The Standardized Assessment of Personality-Abbreviated Scale as a screening instrument for personality disorders in substance-dependent criminal offenders.

Personality and Mental Health (2012) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI 10.1002/pmh.1212

The Standardized Assessment of Personality— Abbreviated Scale as a screening instrument for personality disorders in substance-dependent criminal offenders

BRIGITTE P. M. JANSEN, KATINKA F. M. DAMEN, TONKO O. HOFFMAN AND SIETSKE L. VELLEMA, Triple-Ex & Remise, Palier, Parnassiabavogroup, The Hague, The Netherlands ABSTRACT Personality disorders (PDs) are considered to be potential predictors of treatment outcome in substance-dependent patients and potential treatment matching variables. There is a need for a brief and simple screening instrument for PDs that can be used in routine psychological assessment, especially in a treatment setting for previously substancedependent criminal offenders, where a high prevalence of PDs is expected. This study investigated the psychometric properties of the Standardized Assessment of Personality—Abbreviated Scale (SAPAS), a commonly used screening interview for PDs, in a population of inpatient criminal offenders with a history of substance dependence. Various statistical procedures were used to establish reliability and validity measures, such as Kuder–Richardson 20, confirmative factor analysis, receiver operating characteristic analysis and multitrait multimethod matrix. The SAPAS was administered to 101 inpatient criminal offenders with a history of substance dependence at baseline. Within three weeks, participants were administered the Structured Interview for DSM-IV Personality in order to assess the presence of PDs. Results show limited evidence to make firm conclusions on the psychometric qualities of the SAPAS as a screening instrument for comorbid PDs in a substance dependence treatment setting for criminal offenders. Suggestions for improvement concerning the psychometric qualities of the SAPAS as a screening instrument for this population are noted. Copyright © 2012 John Wiley & Sons, Ltd. In the Netherlands, a group of 18 000 to 19 000 substance (alcohol and drugs)-dependent criminal offenders is regularly arrested by the police for a range of violations (Arts & Ferwerda, 2007). This group of substance-dependent offenders cost the Dutch society about 500 000 euros per person per year (RobzQ, 2003). The Dutch Government and local authorities therefore facilitate initiatives, which reduce these costs. In order to treat the substance dependence and to prevent relapse, this

Copyright © 2012 John Wiley & Sons, Ltd.

group of offenders is admitted to treatment facilities specialized in the treatment of substance dependence and criminal behaviour. Many of these substance-dependent criminal offenders suffer from severe personality pathology (Pluck, Sirdifield, Brooker, & Moran, 2012; Verheul, 1997). It is estimated in various international studies that the prevalence of personality disorders (PDs) among substance-dependent criminal offenders is on average three to six times higher than in

(2012) DOI: 10.1002/pmh

B. P. M. Jansen et al.

the common population (Pluck et al., 2012; Verheul, Ball, & van den Brink, 1998): 74.0–56.5% (Multidisciplinary Guideline Personality Disorders, 2008; Verheul, 1997) vs. 13.5% (Emmelkamp & Kamphuis, 2007; Multidisciplinary Guideline Personality Disorders, 2008; Verheul, 2001). Patients with substance dependence and one or more PDs enter treatment with more severe selfreported drug, alcohol, psychiatric and legal problems (Compton, Cottler, Jacobs, Ben-Abdallah, & Spitznagel, 2003). They also tend to have serious problems in perception, cognition, affect and interpersonal behaviour and show a higher treatment dropout (Verheul, 1997). This comorbidity can interfere with the treatment of the substance dependence of these patients (Blackburn, 2000; Coid, 2005; Emmelkamp & Kamphuis, 2007; Hesse, Rasmussen, & Pedersen, 2008) and is an important indicator of future recidivism (Pluck et al., 2012). Despite improvement of the level of functioning during treatment for substance dependence, patients with substance dependence pathology and PDs remain having more drug, alcohol, psychiatric and legal problems in comparison with patients with substance dependence pathology without PDs (Compton et al., 2003). The aforementioned difficulties support emphasis on both the substance dependence and personality pathology in the treatment of substance-dependent criminal offenders (Damen, 2005; Hesse et al., 2008; Multidisciplinary Guideline Personality Disorders, 2008). A reliable and valid assessment of comorbid PDs is a first step to administer appropriate treatment. A reliable and valid assessment can be obtained with structured interviews but can be very time consuming and therefore expensive (Pluck et al., 2012). Less time-consuming methods such as self-report inventories or screening instruments tend to overestimate the number of PDs and have not been validated for substance-dependent populations (Hesse et al., 2008). A combination of screening instruments with structured interviews in which the structured interview is administered only to patients with positive scores on the screening instrument can contribute to the improvement of effectiveness


