Links Between Psychopathy,Type of Violence,and Severe Mental Disorder among Female Offenders of Lethal Violence in Sweden

Abstract

Knowledge about females who commit lethal violence is limited compared to what we know about their male counterparts. The overall aim of this study was to investigate links between psychopathy, type of violence, and severe mental disorder (SMD), among Swedish female offenders of lethal violence. All records for female offenders (N = 175) who underwent a court-ordered forensic psychiatric investigation in Sweden charged with lethal/attempted lethal violence, between 2000 and 2014, were included. Structured assessments were done based on the Psychopathy Checklist-Revised (PCL-R) concerning psychopathy, and the Violent Incident Coding Sheet (VICS) concerning instrumental/reactive aspects of the crime. Overall, the female offenders were characterized by relatively low levels of psychopathy and acted based on reactive rather than instrumental motives. Modest associations appeared between psychopathy and instrumental, rather than reactive, features of the crime. However, the SMD group (n = 84) scored lower on PCL-R total and interpersonal facet 1, somewhat higher on VICS arousal and planning (<24 h vs. no planning), while showing inconsistent but generally lower scoring on provocation. PCL-R facet 1, and the secondary VICS classifications appeared as covariates associated with an SMD. These results contribute to our understanding of the driving mechanisms and complexity behind female lethal violence, where the SMD group showed a somewhat unexpected multifaceted pattern, including reactive and instrumental VICS aspects. This has especially consequences for the assessment and handling of female offenders of lethal violence within forensic psychiatry and correctional services, also calling for further research focusing on this population.

Keywords

lethal violence severe violence homicide female offender mentally disordered violent offender psychopathy instrumental violence reactive violence

Introduction

Understanding the motivating forces behind lethal violence, and how it could be predicted and prevented, is crucial due to the great suffering it causes. Most offenders of lethal violence are male (Brå, 2017, 2024; Liem et al., 2013), and most research has focused on this group. Consequently, considerably less is known about female offenders. Research focusing specifically on this subgroup's characteristics and motives is important as a way to understand the mechanisms driving female lethal violence, and to develop more suitable preventive measures, treatment interventions, and relapse-reducing strategies. Even if the number of female offenders of lethal violence seems stable (Brå, 2024), participation in different criminal activities, including non-lethal violence, has been shown to increase among females (de Vogel & Louppen, 2017; Nicholls et al., 2015).

Prior research on female lethal violent offenders has demonstrated common prominent motives/triggers for violence such as self-defense (Fridel & Zimmerman, 2022; Mosechkin, 2023), fright, retribution (Vatnar et al., 2018), and circumstantial factors (Moen et al., 2016). Additionally, emotional dysregulation based on personality traits (Ross, 2011), as well as psychopathic traits, have been considered factors relevant to female non-lethal violence and criminality, but psychopathy has comparatively less often been studied for female than male offenders (Nicholls et al., 2005; Nicholls & Petrila, 2005).

The Psychopathy Checklist-Revised (PCL-R) is a structured assessment tool concerning psychopathy, originally a two-factor model, comprising factors 1 interpersonal-affective and 2 lifestyle-antisocial (Hare, 1991), which in later editions are divided into a four-factor model, comprising facets 1 interpersonal, 2 affective, 3 lifestyle, and 4 antisocial (Hare, 2003).

In studies on female offenders focusing on psychopathy, the levels are in general low (Pinheiro et al., 2020), especially when compared to male offenders (Coid et al., 2009; de Vogel & Lancel, 2016; Nicholls et al., 2005; Strand & Belfrage, 2005). The level of psychopathy concerning female offenders also seems to be lower, both on PCL-R total scores as on factor 2, in cases of homicide compared to non-lethal violent and non-violent crimes (Carabellese, Felthous, Tegola et al., 2020; Klein Tuente et al., 2014). When there are higher levels of psychopathy among female homicide offenders, it is primarily factor 1 that is elevated (Carabellese et al., 2019; Carabellese, Felthous, Mandarelli et al., 2020). This systematically low occurrence of psychopathy scores seen in females is mirrored in lower recommended cut-offs on PCL-R (de Vogel et al., 2014; de Vogel & Lancel, 2016; Hicks et al., 2010; Klein Tuente et al., 2014; Weizmann-Henelius et al., 2010). In contrast to a categorical taxonomy defining psychopathy (Harris et al., 1994), other research argues in favour of a dimensional structure (Edens et al., 2006; Guay et al., 2018; Marcus et al., 2004; Sellbom & Drislane, 2021). Higher levels of psychopathy among female homicide offenders have been associated with personality disorders and adverse experiences, but not psychotic disorders and lack of criminal responsibility (Carabellese et al., 2019). Additionally, co-variation of psychopathy and borderline personality disorder seems more frequent among females compared to males (de Vogel & Lancel, 2016), and research has shown that both trait constellations are gendered, but not different gendered alternatives of the same syndrome (Viljoen et al., 2015).

