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The relationship between aggression and serum thyroid hormone level in individuals diagnosed with antisocial personality disorder.

INTRODUCTION

Aggression is one of the diagnostic criteria of antisocial personality disorder (APD) ('). It is also among the symptoms of hyperthyroidism (2,3). There are few studies that indicate a correlation between serum thyroid hormone levels and aggression and tendency to commit a crime. The incidence of crime in individuals with high serum T3 levels is 3.8 times greater than that in those with normal serum T3 levels (4,5). The free T3 level of individuals with high aggression scores is more closer to the upper limit (6,7,8,9). After the application of high doses of anabolic androgenic steroids (AAS), an increase in serum free T4 and TSH levels and aggression was determined ('0). Testosterone, cortisol, and T4 levels were found to be significantly high in individuals exhibiting antisocial behavior (11).

Because of methodological problems, the results of some previous studies are controversial. There are no large-scaled and methodological studies examining the relationship between aggression and serum thyroid hormone levels in samples with antisocial personality disorder In APD, two subgroups were identified as aggression at the forefront and aggression not at the forefront. Perpetrators of violent crimes (murder mutilation, rape, arson, pugnacity, etc.) have been called "aggressive type (criminal)" Perpetrators of nonviolent crimes (theft, fraud, deceit, etc.) have been called "passive type (noncriminal)" ('2).

The aim of this study was to investigate the relationship between aggression and serum thyroid hormone levels in patients with APD. Additionally two sub-groups, "criminal" and "non-criminal" were defined according to crime history in the APD sample to compare this relationship between subgroups.

METHODS

Subjects

The sample group included APD patients who were admitted to the psychiatry polyclinic of a university hospital and who received inpatient or outpatient treatment in sequential order The inclusion criteria were as follows: being diagnosed with APD according to the DSM-IV-TR criteria, being between the ages of 20 and 30 years, having the necessary level of education to take the tests and participate in a structured interview (at least primary school graduates), and giving consent for the study The exclusion criteria were as follows: not giving consent for the study and having comorbid mental-physical illnesses. The control group consisted of healthy volunteers who met the inclusion criteria. Only men were included in the study to ensure the homogeneity of the group and avoid the hormonal effect of the menstrual cycle.

While defining the subgroups of APD, a classification was made based on the nature of the crime pattern. To distinguish between "criminal" and "noncriminal," the rough criteria were committing life-threatening crimes and felonies (armed attacks, grievous bodily harm, murder, arson, serious sexual assaults).

Gulhane Military Medical Academy Ethics Committee approval was received, and the study is in accordance with the Helsinki Declaration. The participants were given information about the study and their written consents were obtained. The study included a total of 100 APD patients and 100 healthy controls. Four APD patients and three healthy controls were excluded because it was found that they did not mark the test in accordance with the instructions. Impaired liver and renal function, autoimmune thyroid disease, and hormone levels outside the normal range were the exclusion criteria; however no participants were excluded because of these reasons. The study was completed with 96 APD patients and 97 healthy controls.

Instruments

Case Report Form: Questions were asked regarding sociodemographic information, alcohol/substance abuse, suicidal attempts, tattoos, self-mutilation, and criminal history Subjects who committed life-threatening crimes were defined by the "criminal" (n=49) subgroup; those who did not have a history of crime or who committed other crimes were defined by the "noncriminal" (n=47) subgroup.

Structured Clinical Interview for DSM-IV Axis 1 Disorders (SCID-1): This is a structured clinical interview form developed to accommodate the DSM-IV Axis 1 diagnosis. The Turkish translation of SCID-1 was used. The reliability and validity study of the Turkish translation was performed by Corapcioglu et al. (13)

Structured Clinical Interview for DSM-III-R Axis 2 Disorders (SCID-2): This is a structured clinical interview form developed to accommodate the DSM-III-R Axis 2 diagnosis. The reliability and validity study of the Turkish translation has been performed by Sorias et al. (14)

Buss-Perry Aggression Questionnaire (BPAQ): This consists of 34 items. The conditions described in the items question five sub-forms of aggression (physical aggression, verbal aggression, anger, hostility, and indirect aggression). It is a five-point Likert-type self-assessment scale. The validity and reliability study of this scale in our country has been performed by Can (15).