and efficiency of both assessment and treatment. The development of a reliable and valid screening instrument to identify personality pathology could enhance the efficiency of assessment procedures by reducing the number of more time-consuming, structured interviews that clinicians are required to complete (Damen, 2005; Hesse et al., 2008). Several screening instruments for PDs are available, for example the Personality Diagnostic Questionnaire for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association (APA), 1994; PDQ-4, PDQ-4+; Hyler, 1994), the Rapid Personality Assessment Schedule (van Horn, Manley, Leddy, Cicchetti, & Tyrer, 2000), the screening version of the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (First, Gibbon, Spitzer, Williams, & Benjamin, 1997), International Personality Disorder Examination (Loranger et al., 1994) and the Standardized Assessment of Personality—Abbreviated Scale (SAPAS; Moran et al., 2003). These screening instruments are standardized self-report questionnaires or interviewer-administered screening instruments based on criteria for Axis II of the DSM-IV (APA, 1994). On the basis of the results of the study by Moran et al. (2003), the Parnassiabavogroup chose the SAPAS as a screening instrument for PDs. The SAPAS is a very short interview consisting of eight questions (see Appendix for the individual items). The study results of Moran et al. (2003) showed promising results for the validity and reliability of the SAPAS: the sensitivity and specificity were good, 0.94 and 0.85 respectively. In 90% of the research population, the existence of one or more DSM-IV PDs was correctly identified with the SAPAS.1 The study also provided preliminary evidence of the usefulness of the SAPAS in routine clinical settings (Moran et al., 2003). Hesse et al. (2008) investigated the validity and reliability of the SAPAS in a sample of 58 methadone maintenance patients in Denmark. The internal Note that the SAPAS is sensitive for ‘any’ diagnosis on Axis II; it does not differentiate between the separate PDs. 1

(2012) DOI: 10.1002/pmh

The SAPAS as personality disorder screening instrument in substance-dependent offenders

consistency was modest (alpha = 0.62). The test– retest correlation at four months was moderately encouraging (n = 31, intraclass correlation coefficient = 0.58). They concluded that the SAPAS is a modestly valid and modestly reliable screening instrument for PDs in patients with ongoing substance abuse. Germans, van Heck, Moran, and Hodiamont (2008) studied the internal consistency, test–retest reliability and validity of the Self-report SAPAS (SAPAS-SR) in a random sample of 195 Dutch psychiatric outpatients. The SAPAS-SR correctly identified 81% of all participants with PDs. The sensitivity and specificity were 0.83 and 0.80 respectively. They concluded that the results provide evidence for the usefulness of the SAPAS as a self-administered screening instrument for PDs in clinical populations. Pluck et al. (2012) investigated the psychometric properties of the SAPAS in a sample of 40 offenders on probation. They found a cut-off score of 3 out of 8, producing a good balance of sensitivity (0.73) and specificity (0.90), and concluded that the SAPAS is a valid screening instrument for PDs among offenders on probation. According to Damen (2005), the content of screening instruments should be attuned to the patient population for which it is used. Moran and Hesse (2010) showed in their study that the SAPAS appears to perform less well as a screening instrument for the antisocial PD. In a population of substance-dependent criminal offenders in a residential setting, a high prevalence of PDs (Pluck et al., 2012), especially the antisocial PD, is expected; therefore, it is important to investigate the psychometric properties of the SAPAS in this particular population. Method