In the present study, the distinction between instrumental (alias proactive) and reactive (alias hostile, affective, impulsive) aggression and violence (Berkowitz, 1993; Cornell et al., 1996) was used. Generally, instrumental violence is characterized by actions to accomplish goals other than the violence itself, often involving planning. Reactive violence is characterized by being exposed to threats and actions driven by high arousal.

Previous studies have shown that it is possible to distinguish between instrumental and reactive offenders (Cornell et al., 1996) as between such offenses (Tapscott et al., 2012) among males. However, knowledge about female offenders is inconclusive, but previous findings have pointed to a predominance of reactive, rather than instrumental motives, especially in cases of homicide (Lehmann & Ittel, 2012; Sea et al., 2020).

When connecting psychopathy and type of violence, instrumental offenders have demonstrated higher levels of psychopathy compared to reactive offenders (Cornell et al., 1996; Sohn et al., 2022; Swogger et al., 2010). Nonetheless, even if female offenders with higher levels of psychopathy seem to offend more often based on instrumental goals (Klein Tuente et al., 2014), and violence, their aggression entailed more reactive qualities, contradicting that higher levels of psychopathy uniquely equal instrumental motives for aggression (Lehmann & Ittel, 2012). In addition, various patterns, and subtypes of psychopathy and aggression among females have previously been considered, however, based on samples other than lethal violent offending. For example, emotional detachment and instrumental aggression have been related, which seem more associated with primary psychopathy comprising fearlessness, lack of anxiety, and non-violent crime (Hicks et al., 2010; Ireland et al., 2020; Pinheiro et al., 2020; Skeem et al., 2011). Contrariwise, relations have been shown between emotional dysregulation and reactive aggression, more related to secondary psychopathy with a proneness to anxiety, fearfulness, mental health issues, violent crimes, and borderline personality disorder (Sprague et al., 2012).

In Sweden, individuals are generally considered accountable concerning criminal conduct regardless of their mental state (Bennet et al., 2022; Svennerlind et al., 2010). However, in the case of severe mental illness at the time of the crime, an offender can be found to have been acting under the influence of a severe mental disorder (SMD; a medico-legal concept). SMD is based on the type and degree of disorders/conditions. Some types of mental disorders (e.g., schizophrenia, severe depression with suicidal ideation) are almost always deemed as SMD while other types (e.g., personality disorders) require their degree to be very grave (i.e., equivalent to psychotic functioning) to be considered. In cases where the offender could be suspected of having perpetrated the crime under the influence of SMD, the court could order a forensic psychiatric investigation (FPI). An FPI is conducted by a professional expert team (i.e., forensic psychiatrist, psychologist, social worker, ward staff) from the Swedish National Board of Forensic Medicine. During the FPI, the team has access to all relevant information/documents (e.g., healthcare, education, social-/correctional services, police investigations) concerning the individual. The assessments are based on various methods including interviews, standardized structured instruments (e.g., personality), and tests (e.g., cognitive, executive functioning). In the case of SMD at the time of the crime, the penal code prescribes compulsory forensic psychiatric care rather than imprisonment.

Overall, the knowledge about what drives female lethal violence is limited, both in terms of the level of psychopathy, instrumental/reactive aspects, and how these factors are linked to each other and the existence of an SMD.

Aim and research questions. The general aim was to explore possible links between the level of psychopathy and the type of violence (instrumental/reactive) displayed at the crime among female lethal violent offenders subjected to an FPI. This was done for the cohort and two subgroups: with and without SMD. More, specifically, this was translated into the following questions:

What level of psychopathy was found among these female offenders? Did the subgroup with SMD differ in this respect from those without SMD?