Procedure

Individual interviews were conducted with the patients. During this interview, SCID 1-2 and the Buss-Perry Aggression Questionnaire were applied. After overnight fasting, blood samples were taken between 7:00 and 9:00 a.m. TSH, free T3, free T4, AntiTPO, and AntiTG levels were tested. Additionally tests for evaluating the steps known to have an effect on production, emissions, and the destruction processes of hormones were also performed to exclude confounding factors that may affect thyroid hormone metabolism (GH, ACTH, free testosterone, total testosterone, DHEA-S, cortisol, albumin, AST ALT GGT creatinine).

Statistical Analysis

Frequency distributions were calculated for descriptive statistics, and mean and standard deviation were calculated for continuous variables. The results were presented as mean [+ or -] standard deviation. Relationships between qualitative data were evaluated by chi-square test. While investigating the differences between the two groups, the t-test was used for data that conformed to a normal distribution, and the Mann-Whitney U test was used for data that did not conform to a normal distribution. a=0.05 was chosen as the error level, and p values less than or equal to this value were interpreted as "statistically significant differences."

RESULTS

Forty-nine of the APD patients (51%) were defined as "criminal" and 47 (49%) as "noncriminal." When the sociodemographic characteristics of the APD and control groups were assessed, significant differences were found in terms of age, education, substance-alcohol abuse, self-mutilation, tattoos, and suicide attempts. The number of single men among the controls was significantly higher than that in the APD group. Substance-alcohol abuse, self-mutilation, tattoos, and suicide attempts were not found in the control group (Table 1). When the sociodemographic characteristics of criminal and noncriminal APD patients were assessed, significant differences were not found in terms of age, education, and suicide attempts. Although no significant difference was detected, it was notable that the likelihood of being a criminal decreased with increasing education levels. The number of single men in the noncriminal APD group was significantly higher than that in the criminal APD group. In the criminal APD group, substance-alcohol usage, self-mutilation, and tattoos were more common than in the noncriminal APD group (Table 2).

When the aggression scores of APD and control groups were examined according to the BPAQ, total and subscale scores were significantly higher in the case group (Table 3). BPAQ, total, and subscale scores were found to be significantly higher in the criminal group than in the noncriminal group (Table 4).

While the free T4 and cortisol levels of the case group were significantly higher than those of the control group, the free T3 level of the case group was lower than that of the control group. There were no differences between the case group and the control group in terms of TSH, free testosterone, and total testosterone levels (Table 5). Serum free T3 levels were significantly higher in the criminal APD group than in the noncriminal APD group. There were no differences between the case group and the control group in terms of free T4, TSH, cortisol, free testosterone, and total testosterone levels (Table 6).

When the relationships between aggression and hormone levels were analyzed by two-tailed Pearson correlation test in the APD group, it was found that BPAQ total (r=0.363, p<0.00l) and subscale scores [(physical aggression: r=0.347, p=0.00l), (verbal aggression: r=0.227, p=0.026), (anger: r=0.398, p<0.00l), (hostility: r=0.403, p<0.00l), (indirect aggression: r=0.324, p=0.00l)] increased with increasing serum free T3 level.

When the same analysis was performed with the control group, it was found that as TSH levels increased, BPAQ total (r=-0.204, p=0.045) and verbal subscale scores (r=-0.358, p<0.00l) decreased. Another finding was that BPAQ total (r=-0.21 8, p=0.032), physical aggression subscale (r=-0.221, p=0.030), and verbal aggression subscale scores (r=-0.332, p=0.00l) decreased as free testosterone levels increased.

