587). Occupational performance depends on a range of learned skills, developmental maturation and the ability to combine and apply skills appropriately at the right time and place (15). Occupational performance is also used as the definition of function (16) in occupational therapy. The concept of function is used more or less implicitly as occupational therapists study strategies to overcome the impaired functioning of the individual (17, 18). Prediction of this type of factors has been studied rather sparsely in the scientific literature. However, in an earlier study (19), MDOs ability of occupational performance was focused, and the results suggested that MDOs had a limited awareness of their disabilities. MDOs with psychopathic-related personality traits are characterized by having very complex personality disorders, which could be defined as emotional/interpersonal traits and social deviancies (20, 21). This may imply obstacles in the apprehension and management of everyday occupations for MDOs with these additional disorders. Therefore, it is hypothesized that MDOs characterized by psychopathic-related personality traits are more restricted in their occupational performance and life satisfaction than are non-psychopathic subjects. The first aim of the present study was to describe and to investigate to what extent personality traits, e.g. proneness for anxiety, socialization, aggression and hostility were associated with and predictive of selfreported and observed occupational performance and perceived life satisfaction among MDOs. The second aim was to compare groups with and without psychopathic-related personality traits with regard to demo-

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graphic variables, occupational performance and life satisfaction.

Method Subjects The original sample consisted of 180 subjects, selected consecutively from the Central Archive of the Swedish National Board of Forensic Medicine during a period of 11 months. Inclusion criteria were male, ]/18 years old and sentenced to forensic psychiatric care with compulsory court review in central Sweden. Because of the available resources, the geographical area was limited to central Sweden. Nineteen subjects who were notified in the record as in need of an interpreter in order to understand Swedish were excluded, resulting in a total of 161 eligible persons. Among these, five were taken care of in unknown places, 17 did not respond and 65 subjects refused further contact. The psychiatrist in charge at each hospital was asked by letter about permission to contact the subjects. A total of 74 subjects were visited for an interview after informed consent within 6 months after their verdict had gained legal force (19). Fifty-five subjects of the 74 completed the Karolinska Scales of Personality (KSP; 10) for the present study. The mean age (9/standard deviation, s ) of the present sample was 33.89/11.8 years (range 18/75), and only three were older than 50 years; 29.1% were immigrants. The group had grown up in working- or middle-class families (83.7%), or in socially outcasted families (16.3%). In school, 61% had been subjected to measures of pupil welfare. At the time of incarceration, 14.5% had no housing, 49.1% reported being out of work and 16.4% were employed. The subjects were diagnosed with one to five disorders on Axis I of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; 22) at the Forensic Psychiatric Investigation. Their main diagnoses were schizophrenia in 27.3%, psychosis in 21.8%, mood and anxiety disorders in 9.1%, attention deficits and hyperactive disorders in 9.1%, pedophilia in 7.3%, dementia in 3.6% and other severe mental disorders in 3.6%. Abuse dependence was not a main diagnose in any case, but occurred equally spread among the subjects. On Axis II (DSM-IV), 38.2% suffered from personality disorders and 12.7% from mental retardation as additional diagnoses. Moreover, 43.7% had been judged as having a conduct disorder before 15 years of age. The index crimes were aggravated assault in 30.9%, homicide in 20%, sex-crimes in 20% and unlawful threats in 12.7% of the cases. Before the current verdict, 23.6% had been incarcerated in forensic psychiatric hospital care, and 27.3% had been imprisoned in jail. At the time of the present research investigation, 43.3% were incarcerated in regional high-security hospitals, 30.9% on NORD J PSYCHIATRY×VOL 59 ×NO 5 ×2005

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local-security forensic psychiatric hospital wards, and 25.5% on general psychiatric hospital wards. A more detailed presentation of demographic data for the sample is given elsewhere (19).