To what degree was the violence perpetrated by these female offenders instrumental/reactive? Did the subgroup with SMD differ in these respects from those without SMD?

Were there any associations between the level of psychopathy and aspects of instrumental/reactive violence among these female offenders, and if so, did they distinguish the subgroup with SMD from the subgroup without SMD?

Methods

Procedure, Study Cohort, and Data Collection

The study cohort consisted of all females subjected to an FPI, during the period 2000–2014, charged with lethal/attempted lethal violence including murder, voluntary manslaughter, attempted murder, attempted voluntary manslaughter, assault combined with involuntary manslaughter, infanticide, and conspiracy/instigation/preparation to murder or attempted murder (N = 178). Three cases (1.7%) were excluded due to obtaining a court discharge since assessed as not guilty, thus the final cohort was N = 175. In Sweden, throughout the study period almost all females charged according to the included offenses underwent an FPI (varying between 70 and 80%; Brå, 2008, 2012, 2017, 2020), thus covering a majority of cases. Based on the inclusion criteria focusing on lethal/attempted lethal violence, the term ‘lethal violence’ is hereafter used. Based on the FPI, the total cohort was divided into those who fulfilled the criteria for SMD and those who did not, resulting in the SMD group (n = 84; 48%), and the no-SMD group (n = 91; 52%). Details on background/demographics, mental health, criminal characteristics, and procedure, have been presented in a previous study (for more info., see Trägårdh et al., 2023). The study was approved by the Regional Ethical Board in Gothenburg (Dnr: 788-14), allowing access to register data without informed consent.

Instruments and Variables

All Swedish FPIs and the related court verdicts concerning included females were coded into a comprehensive research protocol¹ (Trägårdh et al., 2023) connected to a larger project, where the measures in the current study included information about the sentence (i.e., imprisonment/forensic psychiatric care) and several instruments for structured assessment. Among these instruments was PCL-R, concerning the psychopathy of the offender (Hare, 2003), and the Violent Incident Coding Sheet (VICS), concerning instrumental/reactive aspects of the violent crime (Cornell, 1996). The coding was done principally by the first author. For interrater reliability analysis, the authors TN and MHK and a research assistant (KB) coded overlapping one-fifth of the material, thus 20% of the material was coded by two independent assessors (KT + TN; KT + MHK; KT + KB). All coders were licensed clinical forensic psychologists (for more info. about the procedure, data collection, and instruments, see Trägårdh et al., 2023).

PCL-R: Psychopathy. A structured assessment of psychopathy using the PCL-R checklist (Hare, 2003) based on all accessible file material was done. The PCL-R consists of 20 items intended to grasp various aspects of psychopathy, divided into two factors, 1 interpersonal-affective and 2 lifestyle-antisocial, and into four facets 1 interpersonal, 2 affective, 3 lifestyle, and 4 antisocial. Each item can be assessed according to the following three steps, ‘does not apply’ (=0), ‘partial match’ (=1), or ‘reasonably good match’ (=2), rendering a minimum-maximum total score of 0–40. Concerning interrater reliability, the PCL-R has previously been found to have relatively high interview-based interrater reliability for males (Cornell et al., 1996; Hare & Neumann, 2005; Hildebrand et al., 2002), and females (Hicks et al., 2010; Lehmann & Ittel, 2012; Vitale et al., 2002), something also found regarding file-based retrospective ratings on Swedish FPIs (Grann et al., 1998). An interrater reliability analysis was conducted in the current study regarding the PCL-R total score, using the intraclass correlation coefficient (ICC) (Koo & Li, 2016). The analyses showed good to excellent ICC values ([0.873; 0.915] absolute agreement and consistency, respectively; for more info., see Supplemental Material).

VICS: Instrumental/reactive violence. This study used VICS (Cornell, 1996) to code various aspects of the offenses based on the degree of instrumental/reactive aggressive behaviour. VICS consists of the primary classification instrumental/reactive aggression, and the secondary classifications planning, goal-directedness, provocation, arousal, severity of violence, relationship with victim, intoxication, and psychosis. The present study focused on the primary classification and the first four secondary classifications. The remaining secondary classifications were excluded since information concerning these aspects of this cohort has been presented in a previous study (for more info., see Trägårdh et al., 2023). In VICS, the classifications had four to six response alternatives in ascending order (see Table 2).