In the noncriminal APD group, although serum free T3 levels increased, BPAQ total (r=0.507, p<0.00l) scores decreased. Similarly it was found that five subscale scores also increased [(physical aggression: r=0.505 p<0.001), (verbal aggression: r=0.293, p=0.045), (anger: r=0.571, p<0.00l), (hostility: r=0.524, p<0.001), (indirect aggression: r=0.509, p=0.001)]. In the same group, it was found that participants with high serum free T4 levels had higher BPAQ total scores (r=0.371, p=0.010). It was found that BPAQ subscale scores increased with increasing free T4 levels [(physical aggression: r=0.355, p=0.014), (verbal aggression: r=0.389, p=0.007), (anger: r=0.349, p=0.016), (hostility: r=0.426, p=0.003)]. There was no significant relationship between BPAQ indirect aggression score and free T4 level.

It was notable that there was no significant correlation between hormone levels and BPAQ total aggression scores in the noncriminal group. However there was an opposite correlation, but it was not statistically significant.

DISCUSSION

Significantly more frequent substance-alcohol abuse, self-mutilation, tattoos, and suicide attempts as well as significantly more married cases and significantly lower levels of education were found in the APD group; these are expected findings that are consistent with the general characteristics of APD (16). The high mean age in the APD group was thought to stem from imprisonment.

The lack of a significant difference between the criminal and noncriminal groups in terms of age, education, and suicide attempts has been interpreted as an indication of intragroup homogeneity The free T4 and cortisol levels of the case group were found to be significantly higher than those of the control group, whereas the free T3 level was lower This finding was compatible with some study results but not with some others.

The reasons for these discrepancies may include the following: Some of the studies have very small sample sizes (5,6,7,8,9). A diagnostic distinction has not been made in some of the studies (4,9). The reliability of the data obtained from studies not using a healthy control group is controversial (9). The results obtained from studies with samples of psychotic prisoners (5), non-psychotic prisoners (6,7,8), and veterans (11) do not reflect the conditions in the APD sample. Different scales were used in some of the studies. Different findings may have arisen in studies conducted in different societies because of differences in culture-specific characteristics and judgments of society. Our study is important because it is the first study that examines thyroid functions in APD samples.

The mean free and total testosterone levels of the APD group were found to be higher than those of the control group. The testosterone-aggression relationship has been investigated and demonstrated by numerous studies (17). Aggressiveness increases with the use of testosterone analogs. It is not clearly known whether anabolic androgenic steroids increase aggressiveness directly by testosteronergic effects or by raising thyroid hormone levels (10). Significant differences in terms of free and total testosterone were not found between the criminal and noncriminal groups. In the criminal group, it was remarkable that the mean values of the hormones mentioned above were lower No data are available to compare this finding. In APD patients and other people with cluster B personality traits, novelty seeking, impulsivity, and aggression are high. High levels of novelty seeking have been associated with mesolimbic and mesocortical dopaminergic hyperactivity (16). Our finding suggests that aggression does not only occur due to testosterone but also other mechanisms such as dopaminergic mechanisms play a role in the formation of aggression.

When the correlation between hormone levels and aggression scores was examined in the case group, it was found that the aggression scale scores increased with increasing free T3 levels. Many previous studies focused on the differences between the mean values. A correlation analysis that --questions the causal relationship between the two variables was not per formed in these studies (6,7,8,9). The positive correlation found in our study suggests that free T3 levels play an important role in the formation of aggression. Even if free T3 levels do not indicate hyperthyroidism and remains within the normal range, it seems to be effective in causing aggression. Lithium is effective in the treatment of aggression (18). The effect of lithium may be to either directly or indirectly slow thyroid function. This finding needs to be replicated by other studies investigating the drugs used in the treatment of hyperthyroidism, such as propylthiouracil and methimazole, on aggressive people.

In the control group, a negative relationship between testosterone and aggression was found; however, it is noteworthy that this relationship was not generally found in antisocial patients and their subgroups. This finding is consistent with some research results (19,20) and not with others (7,10,21). Our finding suggests that neurobiological processes other than testosterone play a role in the formation of aggression. In both healthy individuals and individuals with APD, the effect of testosterone on aggression may develop through different pathways.