criminal offenders with substance dependence is widespread, but not easily attainable for research, because of imprisonment, ongoing substance abuse and dropout issues. In the environment in which this study took place, participants were abstinent, admitted for several months and resided in an environment that aimed to promote safety and positive engagement with interventions. At the start of the study, every patient in the facility was asked to participate. Participation was voluntary. Every new patient was given the same verbal and written information of the study and asked to participate at admission in the facility. All participants were recruited after detention. Participants were admitted to a drug-free modified therapeutic community that specializes in residential treatment of substance dependence in combination with criminal behaviour and personality pathology. The treatment is based on cognitive behavioural therapy and the treatment method of the therapeutic community (De Leon, 1997, 2000). Inpatient treatment was provided for substance dependence and related issues such as enhancement of social skills, regulation of aggression, cessation of criminal behaviour and psychosocial problems regarding work, finance, family and housing. The severity of the addiction and related problems were assessed by the Addiction Severity Index (ASI; Hendriks, Kaplan, van Limbeek, & Geerlings, 1989; McLellan et al., 1985). Patients admitted for treatment had a wish for abstinence, met the criteria for one or more substance abuse disorders of the DSM-IV (APA, 1994) and were free of drugs and alcohol. Approval for the design of the study was obtained from the medical ethical review board for the mental health care in the Netherlands (Medisch Etische Toetsingscommissie voor de GGz), an independent medical ethical review board in Utrecht.

Participants

Measures

A convenience sample was used. It consisted of 101 criminal offenders with substance dependence admitted to a drug-free inpatient hospital of Palier of the Parnassiabavogroup. The population of

Standardized Assessment of Personality—Abbreviated Scale (Moran et al., 2003). The SAPAS consists of eight dichotomously rated items taken from the opening section of the Standardized Assessment of


(2012) DOI: 10.1002/pmh


Personality (SAP; Mann, Jenkins, Cutting, & Cowen, 1981; Pilgrim & Mann, 1990). The SAP allows an International Classification of Diseases version 2010 or DSM-IV diagnosis of PD to be made (APA, 1994; World Health Organization, 1992). Each of the items corresponds to a descriptive statement about the person and can be scored 0 (not present) or 1 (present). The scores on the eight items can be summed to produce a total score between 0 and 8, with a cut-off score, which marks the boundary between ‘no PD’ and ‘one or more PDs’, of three positive answers. It only provides information on the presence of PDs and does not provide specific information on subtypes of PD. Moran et al. (2003) investigated the reliability and validity of the SAPAS and provided preliminary evidence of the usefulness of the SAPAS in routine clinical settings. A score of three positive answers gave the highest sensitivity of 0.94 and specificity of 0.85. In 90% of the research population, the existence of one or more DSM-IV PDs was correctly identified with the SAPAS. Structured Interview for DSM-IV Personality (Pfohl, Blum, & Zimmerman, 1995). In this study, the Dutch version of a semi-structured interview on PDs, the Structured Interview for DSM-IV Personality (SIDP-IV; de Jong, Derks, van Oel, & Rinne, 1996), was used for the assessment of PDs. The structure of the SIDP-IV can be compared with the structure of the Structured Interview for DSM-III Personality (SIDP; Pfohl, Stangl, & Zimmerman, 1983) and the Structured Interview for DSM-III-R Personality (Pfohl, Blum, Zimmerman, & Stangl, 1989) and addresses personality characteristics covering a period of five years preceding the interview. The SIDP-IV assesses the PDs on Axis II of the DSM-IV (APA, 1994). The fourth edition of the SIDP contains two optional disorders: depressive and negativistic PD, which have yet to be psychometrically evaluated for their reliability and validity. Each criterion is rated with a score ranging from 0 to 3: 0 = not present, 1 = almost present, 2 = present or 3 = strongly present. For each PD,