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Assessment instruments Demographic data were collected from the Central Archive at the Swedish National Board of Forensic Medicine. This archive includes data from all forensic psychiatric investigations in Sweden (23) containing psychiatric and personality diagnoses and demographic data. In addition, self-reported demographic information was collected using questions on ethnicity, occupation, housing and financial support. The Karolinska Scales of Personality (KSP; 10,21,24) is a self-report questionnaire including 135 items representing 15 scales, concerned with the participant’s stable habitual behavior and feelings. The KSP gives an assessment of vulnerability for psychopathology, and includes the following scales: Somatic anxiety, Psychic anxiety, Muscular tension, Social desirability, Impulsiveness, Monotony avoidance, Detachment, Psychastenia (10 items each), Socialization (20 items), Indirect aggression, Verbal aggression, Irritability, Suspicion, Guilt (five items each) and Inhibition of aggression (10 items). Three scales, Impulsiveness, Monotony avoidance and Socialization have been found to be related to Psychopathy (25), which is why a Psychopathy factor is formed by these scales (Impulsiveness/Monotony avoidance /Socialization; 26). An Anxiety-proneness factor is formed by summarizing the Somatic anxiety, Psychic anxiety, Muscular tension and the Psychastenia scales (27). The responses to the questionnaire are given from 1, ‘‘does not apply at all’’ to 4, ‘‘applies completely’’. The raw mean scores for the separate scales are transformed into T-scores (mean9/s/509/10) in accordance with af Klinteberg et al. (25). The KSP raw scores are used in the present study for all data computations and T-scores are used for illustrating results in Figure 1. KSP scores have been found to be stable over 9 years (28) and used in several investigations of similar populations (8, 9, 13, 26). Self-reported occupational performance was assessed by the Capability to Perform Daily Occupations (CPDO; 29). The CPDO is a computer-based self-rating assessment, originally designed for subjects with chronic pain. The subject rates 27 video sequences of daily occupations. (The video sequence ‘‘Clean the Bathroom ’’ was excluded.) A detailed description of the CPDO can be found elsewhere (19). In accordance with Schult (29), the four subscales Interruption, Avoidance, Exertion and Inconvenience were grouped to one factor named ‘‘Performance burden’’. That gives points from 4, which equals no performance burden to 36 indicating high burden performing occupations. The CPDO has earlier NORD J PSYCHIATRY ×VOL 59×NO 5×2005

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been used in studies of MDOs (19) and individuals with severe mental disorders (30). Observation of occupational performance was performed with the Allen Cognitive Level Screen (ACLS; 31). The ACLS is an assessment of the ability to follow instructions and gives a measure of visual-motor planning, problem solving and learning in subjects with mental health problems. The subject is observed while performing three leather-lacing stitches with an increasing degree of difficulty. A detailed description of the ACLS is presented elsewhere (19). The ACLS is based on the Cognitive Disability Model (31, 32), which has six hierarchically organized, cognitive levels. Level 6 is a theoretically normative level for the ability to live an independent community life, and Level 1 implies being taken care of day and night. The cognitive levels are judged on the basis of observations of voluntary motor actions in contrast to most cognitive assessments, which are based on verbal abilities. The ACLS gives a score on a 15-point global scale ranging from 3.0 (low) to 5.8 (high). It has been used in earlier investigations of MDOs (19) and subjects with severe mental disorders 30. Perceived life satisfaction was assessed by the Manchester Quality of Life Scale (MANSA; 33,34). The MANSA is a short version of the Lancashire Quality of Life Profile (LQLP; 35), a questionnaire assessing perceived life satisfaction with nine life domains for subjects with mental health problems: global quality of life, economy, leisure, living situation, occupation, personal safety, family relations, social relations and health. These domains are tapped by 12 structured questions. Satisfaction ratings are given on a 7-point Likert type scale where 1 stands for ‘‘it couldn’t be worse’’, and 7 ‘‘it couldn’t be better’’. The total maximum score is 77 based on eight subscales, global quality of life excluded. The LQLP has been used earlier in two studies of MDOs (36, 37).

Procedure All interviews were performed by the first author (HL). The interview took place in a separate room on the ward, in the majority of cases with only the interviewer and the subject present. In most cases, a joint decision was made by the interviewer and the nursing staff concerning the necessity of having a staff present for security reasons. The subjects were first informed about the proceedings of the session and the purpose of the study. When answering the questions, they were asked to think about how they normally consider their daily reactions and behavior. The session started with questions about self-reported demographic data, followed by the MANSA, the ACLS observation and the CPDO. The KSP and a pre-stamped envelope were then handed over to the subject for completion on his own.

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Fig. 1. Mean T-score (n /55) for the Karolinska Scales of Personality (KSP), mean/509/10.

After the session, demographic data were collected by the first author (HL) from the subject’s forensic psychiatric investigation at the Central Archives at the National Board of Forensic Medicine. Thus, when performing the interview, the author (HL) was unaware of the specific individual circumstances such as the crime and the psychiatric diagnosis of the subject.