In the noncriminal APD subgroup, aggression scores were found to increase with increasing serum free T3 and free T4 levels. Although aggression increases with increasing serum thyroid hormone levels, a lack of violent behavior may be associated with high reward dependence. High reward dependence is associated with serotonergic pathways in the median raphe nucleus and noradrenergic pathways in the ceruleus (16). In addition to thyroid hormones, serotonergic and noradrenergic transmission is effective in the formation and type of aggression. In the criminal APD subgroup, a significant correlation was not detected between hormone levels and BPAQ aggression scores. Although it is not statistically significant, a negative correlation is a significant finding. It is noteworthy that although the criminal subgroup has higher mean T3 levels than the noncriminal subgroup, there was no significant correlation with aggression scores. This finding is important because it indicates that factors other than thyroid hormones may play a role in the aggression of criminals, and there may be many determinants of aggression and violent behavior (22).

In conclusion, these data gave the impression that the criminal and non-criminal groups represent two different groups sociodemographically and biologically. In the literature, although there are studies comparing APD cases with healthy individuals, these studies do not include detailed comparisons in terms of sociodemographic, clinical, and hormonal characteristics of the cases by defining subgroups. This condition prevents further comments; however in the present study it shall be considered that the data may have been interpreted differently. Detailed studies on this topic are needed. The findings suggest a relationship between thyroid hormone levels and aggression in the APD sample. Because of the lack of objective criteria defined by the International Classification System in the discrimination of criminal and non-criminal subgroups of APD, the study sample may not be sufficiently large to reflect the subgroups properly. In terms of the distinction criteria used in this study, a participant who was not a criminal during the study might become a criminal if he committed a felony later Therefore, generalization cannot be made with these findings. Studies with larger samples, questioning personality traits with psychometric tests, and using more objective criteria to distinguish the criminality of APD cases are needed. These studies will not only shed light on this subject but will also contribute to the control of aggression.

DOI: 10.5152/npa.2015.9895

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

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Alper EVRENSEL [1], Baris Onen UNSALVER [1], Aytekin OZSAHIN [2]

[1] Department of Electroneurophysiology, Uskudar University Faculty of Health Sciences, Istanbul, Turkey

[2] Department of Psychiatry, Gulhane Military Medical Academy, Ankara, Turkey

Correspondence Address: Alper Evrensel, Uskudar Universitesi Saglik Bilimleri Fakultesi, Elektronorofizyoloji Bolumu, Istanbul, Turkiye

E-mail: alperevrensel@gmail.com

Received: 31.07.2014 Accepted: 28.12.2014
Table 1. Sociodemographic characteristics
of APD patients and control group

                          APD n=96     Control
                                      group n=97

Sociodemographic          n     %      n     %
characteristics

Marital status

  Married                36    85.7    6    14.3
  Single                 60    39.7   91    60.3

Education level

  University              2    8.3    22    91.7
  High School            24    38.1   39    61.9
  Secondary              16    48.5   17    51.5
  Primary                39    69.6   17    30.4
  Early school leaving   15    88.2    2    11.8

Alcohol abuse

  Yes                    51    100     0     0
  No                     45    31.7   97    68.3

Substance abuse

  Yes                    71    1 00    0     0
  No                     25    20.5   97    79.5

Self harm

  Yes                    58    100     0     0
  No                     38    28.1   97    71.9

Tattoo

  Yes                    36    100     0     0
  No                     60    38.2   97    61.8

Suicide attempt

  Yes                    56    100     0     0
  No                     40    29.2   97    70.8

Age

  23 years and under     48    39.0   75    61.0
  Over 23 years          48    68.6   22    31.4

                         Total n=193   Statistical analysis

Sociodemographic          n      %     [chi square]      p
characteristics

Marital status

  Married                 42    21.8      27.788      <0.001 *
  Single                 151    78.2

Education level

  University              24    12.4      37.519      <0.001 *
  High School             63    32.6
  Secondary               33    17.1
  Primary                 56    29.0
  Early school leaving    17    8.8

Alcohol abuse

  Yes                     51    26.4      70.039      <0.001 *
  No                     142    73.6

Substance abuse

  Yes                     71    36.8     1 13.490     <0.001 *
  No                     122    63.2

Self harm

  Yes                     58    30.1      83.782      <0.001 *
  No                     135    69.9