the number of criteria rated as present (criteria rated 2 or 3) determines the presence of the disorder (de Jong et al., 1996). In addition to the calculation of categorical scores for various disorders, a dimensional profile can be derived from the criterion scores. In a study of the reliability and validity of the SIDP-IV in a Dutch opioid-dependent patient sample, the interrater reliability of the SIDP-IV was found to be excellent with kappa ranging from 0.76 to 0.93 at a criterion level and kappa ranging from 0.66 to 1.00 at a diagnostic level (Damen, de Jong, & van der Kroft, 2004). The construct validity, the diagnostic efficiency and internal consistency were good. Values for sensitivity, specificity and negative predictive power were also found to be good (Damen, de Jong, Breteler, & van der Staak, 2005). Addiction Severity Index (Hendriks et al., 1989; McLellan et al., 1985). The ASI is a European adaptation of the ASI of McLellan et al. (1985) and is a widely accepted multidimensional structured instrument for assessment of substance abusers in clinical practice and research. It covers a broad range of domains that could be affected by substance abuse and/or substance abuse treatment, that is, medical, employment, alcohol, drug, legal, family/social and psychiatric problems. A severity rating (range: 0–9) per section gives the interviewer’s estimate of both the problem severity and the patient’s need for additional treatment (Damen, 2005; Hendriks et al., 1989; McLellan et al., 1985; Verheul, 1997). ASI dimensional measures have acceptable psychometric qualities (Damen, 2005). In this study, the ASI was used for description of the demographic variables. Procedure Participants were recruited from January 2007 to July 2008. The sample consisted of 101 patients (66.9% of all patients in treatment in the period of January 2007 to July 2008). Exclusions were a result of nonnative language (N = 3; 2.0%), refusal of participation (N = 8; 5.3%) and dropout before

(2012) DOI: 10.1002/pmh


completion of the SIDP-IV (N = 17; 11.3%), SAPAS (N = 11; 7.3%) or any test (N = 11; 7.3%). The included patients were a representative sample of criminal offenders with substance dependence treated in this facility. Once admitted, one of the clinicians (nurse, psychologist or social worker) interviewed the patients with the SAPAS as part of routine clinical assessment. This occurred as soon as possible after admission of the patient (0–14 days after admission), but at least one month after detoxification, in order to control for detoxificationrelated stress. Within three weeks after assessment with the SAPAS, the patient was interviewed with the SIDP-IV by a trained independent psychologist. These psychologists were blind with respect to the results of the SAPAS. The four SIDP-IV interviewers all had a Master Degree in Clinical Psychology and extensive experience in psychological testing and treatment of substance dependence. Prior to this study, they followed a two-day SIDP-IV training course. During the study, the interviewers contacted the SIDP-IV trainer who had extensive experience in psychological testing and treatment of substance dependence, with problems or questions about the scoring of the SIDP-IV in order to enhance interrater reliability. The ASI, SAPAS and SIDP-IV were part of the regular assessment procedure in the facility. The results were coded and saved in the electronic patient file of the participant. The research data were processed and analysed anonymously at sample level. Analysis Confirmative factor analysis (CFA) was used to evaluate the factor model of the SAPAS using Structural Equation Modelling (SEM) in EQS (Bentler, 1995). CFA is an advanced method to propose a theoretical model about covariances or correlations (i.e. the loading of particular observed variables on particular factors) and to compare this model with observed covariances or


correlations using tests of goodness of fit. Adequate goodness of fit was considered using chi-square, confirmatory fit index and root mean square error of approximation (RMSEA) according to Bollen (1989) and Hu and Bentler (1999). In this paper, the fit of a one factor model was considered for the SAPAS and was assumed to measure a general factor of PD. In the CFA, tetrachoric correlations were used because of the assumption that latent continuous variables existed underlying the observed binary items of the SAPAS. Tetrachoric correlations were calculated using ‘Statistics and data’ (Stata SE 9.2; StataCorp., 2005). According to Corten et al. (2002), tetrachoric correlations are, however, not always profitable; therefore, the results were confirmed using product–moment correlation coefficients. To identify an optimal cut-off for a diagnosis of PD, two methods were used: a receiver operating characteristic (ROC) analysis and the calculation of sensitivity and specificity at several cut-off scores. Sensitivity corresponds to the proportion of correctly identified patients with PDs, and specificity corresponds to the proportion of correctly identified patients without a PD. Good psychometric properties of the SAPAS are reflected in high sensitivity and specificity. The ROC curve is a plot of ‘1-specificity’ of the SAPAS on the x-axis against its ‘sensitivity’ on the y-axis for all possible cut-off points. The area under this curve (AUC) represents the overall accuracy of the SAPAS with a value approaching 1.0, indicating a high sensitivity and specificity, and a value of 0.5, indicating a test that is no better than a random instrument. The predictive validity corresponds to the extent to which a score on the SAPAS predicts scores on the SIDP-IV and was assessed using a 2 2 chisquare test. In this test, the agreement of both instruments concerning the positive and negative identification of a PD was evaluated. The convergent validity is the extent to which the SAPAS correlates with the SIDP-IV and was evaluated using the multitrait multimethod (MTMM; Campbell & Fiske, 1959). The MTMM is a review of a matrix with correlations and