The primary VICS classification refers to a general and inclusive overall assessment of the offense, while the secondary classifications include detailed instrumental/reactive characteristics of the same incident. In the VICS model, planning and goal-directedness capture instrumental characteristics, whereas provocation and arousal seize reactive characteristics. Research has overall shown high interrater reliability for VICS (Cornell, 1996; Cornell et al., 1996). An interrater reliability analysis for the VICS classifications was accomplished in several steps, comprising some recalibration practice. Based on the ICC values planning and, provocation, showed excellent reliability (0.924; 0.912), arousal good reliability (0.846), instrumental/reactive aggression moderate reliability (0.718), and goal-directedness poor reliability (0.346). Since the latter two variables showed lower ICC values, percentage exact agreement was used as an alternative method to test reliability. This showed that exact agreements in percent for these variables were high (86% for both instrumental/reactive aggression, and goal-directedness), indicating good or excellent interrater reliability overall, arguing in favour of continued inclusion of all scales (for more info., see Supplemental Material). The lower ICC values resulted from a majority scoring ‘no/zero’ leading to low variance negatively affecting the ICC calculation, while the number of ‘no/zero’ agreements was high, and in that way, reliability could be viewed as acceptable for all scales.

Statistical Analyses

The PCL-R and VICS variables were presented, for the total cohort, the ‘SMD group’ and the ‘no-SMD group’, and these two subgroups were compared. The comparisons were made using Chi-square tests for categorical variables and Student t-tests for continuous variables. Some variations in the number of subjects occur in the analyses due to missing data, though all presented percentages are valid. Pearson correlations were made to analyze the association between PCL-R and VICS regarding all female offenders, and the two subgroups separately. Finally, univariable, and multivariable binary logistic regressions were carried out to analyze covariates to SMD status where PCL-R and VICS scores were used as independent variables.

Confidence intervals (95% CI) and two-tailed probability values with an α-level = 0.05, supplemented with a Bonferroni adjusted α-level = 0.004 to give a complete presentation of statistical measures for the group comparisons (see Tables 1 and 2) were utilized. Concerning effect sizes, used to illustrate clinical relevance, Cramer's V was used for categorical variables, Cohen's D for continuous variables, r as strength of association, and Odds ratio for logistic regressions (see Tables 1–4 for cut-off values). All statistical analyses were performed in SPSS version 26 (SPSS Inc, Chicago, IL, USA), or Excel version 2401.

Table 1.

Psychopathy According to PCL-R, Regarding Females with and without a SMD, Charged with Lethal/Attempted Lethal Violence and Assessed within a Court-Ordered Forensic Psychiatric Investigation in Sweden, during 2000–2014.

PCL-R	All offenders (N = 175)	SMD group (n = 84)	No-SMD group (n = 91)	p-value (Students t-test)	Effect size^a
Total score
Mean (SD)	11.01 (6.268)	9.94 (5.908)	11.99 (6.459)	0.030*	0.331
Factors
1 Interpersonal-affective
Mean (SD)	4.47 (2.984)	4.08 (2.942)	4.84 (2.994)	0.096	0.256
2 Lifestyle-antisocial
Mean (SD)	5.75 (3.607)	5.30 (3.299)	6.18 (3.840)	0.108	0.246
Facets
1 Interpersonal
Mean (SD)	0.95 (1.219)	0.69 (1.006)	1.19 (1.349)	0.007**	0.420
2 Affective
Mean (SD)	3.53 (2.170)	3.39 (2.339)	3.65 (2.008)	0.438	0.119
3 Lifestyle
Mean (SD)	3.88 (2.315)	3.64 (2.221)	4.10 (2.390)	0.194	0.199
4 Antisocial
Mean (SD)	1.87 (1.701)	1.65 (1.427)	2.08 (1.905)	0.101	0.254

PCL-R: Psychopathy Checklist-Revised; SMD: severe mental disorder.

Cohen's D, cut-off values: Small = 0.20; medium = 0.50; large = 0.80.

*p < 0.05; **p < 0.01; ***p < 0.001.

No significant difference at α-level corrected by Bonferroni method (i.e., 0.004).

Table 2.

Type of Violence According to VICS, Regarding Females with and without a SMD, Charged with Lethal/Attempted Lethal Violence and Assessed within a Court-Ordered Forensic Psychiatric Investigation in Sweden, during 2000–2014.