Tattoo

  Yes                     36    18.7      44.716      <0.001 *
  No                     157    81.3

Suicide attempt

  Yes                     56    29.0      79.712      <0.001 *
  No                     137    71.0

Age

  23 years and under     123    63.7      15.579      <0.001 *
  Over 23 years           70    36.3

* p<0.05. APD: antisocial personality disorder

Table 2. Sociodemographic characteristics of criminal
and noncriminal APD patients

                          Criminal      Noncriminal
                            n=49           n=47

Sociodemographic          n      %      n       %
characteristics

Marital status

  Married                25    69.4    11     30.6
  Single                 24    40.0    36     60.0

Education level

  University              0      0      2      100
  High School            10    41.7    14     58.3
  Secondary               9    56.3     7     43.8
  Primary                20    51.3    19     48.7
  Early school leaving   10    66.7     5     33.3

Alcohol abuse

  Yes                    32    62.7    19     37.3
  No                     17    37.8    28     62.2

Substance abuse

  Yes                    46    64.8    25     35.2
  No                      3    12.0    22     88.0

Self harm

  Yes                    43    74.1    15     25.9
  No                      6    15.8    32     84.2

Tattoo

  Yes                    28    77.8     8     22.2
  No                     21    35.0    39     65.0

Suicide attempt

  Yes                    33    58.9    23     41.1
  No                     16    40.0    24     60.0

Age

  23 years and under     22    45.8    26     54.2
  Over 23 years          27    56.3    21     43.8

                         Total n=96    Statistical analysis

Sociodemographic          n      %     [chi square]      p
characteristics

Marital status

  Married                36    37.5       7.806       0.005 *
  Single                 60    62.5

Education level

  University              2     2.1       2.872        0.090
  High School            24    25.0
  Secondary              16    16.7
  Primary                39    40.6
  Early school leaving   15    15.6

Alcohol abuse

  Yes                    51    53.1       5.964       0.015 *
  No                     45    46.9

Substance abuse

  Yes                    71    74.0       20.619      0.001 *
  No                     25    26.0

Self harm

  Yes                    58    60.4       31.279      0.001 *
  No                     38    39.6

Tattoo

  Yes                    36    37.5       16.477      0.001 *
  No                     60    62.5

Suicide attempt

  Yes                    56    58.3       3.345        0.067
  No                     40    41.7

Age

  23 years and under     48     50        1.042        0.307
  Over 23 years          48     50

* p<0.05. APD: antisocial personality disorder

Table 3. Total and subscale scores of the Buss-Perry
Aggression Questionnaire of APD patients and control group

Buss-Perry aggression             APD               Control group
questionnaire             (Mean [+ or -] SD)      (Mean [+ or -] SD)
                                 n=96                    n=97

Total score              109.07 [+ or -] 38.76   72.02 [+ or -] 15.98

Physical                 27.32 [+ or -] 11.48    16.10 [+ or -] 6.04
Aggression Subscale

Verbal                    16.28 [+ or -] 6.01    12.15 [+ or -] 3.06
Aggression Subscale

Anger Subscale            22.54 [+ or -] 7.68    14.97 [+ or -] 4.77

Hostility Subscale        26.46 [+ or -] 9.16    18.27 [+ or -] 5.06

Indirect                  16.67 [+ or -] 6.73    10.53 [+ or -] 2.51
Aggression Subscale

Buss-Perry aggression         Statistical
questionnaire                  analysis
                            t/z        P *

Total score               8.69 (t)   <0.001 *

Physical                 -6.68 (z)   <0.001 *
Aggression Subscale

Verbal                   -4.66 (z)   <0.001 *
Aggression Subscale

Anger Subscale           -6.75 (z)   <0.001 *

Hostility Subscale        7.69 (t)   <0.001 *

Indirect                 -5.81 (z)   <0.001 *
Aggression Subscale

* p<0.05, (t): t test, (z): Mann-Whitney U test.
APD: antisocial personality disorder; SD: standard deviation

Table 4. Total and subscale scores of the Buss-Perry Aggression
Questionnaire of criminal and noncriminal APD patients