(2012) DOI: 10.1002/pmh


reliabilities. In this respect, commonly proposed criteria for judging and interpreting values were used. Significance was determined using nominal alpha (p ≤ 0.05), when the appropriate nominal alpha was corrected using a Bonferroni correction (Stevens, 2002). All analyses were performed using Statistical Package for the Social Sciences (SPSS) 18.0.3 for Windows except when noted otherwise (SPSS Inc, 2010). All important statistical assumptions were met (independence of observations and residuals, normality of observations, homoscedasticity, linearity, homogeneity of the variance matrix, acceptable minimal values for expected frequencies, reasonable sample size for proposed model in SEM, identified model for SEM and no outliers). Results A total of 151 patients were asked to enter this study. Table 1 describes the demographic variables of the sample. The sample mostly consisted of male patients (92.1%), Dutch ethnicity (48.5%) with an average age of 37.2 years (SD = 7.4 years) and an average onset of drug use at 21.8 years (SD = 5.8 years). The most preferred substance of use was cocaine (37.6%). Most patients stayed in the programme on account of a judicial enactment (60.4%). Of the sample, 50.5% met the criteria for one or more PDs (SIDP-IV). Of these patients, 15.9% had two or more PDs and 40.6% met the criteria for an antisocial PD.

Table 1: Demographic variables (N = 101) % / mean (SD) % Male Age Ethnicity

N

92.1 93 37.2 (7.4) 101 % Dutch % Other ethnicities

48.5 51.5

49 52

60.4 31.7 7.9 10.1 (2.5) 73.3

61 32 8 96 74

37.6 18.8 9.9 6.0 14.9 11.9 21.8 (5.8)

38 19 10 6 15 12 97

40.6 8.9 6.9 5.0 4.0 3.0 3.0 2.0 2.0 2.0 1.0 1.0 50.6

41 9 7 5 4 3 3 2 2 2 1 1 51

Admission % Judiciary title % Voluntary % Missing Elementary and middle/high school (years) % Lower level education Drug use % Cocaine % Polydrug % Heroin % Other types of drugs % Alcohol use % Alcohol and drug use Age of onset of drug and/or alcohol abuse Personality disorders % Antisocial % Paranoid % Borderline % Avoidant % Obsessive compulsive % Depressive % Narcissistic % Schizoid % Schizotypal % Dependent % Histrionic % Negativistic % Any Axis II disorder

Psychometric properties of the Standardized Assessment of Personality—Abbreviated Scale The internal consistency of the SAPAS was low (Kuder–Richardson 20 = 0.49). As deletion of any item (Table 2) did not show an improvement in internal consistency, it can be concluded that all of the items assess a different aspect of PD. Confirmative factor analysis did not support the one factor model for the SAPAS (chi-square (20) = 153.5, p < = 0.00, CFI = 0.44, RMSEA = 0.24). Only two items (item 3: ‘trusts people’; item 4: ‘normally loses temper easily’) showed


reasonable loadings (0.83 and 0.76 respectively). Three items showed low loadings (lower than 0.4; item 2: ‘usually a loner’; item 6: ‘normally a worrier’; item 8: ‘perfectionist’). No support was found for the claim of the SAPAS to assess a general factor of PD. A CFA using product–moment correlation coefficients showed similar results. Convergent validity of the SAPAS was poor (Pearson r = 0.20). There is little agreement between the SAPAS and the SIDP-IV in assessing

