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“Dr Jekyll and Mr Hyde?”: Abuse of potent benzodiazepines, exemplified by flunitrazepam, in mentally disordered male offenders
2005 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Flunitrazepam (FZ) is an example of a sedative-hypnotic benzodiazepine whose pharmacokinetic properties include a rapid onset of action and an intermediate duration of action. It has a high affinity to central benzodiazepine receptors and affects them profoundly. These properties, and its profile of activity, increase the probability of abuse by those who have access to it. Known side effects of FZ are abuse and amnesia. FZ is widely abused and it has become a drug of choice among opioid abusers, as a club drug, and as a classic “date-rape” drug. FZ is often involved in fatal intoxication. It is therefore expected that FZ abuse is common in serious offenders. I have studied the reasons for FZ abuse and mapped the prevalence of the abuse, with the objective of studying the personalities and the background factors of the abusers, and of drawing some conclusions about assessment procedures of FZ abuse and the position of FZ in society.

The participants in the studies summarised here were fifty-six juvenile delinquents from Swedish youth correctional institutions, aged 14-20 years, and sixty non-psychotic male offenders referred for a forensic psychiatric evaluation (FPE), aged 16-35 years. The participants answered questions regarding their abuse, and this enabled us to understand why they abused just FZ (and not another substance). The participants also completed a number of self-reported inventories, which enabled us to obtain measures of personality traits. They were also rated for psychopathy. Five forensic psychiatric cases of FZ abusers were studied in more detail. Furthermore, the forensic psychiatric participants’ psychiatric diagnoses, and both groups’ crime-related measures, were obtained from their files.

About 40% of the juvenile delinquents and 30% of the offenders referred for a forensic psychiatric evaluation abused FZ. The main reason for the FZ abuse was to change a perception of reality and to obtain an increased feeling of power and self-esteem, a feeling that everything was possible. Both samples of offenders differed from the normal population in many personality traits, suggesting that the participants possessed a high level of vulnerability for developing mental disorders, but only a few differences in personality traits were found between FZ abusers and non-FZ abusers. The juvenile delinquent FZ abusers had higher scores than non-FZ abusers in the verbal aggression and sensation-seeking boredom susceptibility scales. In the juvenile sample, FZ abuse was associated with the abuse of amphetamines and/or cocaine, cannabis, and opiates, and with childhood psychological/psychiatrical contact, with living in a metropolitan housing area, and with recidivism into crimes leading to care in a juvenile correctional institution. In this sample, FZ abuse was also associated with weapons offences and narcotics-related crimes. In the forensic psychiatric sample, FZ abuse was significantly associated with previous admission to an FPE, and convictions for robbery, for weapons-related offences, for narcotics-related offences and for theft. The results show that FZ is more common in offenders who score high on Facet 4 (Antisocial) in the Hare psychopathy model, and that FZ abuse has high correlation with Item 20 (Criminal versatility). All of the FZ abusers reported side effects from FZ that resulted in the brutality of their violent acts and anterograde amnesia. FZ abusers, when intoxicated with FZ, had a reduced capacity for both empathy and anticipatory anxiety, in contrast to their “daily” behaviour and “ordinary” (i.e., without the influence of the FZ) personality characteristics. They were not characterised by classic characteristics of psychopathy, such as lack of empathy. This may indicate that FZ induces psychopathic-like state-dependant (FZ intoxication) traits, and temporary dissociate states (“Dr Jekyll and Mr Hyde”?).

In conclusion, FZ abuse is common in the population of young offenders with mental disorders, and FZ is often used for nonmedical purposes. The practical implications of these conclusions are that clinicians and those who develop or manage therapeutic programs should be aware of FZ abuse when choosing the most effective treatment for male offenders. General practitioners who prescribe potent sedative compounds should be aware of their possible adverse effects. The availability of FZ should be limited further, because FZ is frequently abused in vulnerable male offenders, and because FZ has serious adverse mental health-related effects and is related to robbery and weapons‑related crimes.