Buss-Perry                   Criminal               Noncriminal
aggression              (Mean [+ or -] SD)      (Mean [+ or -] SD)
questionnaire                  n=49                    n=47

Total score            125.76 [+ or -] 29.61    91.68 [+ or -] 39.77

Physical Aggression     32.80 [+ or -] 8.94     21.62 [+ or -] 11.12
Subscale

Verbal Aggression       18.78 [+ or -] 5.18     13.68 [+ or -] 5.75
Subscale

Anger Subscale          25.39 [+ or -] 6.62     19.57 [+ or -] 7.65

Hostility Subscale      29.86 [+ or -] 6.52     22.91 [+ or -] 10.19

Indirect Aggression     19.49 [+ or -] 5.86     13.53 [+ or -] 6.26
Subscale

Buss-Perry             Statistical analysis
aggression                t/z         P *
questionnaire

Total score             4.77 (t)      0.03 *

Physical Aggression     -4.0 (z)    <0.001 *
Subscale

Verbal Aggression      -4.27 (z)    <0.001 *
Subscale

Anger Subscale         -3.83 (z)    <0.001 *

Hostility Subscale      3.99 (t)    <0.001 *

Indirect Aggression    -4.40 (z)    <0.001 *
Subscale

* p<0.05, (t): t test, (z): Mann-Whitney U test.
APD: antisocial personality disorder; SD: standard deviation

Table 5. Hormone levels of APD patients and control groups

Hormones                       APD                 Control group
                        (Mean [+ or -] SD)       (Mean [+ or -] SD)
                               n=96                     n=97

Free T3                 3.52 [+ or -] 0.47       3.86 [+ or -] 0.36
Free T4                 1.28 [+ or -] 0.21       1.23 [+ or -] 0.14
TSH                     1.72 [+ or -] 0.94       1.97 [+ or -] 1.17
Cortisol               13.73 [+ or -] 3.03      10.28 [+ or -] 4.02
Free testosterone      27.05 [+ or -] 8.20      22.95 [+ or -] 8.26
Total testosterone    631.52 [+ or -] 146.66   525.23 [+ or -] 130.08

Hormones              Statistical analysis

                         t/z         p *

Free T3               -5.63 (t)    0.004 *
Free T4                2.10 (t)    0.044 *
TSH                   -1.78 (z)    0.074
Cortisol               6.72 (t)    0.003 *
Free testosterone      3.46 (t)    0.848
Total testosterone     5.32 (t)    0.541

* p<0.05, (t): t test, (z): Mann-Whitney U test.
APD: antisocial personality disorder; SD: standard deviation

Table 6. Hormone levels of criminal and noncriminal APD patients

Hormones                    Criminal               Noncriminal
                       (Mean [+ or -] SD)       (Mean [+ or -] SD)
                              n=49                     n=47

Free T3                3.60 [+ or -] 0.37       3.44 [+ or -] 0.55
Free T4                1.31 [+ or -] 0.26       1.25 [+ or -] 0.13
TSH                    1.72 [+ or -] 0.79       1.72 [+ or -] 1.08
Cortisol              13.94 [+ or -] 3.21      13.52 [+ or -] 2.85
Free testosterone     26.41 [+ or -] 8.81      27.71 [+ or -] 7.56
Total testosterone   628.97 [+ or -] 174.12   634.18 [+ or -] 113.01

Hormones             Statistical analysis

                        t/z        p *

Free T3              1.62 (t)    0.002 *
Free T4              1.44 (t)     0.112
TSH                  -0.51 (z)    0.610
Cortisol             0.67 (t)     0.368
Free testosterone    -0.77 (t)    0.296
Total testosterone   -0.1 (t)     0.132

* p<0.05, (t): t test, (z): Mann-Whitney U test.
APD: antisocial personality disorder; SD: standard deviation
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Title Annotation:Research Article
Author:Evrensel, Alper; Unsalver, Baris Onen; Ozsahin, Aytekin
Publication:Archives of Neuropsychiatry
Article Type:Report
Date:Jun 1, 2016
Words:4581
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