(2012) DOI: 10.1002/pmh


Table 2: Internal consistency if item deleted K-R 20 if item deleted In general, do you have difficulty making and keeping friends? Would you normally describe yourself as a loner? In general, do you trust other people? Do you normally lose your temper easily? Are you normally an impulsive sort of person? Are you normally a worrier? In general, do you depend on others a lot? In general, are you a perfectionist?

0.40 0.51 0.41 0.46 0.47 0.47 0.44 0.47

K-R 20, Kuder–Richardson 20.

PD. It is, however, a good sign that the internal consistency of both instruments was higher than the convergent validity (Campbell & Fiske, 1959). This means that the agreement of all items of an instrument is higher than the agreement of different instruments measuring a similar construct. Table 3 describes the sensitivity and 1-specificity of several cut-off scores on the SAPAS. The conventional cut-off score of 3 for the diagnosis of ‘any PD’ showed a high probability of correctly identifying patients with a PD (sensitivity = 77.4%), but also showed a high probability of incorrectly identifying patients without a PD (1-specificity = 58.3%). A cut-off score of 4 proved to be more efficient (sensitivity = 69.8%; Table 3: Cut-off scores of the Standardized Assessment of Personality—Abbreviated Scale Cut-off 0 1 2 3 4 5 6 7 8

Sensitivity (%)

1-specificity (%)

0.0 96.2 92.5 77.4 69.8 41.5 17.0 3.8 1.9

0.0 93.8 81.3 58.3 35.4 22.9 4.2 2.1 2.1


1-specificity = 35.4%). These results were confirmed by an ROC analysis (AUC = 0.67; Figure 1). The use of a cut-off score of 4 proved to be an optimal choice to asses PD because using a cut-off score of 3 resulted in almost twice as much false positive identifications. Using a cut-off score of 4 also resulted in good prediction validity. A PD assessed by the SIDP-IV using a cut-off score of 4 can be predicted by the SAPAS (chi-square (1) 11.98, p ≤ 0.00, Cramer’s V = 0.34). Discussion The results show limited evidence to make any firm conclusions about the reliability of the SAPAS as a screening instrument for substance-dependent criminal offenders. The fact that all eight items are derived from the SAP (Mann et al., 1981; Pilgrim & Mann, 1990) and primarily tend to diagnose different parts of PD can explain the low internal consistency (Kuder–Richardson 20 = 0.49). As the purpose of a screening instrument is to screen quickly and efficiently for the presence of a disorder, the internal consistency is usually low, and this should not indicate a problem. Moran and Hesse (2010) showed that the SAPAS appears to perform less well as a screening instrument for the antisocial PD, which is the category with the highest prevalence among substance abusers (Emmelkamp & Kamphuis, 2007). This could have resulted in the under-detection of the antisocial PD and can explain the poor convergent validity in this study, which is consistent with the findings of Moran and Hesse (2010). Still, the inclusion of an item assessing antisocial PD seems reasonable. The best cut-off point on the SAPAS for a residential forensic setting can be subject for debate. The cut-off score of 4 showed an optimal tradeoff between sensitivity and specificity, but the cut-off score of 3 had a higher sensitivity. Taking into account the high prevalence of PDs in this population, the authors suggest using the cut-off score of 4 because using a cut-off score of 3 will result in almost twice as much false positive