Place, publisher, year, edition, pages
Stockholm: Karolinska Institutet , 2005. , 124 p.
Keyword [en]
Flunitrazepam (FZ) abuse, side effects of FZ, offenders referred to forensic psychiatric evaluation, juvenile delinquents, personality traits, psychopathic traits and lifestyle (PCL-R)
National Category
Medical and Health Sciences
Research subject
SOCIAL SCIENCE, Psychology
Identifiers
URN: urn:nbn:se:hv:diva-5047ISBN: 91-7140-584-4 (print)OAI: oai:DiVA.org:hv-5047DiVA: diva2:586069
Public defence
2005-12-02, Bi 3-221, Alfreds Nobels Allé 10, Huddinge, 10:00 (Swedish)
Opponent
Supervisors
Projects
“Dr. Jekyll och Mr. Hyde beteende” bland manliga kriminella ungdomar i samband med alkohol kombinerad med bensodiazepiner: Biologiska och psykologiska indikatorerDyslexi bland rättspsykiatriskt undersökta män: Psykologiska, sociala och biologiska indikatorer
Note

1. Följande forskningsfinansiärer (det går inte att skriva in dem i följande ruta): Preparation of this thesis was supported by a doctoral fellowship from the Swedish Foundation for Care Sciences and Allergy Research. I have also been twice awarded a scholarship for research with violent offenders from the Swedish Carnegie Institute, and a scholarship for an “in-depth study into alcohol and drugs” from the Swedish Medical Society of Addiction Medicine. The Swedish National Board of Forensic Medicine (Rättsmedicinalverket), The Swedish Alcohol Research Fund, Karolinska Institute, Lund University, Stockholm University, and The Söderström-Königska Foundation also supported this thesis by grants.

2. Forskningsämne är rättspsykiatri (detta går inte heller att välja i rutan ovan)

Available from: 2013-01-11 Created: 2013-01-10 Last updated: 2014-01-10Bibliographically approved
List of papers
1. Flunitrazepam (Rohypnol) abuse in combination with alcohol causes premeditated, grievous violence in male juvenile offenders
Open this publication in new window or tab >>Flunitrazepam (Rohypnol) abuse in combination with alcohol causes premeditated, grievous violence in male juvenile offenders
1999 (English)In: The journal of the American Academy of Psychiatry and the Law, ISSN 1093-6793, Vol. 27, no 1, 83-99 p.Article in journal (Refereed) Published
Abstract [en]

This study focuses on 19 juvenile offenders who were frequently intoxicated by flunitrazepam (FZ), almost exclusively under the brand name Rohypnol. Street names for Rohypnol tablets are Rophies, Ropies, Roofies, Ropes, Roches, Rochas, Rochas Dos, Rophs, Ropers, Ribs, R-25, Roach-2s, Trip and Fall, Remember All, Mind Erasers, Forget Pills, and the Date Rape Drug. An overdose of FZ gives an increased feeling of power and self-esteem, reduces fear and insecurity, and provides the belief that everything is possible. FZ is also associated with loss of episodic memory and with impulsive violence, particularly when combined with alcohol. The subjects were taken from a subpopulation of 47 male juvenile offenders from Swedish national correctional institutions. Background information for subjects was obtained by in-depth interviewing and personality inventories including the Zuckerman Sensation-Seeking Scales, the Eysenck Personality Questionnaire, and the Karolinska Scales of Personality. Data concerning previous criminal offenses was obtained from the Swedish National Police Board. Almost all of the FZ abusers had been previously sentenced for serious violent offenses. Our data suggest that FZ abused by psychiatrically vulnerable subjects (i.e., with high scores on boredom susceptibility and verbal aggression) poses a serious hazard both to the abusers as well as the community. Our results support the finding that FZ should be classified as a Schedule I drug (i.e., a drug similar to heavy narcotics).