VICS	All offenders (n = 175)	SMD group (n = 84)	No-SMD group (n = 91)	p-value (χ²)	Effect size^a
Instrumental vs. reactive/hostile aggression, n (%)				0.190	0.171
Clearly instrumental aggression (e.g., crime-related incident, drug deal)	2 (1.2%)	1 (1.3%)	1 (1.1%)
Primarily instrumental, some reactive qualities	6 (3.7%)	3 (3.9%)	3 (3.4%)
Primarily reactive hostile aggression, some instrumental qualities	12 (7.3%)	2 (2.6%)	10 (11.5%)
Clearly reactive hostile aggression (e.g., interpersonal conflict)	144 (87.8%)	71 (92.2%)	73 (83.9%)
Planning, n (%)				0.019*	0.242
Extensive planning (detailed plan/preparation, rehearsal)	3 (1.8%)	2 (2.4%)	1 (1.1%)
Moderate planning (contemplation of action >24 h)	13 (7.6%)	7 (8.4%)	6 (6.9%)
Some planning (action <24 h, some plan/preparation)	39 (22.9%)	27 (32.5%)	12 (13.8%)
Very little/no planning (acts during argument/fight, no preparation)	115 (67.6%)	47 (56.6%)	68 (78.2%)
Goal-Directedness, n (%)				0.524	0.116
Clear, unequivocal goal-directedness	1 (0.6%)	0 (0.0%)	1 (1.2%)
Primarily goal-directedness, in the presence of other motives	6 (3.6%)	4 (5.1%)	2 (2.3%)
Secondary goal-directedness, in the presence of other primary motives	13 (7.9%)	5 (6.3%)	8 (9.3%)
No apparent goal-directedness (motive to injure victim, retaliate, defend)	145 (87.9%)	70 (88.6%)	75 (87.2%)
Provocation, n (%)				0.000***	0.365
Exceptionally strong provocation (repeated assault, severe abuse)	28 (16.6%)	5 (6.0%)	23 (26.7%)
Very strong provocation (assault)	21 (12.4%)	9 (10.8%)	12 (14.0%)
Strong provocation (break-up of a romantic relationship, threat of major life change)	40 (23.7%)	22 (26.5%)	18 (20.9%)
Moderate provocation (serious argument/dispute, threat of assault)	32 (18.9%)	13 (15.7%)	19 (22.1%)
Mild provocation (insult, minor argument, confrontation with police)	16 (9.5%)	10 (12.0%)	6 (7.0%)
No apparent provocation	32 (18.9%)	24 (28.9%)	8 (9.3%)
Arousal, n (%)				0.008**	0.269
Enraged, furious, ‘out of control’, ‘irrational’, panicked (brief state)	84 (51.2%)	48 (60.0%)	36 (42.9%)
Angry, mad, extremely frightened (can be protracted state)	41 (25.0%)	11 (13.8%)	30 (35.7%)
Excited, very nervous, anxious, scared	21 (12.8%)	13 (16.3%)	8 (9.5%)
Calm or tense at most	18 (11.0%)	8 (10.0%)	10 (11.9%)

VICS: Violent Incident Coding Sheet; SMD: severe mental disorder.

Cramer's V, cut-off values (incident to df): small = 0.04–0.10; medium = 0.13–0.30; large = 0.22–0.50.

*p < 0.05; **p < 0.01; ***p < 0.001.

Bold figures in cells: Significant difference at α-level corrected by Bonferroni method (i.e., 0.004).

Table 3.

Correlations According to PCL-R and VICS, regarding females with and without an SMD, Charged with Lethal/Attempted Lethal Violence and Assessed within a Court-Ordered forensic psychiatric investigation in Sweden, during 2000–2014.