Data analyses All statistics were computed using the Statistical Package for the Social Sciences software (SPSS, 2000). Three types of analyses were performed: 1) correlations were calculated by Pearson product-moment coefficients between the KSP scales and factors as independent variables, and the CPDO Burden factor, the ACLS and the MANSA as dependent variables. 2) The second step was to perform multivariate regression analyses (38). Those independent scales and factors that were significantly correlated with the dependent variables were entered in the regression analyses. These were done between the Somatic-anxiety, the Psychastenia KSP scales and the ACLS. Seven KSP scales (Somatic anxiety, Psychic anxiety, Muscle tension, Psychastenia, Socialization, Suspicion and Guilt) were entered in the multivariate regressions with the MANSA. Multivariate regression was also performed between the KSP factors (Psychopathy and Anxiety proneness) and the MANSA. 3) Univariate regression analyses were then performed between the single KSP scales and factors that were significantly correlated with the dependent variables. Analyses were performed between the KSP Socialization

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scale and the CPDO Burden factor, the Psychopathy factor and the CPDO Burden factor, and between the KSP Anxiety-proneness factor and the ACLS. With the purpose of comparing groups with and without psychopathy, the subjects were split into two groups by noting the absence (n/38) or presence (n/ 17) of these personality traits. The presence of psychopathy was defined as one standard deviation above the mean T-score of the KSP Psychopathy factor. Differences between groups with and without psychopathy were calculated with one-way analyses of variance (ANOVAs). These analyses were performed separately for the CPDO Burden factor, the ACLS mean score and the MANSA total mean score. Comparisons of demographic variables between these two groups were performed by the chi-squared test.

Results The KSP mean T-scores for the separate scales were distributed with a range of 31.2 /62.2 (Fig. 1). The high levels of the anxiety scales (Somatic Anxiety mean / 60.19/13.9; Psychic Anxiety mean /58.89/12.4; Muscle Tension mean /62.29/14.1; Psychastenia mean /58.79/ 15.3) indicate restlessness, worry, lacking self-confidence, muscular tension and being easily fatigued (10). Low Socialization scores (mean /31.29/12.5) suggest that the MDOs lack positive interpersonal family experiences, empathy and satisfaction (10). The T-scores for the five aggression scales, Indirect Aggression (mean/52.69/ 11.9), Verbal Aggression (mean /49.19/10.3), Irritability (mean /49.89/11.8), and the two included hostility NORD J PSYCHIATRY×VOL 59 ×NO 5 ×2005

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scales, Suspicion (mean/56.79/11.4) and Guilt (mean /55.99/9.6), were close to a mean of 50 and an SD of 10, suggesting normal levels in these respects. The sample mean of the CPDO Burden factor was relatively low (mean /9.89/3.9, 3.7 /21.0), indicating that the subjects apprehended themselves performing occupations without burden. The fact that this value is lower than 104 also suggests that the subjects judge some activities as not relevant for them. In contrast, the ACLS mean score indicates a relative low ability of observed occupational performance (mean /5.19/0.3, 4.2 /5.8). The total mean score of the MANSA (mean /50.29/9.5, 26/71) was surprisingly high for this sample. It seems that the MDOs were not aware of their shortcomings in occupational performance. However, they perceived a rather high satisfaction with their life situation.

Personality traits and occupational performance/ perceived life satisfaction: Intercorrelations Seven KSP scales and the two KSP factors (Psychopathy and Anxiety-proneness) correlated significantly with the three dependent variables, i.e. Self-reported Performance Burden, Observed Occupational Performance and Perceived Life Satisfaction (Table 1). The KSP Socialization scale correlated negatively with self-reported performance burden and positively with perceived life satisfaction (Table 1). This suggests that the MDOs who reported negative interpersonal family experiences (Socialization) also reported more performance burden, and that they were less satisfied with their life situation than those who did not report such experiences. The KSP Somatic-anxiety scale correlated negatively with observed occupational performance and perceived life satisfaction, suggesting that subjects who reported restlessness (Somatic anxiety) also reported a low occupational performance and reported a lower satisfaction with life (Table 1). The KSP Psychic-anxiety and the