Place, publisher, year, edition, pages
Bloomfield, CT, USA: , 1999
Keyword
Alcoholic intoxication; Anti-anxiety agents; Flunitrazepam; Juvenile delinquency; Male; Psychological theory; Risk factors; Substance-related disorders; Violence
National Category
Forensic Science Social and Clinical Pharmacy
Research subject
SOCIAL SCIENCE, Psychology
Identifiers
urn:nbn:se:hv:diva-4980 (URN)
Projects
“Dr. Jekyll och Mr. Hyde beteende” bland manliga kriminella ungdomar i samband med alkohol kombinerad med bensodiazepiner: Biologiska och psykologiska indikatorer
Available from: 2012-12-30 Created: 2012-12-30 Last updated: 2015-02-03Bibliographically approved
2. Flunitrazepam abuse and personality characteristics inmale forensic psychiatric patients
Open this publication in new window or tab >>Flunitrazepam abuse and personality characteristics inmale forensic psychiatric patients
2001 (English)In: Psychiatry Research, ISSN 0165-1781, E-ISSN 1872-7123, Vol. 103, no 1, 27-42 p.Article in journal (Refereed) Published
Abstract [en]

Sixty male non-psychotic forensic psychiatric patients, aged 16-35 years, were studied after they completed their ordinary forensic psychiatric assessment (FPA). The prevalence of flunitrazepam (FZ) abuse was investigated by using both structured and in-depth interviews with the objective of studying the relationship between the abuse and personality traits. The patient’s characteristics, DSM-IV disorders, and actual sentences were obtained by studying their files. In order to obtain measures on their personality traits, self-report inventories were administered to the patients. Eighteen out of 60 patients were FZ abusers, but only 4 of them received a diagnosis related to the FZ abuse during the ordinary FPA. In almost all cases, however, indications of the FZ abuse were found in the files. No differences in personality traits were found between the groups. The frequency of previous admissions to an FPA and actual sentences of robbery, weapons offenses, narcotic-related offenses, and other crimes, such as theft, among the FZ abusers deviated significantly from forensic non-FZ abusers. Therefore, the FZ abuse per se might be more responsible for their tendency to commit crimes characterized by danger and thrill-seeking, such as robbery, weapons offences, and theft, than personality. The most important conclusion is that assessment of FZ abuse is needed in forensic psychiatry.

Place, publisher, year, edition, pages
Goettingen: Elsevier, 2001
Keyword
Flunitrazepam abuse; Forensic psychiatry; Robbery and weapons offences; Personality traits; Risk assessment
National Category
Forensic Science Psychiatry
Research subject
SOCIAL SCIENCE, Psychology
Identifiers
urn:nbn:se:hv:diva-4978 (URN)
Projects
Dyslexi bland rättspsykiatriskt undersökta män: Psykologiska, sociala och biologiska indikatorer
Available from: 2012-12-30 Created: 2012-12-30 Last updated: 2015-02-03Bibliographically approved
3. Violent behavior, impulsive decision-making, and anterograde amnesia while intoxicated with Flunitrazepam and alcohol or other drugs: A case study in forensic psychiatric patients
Open this publication in new window or tab >>Violent behavior, impulsive decision-making, and anterograde amnesia while intoxicated with Flunitrazepam and alcohol or other drugs: A case study in forensic psychiatric patients
Show others...
2002 (English)In: The journal of the American Academy of Psychiatry and the Law, ISSN 1093-6793, E-ISSN 1943-3662, Vol. 30, no 2, 238-251 p.Article in journal (Refereed) Published
Abstract [en]