(2012) DOI: 10.1002/pmh


Figure 1: Receiver operating characteristic (ROC) curve of the Standardized Assessment of Personality—Abbreviated Scale and the Structured Interview for DSM-IV Personality

identifications. As the purpose of a screening instrument is to quickly and efficiently identify the presence of a disorder, this suggestion seems valid. The construct validity in this sample was not convincing. The performance of an assessment instrument can, however, change between different settings because of changes in the patient case mix, and the sample of this study was highly selected. There is modest evidence for a ‘one factor’ model that corresponds to the theoretical principle of the SAPAS: the presence of ‘any PD’ (Moran et al., 2003). There is limited evidence for a three factor model representing the commonly used triad of cluster A, B or C. The total sample size in this study and the number of items of the SAPAS were too small for a reliable confirmative three factor analysis. For a reliable and valid assessment of various types of PD, the use of a structured interview such as the SIDP-IV (Pfohl et al., 1995) is still advocated. The SAPAS remains a screening instrument for the presence of PDs and should be used as such. A positive identification of PDs on the SAPAS should always be followed by an assessment of PDs using a structured interview such as the SIDP-IV (Pfohl


et al., 1995). The benefit of using a screening instrument is that an expensive assessment for PDs in every patient is prevented. Comparison with the results of Moran et al. (2003), Hesse et al. (2008) and Pluck et al. (2012) The psychometric qualities of the SAPAS in this study are less convincing than the results of Moran et al. (2003), Hesse et al. (2008) and Pluck et al. (2012). The differences between the psychometric properties of the SAPAS found in this study and those of Hesse et al. (2008), Moran et al. (2003) and Pluck et al. (2012) can partly be explained by the use of different settings. Different settings can result in differences in the patient case mix, which can influence the psychometric properties of an instrument. Because this sample was highly selected and different from the sample of the studies by Hesse et al. (2008), Moran et al. (2003) and Pluck et al. (2012), it can at least partly explain the differences found in the psychometric qualities of the SAPAS. However, the prevalence of PDs is fairly similar in all four studies. Furthermore, the sample in this study is larger than those of Moran et al. (2003),

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Hesse et al. (2008) and Pluck et al. (2012) and, last but not least, includes a heterogeneous population. Therefore, it seems appropriate to state that there is limited evidence to make any firm conclusion about the reliability of the SAPAS as a screening instrument for comorbid PDs in a substance dependence treatment setting for criminal offenders. There is need for further research of the psychometric qualities of the SAPAS as a screening instrument for PDs in this specific population. Study limitations Several limitations can be mentioned. First, it remains difficult to differentiate between state and trait when assessing PDs, especially when administered at the start of a treatment. Furthermore, the influence of overstimulation in the first few weeks of treatment should not be underestimated. Difficulty in differentiating state and trait is, however, not exclusively a characteristic of the SAPAS; most assessments of personality and PDs are subjected to this distortion. The second limitation concerns the sample. The study used a nonrandom sample of inpatients. The included patients are, however, representative of the criminal offenders with substance dependence in an inpatient treatment setting. Recommendations for further research This study showed no significant differences between Dutch patients and patients with a nonWestern background. The cultural sensitivity of the SAPAS seems to be low and suggests that the SAPAS can be administered in different ethnic populations. It is recommended to investigate the concurrent and construct validity with other patient samples, including patients with a nonWestern background. It is also recommended to focus on the improvement of the psychometric properties of the SAPAS as a screening instrument for criminal offenders with substance dependence by adding appropriate criteria for this population. The addition of items that are related to the antisocial PD will improve the properties of the