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Muscle-tension scales also correlated negatively with perceived life satisfaction indicating that subjects who reported less self-confidence, who worry easily (Psychic anxiety), and who had difficulties to relax (Muscle tension), reported less satisfaction with their life. The Psychastenia scale also correlated negatively with observed occupational performance and perceived life satisfaction (Table 1). This indicates that subjects who reported being easily fatigued and sensitive to time stress were observed to some extent to have obstacles performing occupations and reported a low satisfaction with life. The KSP Anxiety-proneness factor also correlated negatively with observed occupational performance and life satisfaction (Table 1). The two hostility scales, Suspicion and Guilt, correlated negatively with perceived life satisfaction (Table 1). This suggests that subjects who reported negative evaluations of people and events (Suspicion), and those who reported strong guilt feelings after doing wrong (Guilt) also to some extent reported lower perceived life satisfaction. The KSP Psychopathy factor correlated positively with self-reported performance burden and negatively with perceived life satisfaction (Table 1). This indicates that subjects with psychopathy reported more burden with performing occupations, and lower satisfaction with life than non-psychopaths.

Personality traits and occupational performance/life satisfaction: Multivariate regressions The predictability of occupational performance and life satisfaction on the basis of personality traits was studied by standard multivariate regression analyses. The standardized b-coefficients are presented in Table 1. These analyses showed that the KSP Somatic anxiety and Psychastenia scales together explained 14% of the ACLS variance (adjusted R2 /0.10, P /0.02). There were no significant standardized b-coefficients in these analyses.

Table 1. Correlations (r ) and standardized b-coefficients between seven scales and two factors of the Karolinska Scales of Personality (KSP), and occupational performance assessed by the Burden factor in the Capability to Perform Daily Occupations (CPDO), the Allen Cognitive Level Screen (ACLS), and perceived life satisfaction assessed by the Manchester Quality of Life Scale (MANSA; n /55). CPDO Burden KSP, seven scales and two factors Somatic anxiety Psychic anxiety Muscle tension Psychastenia Socialization Suspicion Guilt Psychopathy factor Anxiety-proneness factor

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0.35 /0.14 /0.20 /0.29 0.42$ /0.03 /0.04 /0.25 /0.34*

*P B/0.05; $P B/0.01. NORD J PSYCHIATRY ×VOL 59×NO 5×2005

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The analyses revealed that the Somatic-anxiety, Psychic-anxiety, Muscle-tension, Psychastenia, Socialization, Suspicion and the Guilt KSP scales together explained 39% (adjusted R2 /0.29, P /0.001) of the total MANSA score variance. Among these independent variables, only the Socialization scale had a significant bcoefficient (Table 1). Also, a combination of the Psychopathy and the Anxiety-proneness factors explained 27% (adjusted R2 /0.24, P B/0.0001) of the MANSA variance. Only the Anxiety-proneness factor’s b-coefficient was significant in predicting perceived life satisfaction (Table 1).

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Personality traits and occupational performance/life satisfaction: Univariate regressions In the univariate regression analyses, the KSP Socialization scale by itself explained 17% (adjusted R2 /0.15, P/0.002) of the shared variance in the CPDO Burden factor. The analyses also showed that the Psychopathy factor explained 9% of the CPDO Burden factor (adjusted R2 /0.07, P /0.01), and that the KSP Anxiety-proneness factor explained 10% of the ACLS variance (adjusted R2 /0.09, P /0.02; Table 1).

Comparisons between subjects with or without psychopathy There were no differences between subjects with (n/17) and those without (n/38) psychopathy with respect to occupational performance and perceived life satisfaction. Only three demographic variables differed between the groups. There were more subjects (54%) with psychopathy than subjects (46%) without, who were judged as having a Conduct Disorder (DSM-IV; chisquared/10.42, df/1, P /0.001). Also, there was a larger part of subjects with psychopathy (67%) than nonpsychopaths (33%) who had grown up in socially outcasted families (chi-squared/6.44, df /1, P /0.01). However, there was a smaller part of the subjects with psychopathy (45%) than without (55%) who had been subject to measures of pupil welfare activities in school (chi-squared /8.19, df/1, P /0.004).