VICS	All offenders (N = 175)				SMD group (n = 84)				No-SMD group (n = 91)
	PCL-R facets
	1 Interpersonal	2 Affective	3 Lifestyle	4 Antisocial	1 Interpersonal	2 Affective	3 Lifestyle	4 Antisocial	1 Interpersonal	2 Affective	3 Lifestyle	4 Antisocial
Instrumental aggression	0.196*	0.286**	0.068	−0.108	0.167	0.217	−0.011	−0.181	0.247*	0.382***	0.156	−0.050
Planning	0.118	0.239**	−0.048	−0.042	0.266*	0.265*	−0.015	0.097	0.099	0.223*	−0.058	−0.119
Goal-directedness	0.108	0.217**	0.053	−0.167*	0.283*	0.244*	−0.007	−0.212	0.040	0.170	0.047	−0.176
Provocation	−0.090	−0.196*	−0.072	−0.028	−0.310**	−0.303**	−0.237*	−0.023	−0.093	−0.111	0.010	−0.105
Arousal	−0.178*	−0.267**	−0.023	0.099	−0.319**	−0.385**	−0.145	−0.004	−0.068	−0.136	0.082	0.187

PCL-R: Psychopathy Checklist-Revised; VICS: Violent Incident Coding Sheet; SMD: severe mental disorder.

r, cut-off values: small = 0.1; medium = 0.3; large = 0.5.

*p < 0.05; **p < 0.01; ***p < 0.001.

Table 4.

Covariates Associated with SMD According to PCL-R and VICS, Regarding Females Charged with Lethal/Attempted Lethal Violence and Assessed within a Court-Ordered Forensic Psychiatric Investigation in Sweden, during 2000–2014.

PCL-R, facets, and VICS	β	SE β	Wald χ²	p	OR^a	95% CI
PCL-R, facets, and VICS	β	SE β	Wald χ²	p	OR^a	Lower	Upper
Univariable binary logistic regression
1 Interpersonal	−0.362	0.138	6.888	0.009**	0.696	0.531	0.912
Constant	0.251	0.195	1.655	0.198	1.286
2 Affective	−0.055	0.070	0.607	0.436	0.947	0.825	1.086
Constant	0.113	0.290	0.151	0.698	1.119
3 Lifestyle	−0.086	0.066	1.692	0.193	0.917	0.805	1.045
Constant	0.254	0.298	0.727	0.394	1.289
4 Antisocial	−0.152	0.093	2.641	0.104	0.859	0.716	1.032
Constant	0.201	0.228	0.775	0.379	1.223
Planning	0.532	0.233	5.232	0.022*	1.703	1.079	2.686
Constant	−0.806	0.362	4.947	0.026	0.447
Goal-Directedness	−0.040	0.312	0.016	0.899	0.961	0.521	1.773
Constant	−0.039	0.397	0.009	0.922	0.962
Provocation	−0.407	0.102	16.016	0.000***	0.666	0.545	0.812
Constant	1.391	0.392	12.615	0.000	4.020
Arousal	0.136	0.154	0.785	0.376	1.146	0.848	1.548
Constant	−0.480	0.512	0.879	0.349	0.619
Multivariable binary logistic regression
1 Interpersonal	−0.548	0.215	6.515	0.011*	0.578	0.379	0.880
2 Affective	−0.024	0.121	0.038	0.845	0.977	0.770	1.239
3 Lifestyle	0.124	0.122	1.036	0.309	1.133	0.891	1.439
4 Antisocial	−0.191	0.155	1.509	0.219	0.826	0.609	1.120
Planning	1.194	0.349	11.712	0.001**	2.741	1.449	5.186
Goal-directedness	−0.965	0.474	4.140	0.042*	0.381	0.150	0.965
Provocation	−0.684	0.145	22.193	0.000***	0.505	0.380	0.671
Arousal	0.550	0.234	5.526	0.019*	1.734	1.096	2.744
Constant	0.422	1.194	0.125	0.723	1.526

SMD: severe mental disorder; PCL-R: Psychopathy Checklist-Revised; VISC: Violent Incident Coding Sheet.

Odds ratio, 95% confidence interval, cut-off values: no association between dependent and independent variables = 1.0; positive association > 1.0; negative association < 1.0.

*p < 0.05; **p < 0.01; ***p < 0.001.

Results

PCL-R: Psychopathy

In the overall cohort, low PCL-R scores were found in total (M = 11.01, SD = 6.268), and on factor and facet levels (Table 1). Comparing the SMD versus no-SMD group, the SMD group had a significantly lower score regarding total score (M = 9.94, SD = 5.908 vs. M = 11.99, SD = 6.459; Cohen's D = 0.331) and facet 1 (M = 0.69, SD = 1.006 vs. M = 1.19, SD = 1.349; Cohen's D = 0.420). All significant differences showed small effect sizes.