SAPAS as a screening instrument for this population. Finally, because there is limited evidence to make any firm conclusion about the reliability of the SAPAS in this specific population, it is recommended to assess the psychometric properties of other screening instruments for PDs in this specific population. Acknowledgements This study was made possible by the support of Chris W. van der Meer (MA), head of Palier, and Vincent M. Hendriks (PhD), head of the Parnassia Addiction Research Centre, and the work of several nurses, caretakers and psychologists of Triple-Ex and Remise, who participated in the data collection. Special thanks go to Pablo Crivelli (MA), whose contribution to the data collection was inspiring. This study did not receive any extramural financial support. References APA (American Psychiatric Association). (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington DC: American Psychiatric Press. Arts, N., & Ferwerda, H. (2007). De Haagse veelplegersaanpak doorgelicht. Een evaluatie van de Haagse ketenaanpak van volwassen veelplegers (The evaluation of the The Hague approach of repeat offenders). Arnhem: Advies- en onderzoeksgroep Beke. Bentler, P. M. (1995). EQS structural equations program manual. Encino, CA: Multivariate Software, Inc. Blackburn, R. (2000). Treatment or incapacitation? Implications of research on personality disorders for the management of dangerous offenders. Legal and criminal psychology, 5, 1–21. Bollen, K. A. (1989). Structural equations with latent variables. Wiley Series in Probability and Mathematical Statistics. New York: John Wiley & Sons. Campbell, D. T., & Fiske, D. W. (1959). Convergent and discriminant validation by the multitrait-multimethod matrix. Psychological bulletin, 56, 81–105. Coid, J. (2005). Correctional populations. In J. M. Oldham, A. E. Skodol, & D. S. Bender (Eds.), The American psychiatric publishing textbook of personality disorders. Washington, D. C. & London: American Psychiatric Publishing, Inc. Compton, W. M., Cottler, L. B., Jacobs, J. L., Ben-Abdallah, A., & Spitznagel, E. L. (2003). The role of psychiatric

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Address Correspondence to: Brigitte P. M. Jansen, De Uilenboom 58, 6602 CV Wijchen, The Netherlands. Email: [email protected]


Appendix Standardized Assessment of Personality— Abbreviated Scale Choose the answer of which the patient thinks the description applies most of the time and in most situations 1. In general, do you have difficulty making and keeping friends? Y/N (yes = 1, no = 0) 2. Would you normally describe yourself as a loner? Y/N (yes = 1, no = 0) 3. In general, do you trust other people? Y/N (yes = 0, no = 1) 4. Do you normally lose your temper easily? Y/N (yes = 1, no = 0) 5. Are you normally an impulsive sort of person? Y/N (yes = 1, no = 0) 6. Are you normally a worrier? Y/N (yes = 1, no = 0) 7. In general, do you depend on others a lot? Y/N (yes = 1, no = 0) 8. In general, are you a perfectionist? Y/N (yes = 1, no = 0)

(2012) DOI: 10.1002/pmh

Standardized assessment of personality disorders in obsessive-compulsive disorder.

Psychopathology and personality characteristics of criminal sexual offenders as a function of victim age.

Assessment of psychiatric disorders among sex offenders: Prevalence and associations with criminal history.

The reliability and validity of the rating scale of criminal responsibility for mentally disordered offenders.

The Self-Stigma Process in Criminal Offenders.

Criminal Recidivism Among Homicide Offenders.

Socio-neuro risk factors for suicidal behavior in criminal offenders with psychotic disorders.

A standardized psychiatric assessment scale for rating chronic psychotic patients.

Development and validation of a treatment progress scale for personality disordered offenders.

Assessment of DSM-III-R personality disorders by self-report questionnaire: the role of informants and a screening test for co-morbid personality disorders (STCPD)

The impact of DSM-5's alternative model for personality disorders on criminal defendants.

Premorbid adjustment of schizophrenic criminal offenders.

The Semiology of Motor Disorders in Autism Spectrum Disorders as Highlighted from a Standardized Neuro-Psychomotor Assessment.

Alcohol and drug abuse-dependence disorders in psychopathic and nonpsychopathic criminal offenders.

High impulsivity as a risk factor for the development of internalizing disorders in detained juvenile offenders.

A comparison of criminal recidivism among schizophrenic and nonschizophrenic offenders.

The measurement of criminal dangerousness as a personality construct: further validation of a research index.

Problems and considerations in the valid assessment of personality disorders.

The SPQ: a scale for the assessment of schizotypal personality based on DSM-III-R criteria.

Criminal behavior and cognitive processing in male offenders with antisocial personality disorder with and without comorbid psychopathy.

The Personality Inventory Scales: a self-rating clinical instrument for diagnosis of personality disorder.

Standardized methodological assessment of research presentations (SHARP): development of a new instrument.

Validation of Finnish Neecham Confusion Scale and Nursing Delirium Screening Scale using Confusion Assessment Method algorithm as a comparison scale.

Assessment of saccadic eye movements as an instrument of differential diagnostic screening.