It is known that many male juvenile delinquents commit violent crimes while intoxicated with flunitrazepam (FZ), often in combination with alcohol or other drugs. We have also noted the combined abuse of FZ with, for example, alcohol in male forensic psychiatric patients. Our objective was to study violent behavior, impulsive decision making, and amnesia in male forensic psychiatric patients who were intoxicated predominantly with FZ, to increase knowledge of the abuse of FZ in vulnerable subjects. We studied five forensic psychiatric patients, all of whom were assessed in 1998. All of the subjects reported earlier reactions to FZ, including hostility and anterograde amnesia. At the time of their crimes they were all intoxicated with FZ, often in combination with alcohol or other drugs, such as amphetamine or cannabis. In contrast to their behavior based on their ordinary psychological characteristics, their crimes were extremely violent, and the subjects lacked both the ability to think clearly and to have empathy with their victims. Our observations support the view that FZ abuse can lead to serious violent behavior in subjects characterized by vulnerable personality traits, and that this effect is confounded by the concurrent use of alcohol or other drugs. It is evident that FZ causes anterograde amnesia. Previous research and the results presented herein allow us to draw the following conclusion: on the basis of the neuropsychopharmacologic properties of FZ, legal decisions, such as declaring FZ an illegal drug, are needed in countries where it is now legal.

Place, publisher, year, edition, pages
Bloomfield, CT, USA: , 2002
Keyword
Rohypnol, violent offences, forensic psychiatry, case study, psychological consequences
National Category
Forensic Science Psychiatry
Research subject
SOCIAL SCIENCE, Psychology
Identifiers
urn:nbn:se:hv:diva-4977 (URN)
Projects
Dyslexi bland rättspsykiatriskt undersökta män: Psykologiska, sociala och biologiska indikatorer
Available from: 2012-12-30 Created: 2012-12-30 Last updated: 2015-10-14Bibliographically approved
4. Psychopathic traits and lifestyle in flunitrazepam abusers
Open this publication in new window or tab >>Psychopathic traits and lifestyle in flunitrazepam abusers
Show others...
2005 (English)Article in journal (Other academic) Submitted
Abstract [en]

The abuse of flunitrazepam (FZ) compounds is world-wide. We have examined whether any of the four facets of the Psychopathy Checklist-Revised (PCL-R) (Interpersonal, Affective, Lifestyle, and Antisocial) (Hare, 2003) is related to different substance use disorders, with the focus on FZ abuse. Participants were 114 male offenders aged 14-35 years, all of whom were convicted for severe, predominantly violent, offences. Abuse of FZ was more common in offenders who scored high in Facet 4 (Antisocial) of the PCL-R (odds ratio = 4.30, 95% C.I. 1.86 - 9.94). Using all 20 PCL‑R items as individual predictors of being an FZ abuser, only one of the items, Item 20) (Criminal versatility) was significantly associated with FZ abuse (odds ratio = 3.72, 95% C.I. 1.85 - 7.50). We suggest that abuse of FZ is more common in offenders who score high in Facet 4, and that FZ abuse is significantly associated with Item 20. Our results show that clinicians and those who develop or manage therapeutic programs should be aware of FZ abuse when choosing the most effective treatment for young mentally disordered severe offenders.

Keyword
Flunitrazepam abuse, psychopathy (PCL-R, PCL-YV), the 4-facet model, male offenders
National Category
Medical and Health Sciences
Research subject
SOCIAL SCIENCE, Psychology
Identifiers
urn:nbn:se:hv:diva-5046 (URN)
Projects
Dyslexi bland rättspsykiatriskt undersökta män: Psykologiska, sociala och biologiska indikatorer“Dr. Jekyll och Mr. Hyde beteende” bland manliga kriminella ungdomar i samband med alkohol kombinerad med bensodiazepiner: Biologiska och psykologiska indikatorer
Note

Ingår som manuskript (study IV) i doktorsavhandling "Dr Jekyll and Mr Hyde?" (medicine doctor), 2005, Karolinska Institutet. Senare publicerat i kraftigt omarbetat form.

Available from: 2013-01-10 Created: 2013-01-10 Last updated: 2014-01-10Bibliographically approved

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