VICS: Instrumental/Reactive Qualities of the Violent Incident

Overall, based on VICS ratings (Cornell, 1996), the offenders displayed mainly reactive rather than instrumental aggression (95.1% vs. 4.9%) at the crime (Table 2). The low degree of instrumental aggression was further illustrated by neither planning (67.6%), nor goal-directedness (87.9%). The majority also experienced at least some provocation (81.1%) and high/very high arousal levels (76.2%).

Regarding the two subgroups and significant differences, the SMD group was more likely to have done some planning (<24 h; 32.5% vs. 13.8%; Cramer's V = 0.242, i.e., medium effect) and experiencing very high arousal (60.0% vs. 42.9; Cramer's V = 0.269, i.e., medium effect). Moreover, the SMD group experienced less obvious provocation (Cramer's V = 0.365, i.e., large effect).

Associations between Psychopathy and Instrumental/Reactive Violence and their Covariation with SMD

Pearson correlation analyses on PCL-R and VICS are presented in Table 3. Of special interest is that in the SMD group, both facets 1 and 2 were positively associated with planning (r = 0.266; 0.265), and goal-directedness (r = 0.283; 0.244), and negatively associated within the range of medium strength with provocation (r = −0.310; −0.303) and arousal (r = −0.319; −0.385). For the no-SMD group, facets 1 and 2 were positively associated with instrumental aggression (r = 0.247; 0.382), the latter with medium strength, and facet 2 was positively associated with planning (r = 0.223). The correlations were generally weak, except for the five medium strengths associations described above.

Binary logistic regression was performed to assess the impact of PCL-R facets, and VICS planning, goal-directedness, provocation, arousal, on the likelihood of the offender being classified as having SMD (Table 4). Based on univariable binary logistic regression, the results showed that planning, provocation, and facet 1, appeared as covariates associated with offenders’ SMD status. Accordingly, the covariates associated with SMD status were higher levels of planning (OR = 1.703), lower scores on facet 1 (OR = 0.696), and lower levels of provocation (OR = 0.666). However, when using all variables in a multivariable binary logistic regression, all four VICS classifications, and PCL-R facet 1, were significantly associated covariates to SMD status. Specifically, the covariates were higher levels of planning (OR = 2.741), and arousal (OR = 1.734), and lower scores on facet 1 (OR = 0.578), and lower levels of goal-directedness (OR = 0.381), and provocation (OR = 0.505) .

Discussion

Overall, both the SMD and no-SMD subgroups showed generally low levels of psychopathy, and reactive rather than instrumental features characterized their lethal violence. Modest associations appeared between higher levels of psychopathy and instrumental qualities of the violent incident. The SMD group scored lower on PCL-R total and interpersonal facet 1, more VICS arousal, some planning (<24 h vs. no planning), and generally less provocation, than the no-SMD group. Of these results, the strongest effects were found for the VICS factors. Lower scores on the PCL-R interpersonal facet 1, and the secondary VICS classifications, especially some planning, and less provocation, appeared as covariates more prominently associated with the SMD group.

Psychopathy

Relatively low levels of psychopathy emerged as typical for the large majority of these female offenders, consistent with previous research on female offenders (Coid et al., 2009; Pinheiro et al., 2020), especially regarding lethal violence (Carabellese, Felthous, Tegola et al., 2020; Klein Tuente et al., 2014). Further, the higher scores on factor 1 interpersonal-affective relative to factor 2 lifestyle-antisocial found among female homicide offenders with psychopathy (Carabellese et al., 2019), did not emerge within the current cohort showing relatively low levels of psychopathy. Instead, the result demonstrated relatively higher scores on facets 2 affective, and 3 lifestyle, compared to facets 1 interpersonal, and 4 antisocial, in line with previous research by Pinheiro et al. (2020).

The SMD group showed significantly lower levels of psychopathy than the no-SMD group, both overall and for the interpersonal facet 1. These results were consistent with prior research, indicating no support for an association between psychopathy and severe mental illness (e.g., psychotic disorders) among female offenders of lethal violence (Carabellese et al., 2019). The somewhat higher prevalence of psychopathy within the no-SMD group, in combination with a higher frequency of personality disorders (see Trägårdh et al., 2023), is also consistent with prior research (de Vogel & Lancel, 2016; Viljoen et al., 2015). To summarize, the occurrence of high levels of psychopathy seems unusual among female offenders of lethal violence, especially among females with SMD, both in our cohort and in previous research. When psychopathy was more pronounced, potentially driving the violence, this occurred more often among females within the no-SMD group.

