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UPPRÄTT - Forensic Psychiatric Follow-up Studies

This project is a follow-up of several cohorts of forensic psychiatric investigees, convicted perpetrators of violent and sexual crimes, and youths placed in institutional care, with the aim of describing the development of aggressive antisociality and mental disorders during periods from 3-5 years up to 10-15 years, and in some cases even nearly 20 years. The following study groups/cohorts are included in the UPPRÄTT project:

  • The Gothenburg Forensic Neuropsychiatry Project, which consists of 170 perpetrators of severe violent and/or sexual crimes (in two pilot studies and one main study) who underwent forensic psychiatric investigations between 1998 and 2001.
  • The Gothenburg Sexual Child Abuse Studies, consisting of all 196 perpetrators of sexual crimes against minors in the Västra Götaland region between 1993 and 1997, and two clinically-referred study groups of forensic psychiatric investigees, in which all cases underwent a forensic psychiatric investigation during the same period. The first group consisted of 185 individuals convicted of sexual crimes against minors, and the second of 153 individuals convicted of sexual crimes against adults.
  • The Malmö Clinical Forensic Psychiatric Cohort includes 125 subjects living in the Malmö University Hospital (MAS) catchment area who, after forensic psychiatric investigation (or an extended § 7 evaluation) had been sentenced to compulsory forensic psychiatric treatment between 1999 and 2005.
  • Clinical, Actuarial, and Treatment-related prognostic factors in SiS institutions (SiS-CAT), consisting of 110 clinically well-documented adolescents admitted to a SiS institution in the western region of Sweden according to the Care of Young Persons (special provisions) Act (SFS 1990:52) or the Care of Young Offenders Act (SFS 1998:60) between 2004 and 2007.
  • A population-based cohort consisting of 349 all male offenders from the Västra Götaland region of Sweden, consecutively admitted for forensic psychiatric investigation between 1988 and 1995 (except 1991 to 1992, when there was an overhaul of legislation).

This project has in its initial, descriptive studies, so far demonstrated the central importance of childhood-onset hyperactivity, conduct disorder, and early substance abuse in relation to aggressive antisocial behaviours (Söderström et al., 2004, 2005; Gustavson et al., 2007). Among the individuals with aggressive antisocial behaviours in our study groups/cohorts, one third up to one half of the subjects showed pronounced executive dysfunctions, between one sixth and one fourth had reduced capacity for social interaction and communication (atypical autism rather than classical autism states), and an equally large proportion had learning difficulties (Ståhlberg et al., 2010).

We are now working with follow-up data with the aim of describing thelong-term prognoses and identifying predictors of violent and other crimes against persons and factors predicting mental disorders. In a study on MAO-B activity, which in earlier studies has emerged as a risk marker, we found no relationship between such activity and destructive personality traits or criminal recidivism (Gustavson et al., 2010). Several ongoing studies have also been focused on the extent to which various destructive and antisocial personality traits, particularly psychopathic personality traits, are related to recidivism in violent crimes.

Results indicate a limited predictive value of complex personality traits, compared to behavioural variables such as “previous violent criminality” and criminological variables such as “age at first conviction” (Wallinius et al., 2012; Nilsson et al., 2011). The overall relapse rate into violent criminality among these groups of mentally disordered offenders emerged as rather modest during follow-up periods of about five years, with significantly more relapses among subjects sentenced to prison (up to 28%) as compared to forensic psychiatric treatment (around 10%) (Nilsson et al., 2011; Lund et al., 2012). With follow-up periods extending teen years the relapse pattern equaled out with approximately 50% violent relapses regardless of whether they were sentenced to forensic psychiatric treatment, prison or noncustodial sanctions, while diagnostic groups that included substance abuse stood out with the significantly highest relapse rates, reaching almost 60% among those with substance abuse and personality disorders versus 30% among those with none of these disorders (Lund et al., submitted). The child sexual abusers showed with a general follow-up time of 10 years rather modest relapse rates varying between 10-14% for sexual recidivism and approximately 12% for violent recidivism, with significantly more relapses among subjects with extra-familial victims at index compared to those with intra-familial victims (Nilsson et al., submitted).