Discussion The results illuminate the importance of KSP personality traits, i.e. socialization, anxiety proneneness and, to some extent, assessed psychopathy, for occupational performance and perceived life satisfaction among MDOs. The low scores of socialization imply that the negative upbringing influenced to what extent the MDOs reported occupations as a burden and negative life satisfaction as an adult. The high proneness for anxiety was related to the level of the occupational performance and perceived life satisfaction. Similar results regarding the KSP scores have been found in two different criminal samples by Sta˚lenheim & von

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Knorring (26) and Longato-Stadler (13). Interestingly, the MDOs with and those without psychopathic-related personality traits did not differ with respect to occupational performance or perceived life satisfaction, whereas there were differences in some demographic respects between these two groups. Not surprisingly, MDOs with KSP-defined psychopathy were reported to have had a DSM-IV conduct disorder before 15 years and more were grown up in socially outcasted families than were non-psychopathic subjects. However, the MDOs with psychopathy had, to a lower extent, been subjects in pupil welfare activities in schools. The present results are similar to those of Skodol et al. (39) and Seivewright et al. (5) in the sense that personality disorders are related to social dysfunction. Eklund et al. (6) reported that personality is strongly associated with the level of functioning and all aspects of psychological health in schizophrenia patients. In another study by Eklund et al. (7), it was demonstrated that personality determined the major part of perceived life satisfaction among schizophrenia outpatients. The main difference between the four samples of Skodol et al. (39), Seivewright et al. (5) and Eklund et al. (6, 7) and the present results is that only the MDOs have committed crimes. However, an important similarity is that they all suffer from severe mental disorders. A verification of already known facts is that life history is an important factor for the present population (40, 41). A deviant life history is one criterion for antisocial personality disorder (DSM-IV), and is also associated with a low socio-economic status during upbringing and adulthood. A present study, by using the KSP, demonstrates that having been brought up in outcasted families and having conduct disorders before 15 years can distinguish a psychopathic group from the non-psychopathic group. The present results indicate the other differences between these two groups: the subjects with psychopathy judged performance burden and life satisfaction lower than non-psychopaths. In general, the life history of the MDOs, and particularly for those who were characterized by psychopathy, is considered important for predicting adjustment in the community (1). The correlation coefficients were relatively low between the independent KSP scales and factors and the dependent variables in the prediction analyses. Also, the regression coefficients were low. Although other factors than personality traits are assumed also to influence occupational performance and life satisfaction among the MDOs, these relations may still be of specific importance. The validity of the present study can be questioned concerning the selection of the sample and the high attrition rate. This has also been thoroughly discussed elsewhere (19) for the original sample. Regarding the drop-outs, five were cared for in unknown places, 17 NORD J PSYCHIATRY×VOL 59 ×NO 5 ×2005

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PREDICTORS

subjects did not respond and 65 refusers (54% of total 161 eligible subjects), they can be considered as threats to the internal validity of the study. Therefore, according to Polit & Beck (42), available demographic characteristics were compared [e.g. age, main diagnoses, diagnoses of substance-related disorders, the scores on the Global Assessment of Functioning (GAF) the last year, and categories of psychosocial and environmental problems on Axis IV, the four last factors of the DSM-IV] between the drop-outs (n /87) and the participating subjects (n /74). There were no significant differences between the groups in this respect. Thus, the validity of the results can be considered as supported. Another methodological factor that may have affected the results is the way the KSP was administered. After the interview, the subject was asked to complete it by himself and to send it by letter. This procedure may have been the main reason why only 55 subjects of 74 returned the questionnaire. Attrition rates over 20% are of concern for sample biases (42). In the present study, 19 subjects (25%) were drop-outs. However, 55 subjects are 6.4% of the total estimated MDO population in Sweden at a certain point in time, which can be quite satisfactory supporting the external validity for the present study. This low number of subjects gave a low power in the regression analyses; however, since there were only three dependent variables, the results still can be trustworthy. The obtained results demonstrate that this forensic psychiatric population is heterogeneous and that occupational performance and perceived life satisfaction were found to be complex concepts. The present study points out some important predictors of occupational performance and life satisfaction among MDOs. The most intriguing results were that the MDOs’ life history in terms of the KSP Socialization scale and demographic variables were related to occupational performance and life satisfaction. Subjects with high anxiety proneness should be given attention in treatment planning.

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Helena Lindstedt, ROT, M.Sc., doctoral candidate, Department of Public Health and Caring Sciences, Uppsala University, Sweden. Anne So¨derlund, RPT, Ph.D., Department of Public Health and Caring Sciences, Uppsala University, Sweden. Gunilla Sta˚lenheim, M.D., Department of Neuroscience, Psychiatry, Uppsala University, Sweden. Per-Olow Sjo¨de´n, Ph.D., Professor, Department of Public Health and Caring Sciences, Uppsala University, Sweden.

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