A consistent finding valid for almost all study groups in the UPPRÄTT project is that age of onset of criminality (self-reported or register based as age at first conviction) emerged as the strongest predictor of recurrent violent criminality with an AUC ranging between 0.70 and 0.80 (Nilsson et al., 2011; Wallinius et al., 2012; Nilsson et al., submitted). During the next few years, we intend to further explore risk and protective factors in mentally disordered offenders, especially with regard to intimate partnership violence and sexual crimes against adults, along with the explanatory value of such factors in terms of long-term outcome. Another focus will be on victim preferences among child sexual abusers with repeated criminality and whether they are stable with regard to victim-offender relationship and age, as well as gender, of victims.

Principal Investigator: Thomas Nilsson


Doctoral theses with connection to UPPRÄTT

1. Gustavson, C. (2010). Risk and prediction of violent crime in forensic psychiatry. Lund University, Faculty of Medicine, Doctoral Dissertation Series 2010:120. Lund: Lund University.

2. Carlstedt, A. (2012). Child sexual abuse; crimes, victims, offender characteristics, and recidivism. Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Doctoral Dissertation. Gothenburg: University of Gothenburg.

3. Wallinius, M. (2012). Aggressive antisocial behavior. Clinical, cognitive, and behavioral covariates of its persistence. Department of Clinical Sciences, Malmö, Faculty of Medicine, Doctoral Dissertation Series 2012:96. Lund: Lund University.


1. Carlstedt, A., Nilsson, T., Brimse, A., Innala, S., Anckarsäter, H. (2009). Does victim age differentiate between perpetrators of sexual child abuse? A study of mental health and crime characteristics. Sexual Abuse: A Journal of Research and Treatment. 21(4), 442-454.

2. Gustavson, C., Ståhlberg, O., Sjödin, A-K., Forsman, A., Nilsson, T., Anckarsäter, H. (2007). Age at onset of substance abuse: A crucial covariate of psychopathic traits and aggression in adult offenders. Psychiatry Research, 153, 195-198.

3. Gustavson, C., Wass, C., Månsson, J-E., Blennow, K., Forsman, A., Anckarsäter, H., Nilsson, T. (2010). Platelet Monoamine Oxidase-B activity is not associated with childhood disruptive disorders, personality traits, psychopathic traits or recidivistic criminality in a prospective study of forensic psychiatric examinees. Neuropsychobiology. 61(2), 87-96.

4. Lund, C., Forsman, A., Anckarsäter, H., Nilsson, T. (2012). Early criminal recidivism among mentally disordered offenders. International Journal of Offender Therapy and Comparative Criminology, 56(5), 749-768.

5. Lund, C., Hofvander, B., Forsman, A., Anckarsäter, H. Nilsson, T. Violent criminal recidivism in mentally disordered offenders: A follow-up study of 13-20 years through different sanctions. Submitted.

6. Nilsson, T., Wallinius, M., Gustavson, C., Anckarsäter, H., Kerekes, N. (2011). Violent recidivism: A long-time follow-up study of mentally disordered offenders. PLoS ONE, 6(10), e25768. Doi:10.1371/journal.pone.0025768.

7. Nilsson, T., Carlstedt, A., Baudin, C., Jakobsson, C., Forsman, A., Anckarsäter, H. Child sexual abusers and recidivism: A 10 to 15 year follow-up study. Submitted.

8. Soderstrom, H., Nilsson, T., Sjodin, AK., Carlstedt, A., Forsman, A. (2005). The childhood-onset neuropsychiatric background to adulthood psychopathic traits and personality disorders. Comprehensive Psychiatry, 46, 111-116.

9. Soderstrom, H., Sjodin, AK., Carlstedt, A., Forsman, A. (2004). Adult psychopathic personality with childhood-onset hyperactivity and conduct disorder: a central problem constellation in forensic psychiatry. Psychiatry Research, 121, 271-280.

10. Ståhlberg, O., Anckarsäter, H., Nilsson, T. (2010). Mental health problems in youths committed to juvenile institutions: prevalences and treatment needs. European Child & Adolescent Psychiatry. 19, 893–903.

11. Wallinius, M., Nilsson, T., Hofvander, B., Anckarsäter, H., Stålenheim, G. (2012). Facets of psychopathy among mentally disordered offenders: Clinical comorbidity patterns and prediction of violent and criminal behavior. Psychiatry Research, 198, 279-284.

Contact Information

Thomas Nilsson

Page Manager: Stefan Axelsson|Last update: 8/26/2014

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