Instrumental/Reactive Qualities of the Violent Incident

The violence displayed by the large majority of the female offenders was based on reactive rather than instrumental motives. These acts most often represented the goal in itself, such as vengeance and self-protection, rather than instrumental goals. They were also most often characterized by no or limited planning and higher levels of experienced provocation and arousal. These findings are consistent with previous research emphasizing reactive motives behind female violence (Lehmann & Ittel, 2012; Sea et al., 2020).

However, the SMD group more often committed the offense based on higher arousal, some planning (<24 h vs. no planning), and at the same time less obvious provocation. The no-SMD group, on the other hand, more often committed the crime in response to provocation, with very little or no planning (no preparation, actions within argument/fight), while experiencing high arousal (although not as high as the SMD group did).

This aspect of somewhat more planning within the SMD group is interesting since planning is generally not associated with severe mental illness or reactive violence. A plausible interpretation of the short-term planning component in the SMD group is that it is an expression of rumination and a fixation of thought on how to protect oneself, more than actual planning in the instrumental meaning. In addition, the high level of arousal characterizing the majority within the SMD group should be emphasized since such an ‘irrational’, and ‘out of control’ state influences the character of potential planning. Thus, an amount of planning combined with very high arousal and no/low goal-directedness outlines something different from planning following other traditionally instrumental aspects (low arousal, high goal-directedness). Hence, it is obvious that what drives and motivates females’ violent acts is a complex pattern consisting of both reactive and instrumental components.

Associations between Psychopathy and Instrumental/Reactive Violence and their Covariation with SMD

The current findings generally highlight psychopathy captured within the PCL-R, especially facets 1 interpersonal, and 2 affective, as associated with higher levels of instrumental aspects in different ways. This is in line with previous research where psychopathy is shown to be positively associated with more instrumentally oriented qualities rather than reactive ones (Cornell et al., 1996; Lehmann & Ittel, 2012). Additionally, the associations between psychopathy and instrumental aspects differed qualitatively between the SMD and no-SMD groups, indicating that these associations manifested somewhat differently in the two subgroups. In the SMD group, higher levels of facets 1 interpersonal, and 2 affective, were associated with the secondary VICS classifications, positively with planning, and goal-directedness, and negatively with provocation, and arousal. Higher levels of the same psychopathy traits among the no-SMD group were instead positively associated with the primary VICS distinction instrumental/reactive aggression. This indicates that the conceptually distinguishable secondary VICS specifications are more constructive in addressing the associations between the higher levels of psychopathy and the VICS factors within the SMD group, while the primary VICS distinction works better for the no-SMD group. Thus, the instrumental/reactive motivations behind the violence are often intertwined and sometimes hard to distinguish among female homicide offenders as previously pointed out (Bushman & Anderson, 2001; Romero-Martínez et al., 2022).

When analyzing variables individually versus together, the emerging covariates for SMD status persisted throughout and increased in number when moving from the univariable to a multivariable level of analysis. Concerning the impact of psychopathy, a higher level of interpersonal facet 1 was a negative covariate for SMD status. Further, the results indicated that instrumental patterns, with somewhat more planning, and less provocation, constituted covariates to SMD status. Simultaneously, reactive patterns such as higher arousal, and lower goal-directedness, also constituted covariates to SMD status.

The somewhat higher level of planning (<24 h) for the SMD group could be understood differently considering the individual's mental state, as mentioned above. More planning could be interpreted as an instrumental aspect but be said to differ from the traditional notion of planning within a criminal context referred to in previous studies, which include obvious instrumental goals and low arousal. Hence, it could be questioned that ‘planning’ per se should always be emphasized as an instrumentally charged aspect of violence (Cornell et al., 1996). This relatively higher degree of planning within the SMD group may be of interest within the FPI assessment praxis, at least in the case of female offenders of lethal violence. The somewhat longer planning period in the SMD group also constitutes an opportunity for prevention if such plans/ruminations can be detected among individuals within, for example, health or social services. This opportunity could be further employed since female homicide offenders more often seem to seek help from various institutions before the crime is committed compared to their male counterparts (Yourstone et al., 2008). Further, in some cases with child victims, experiences of provocations were a crucial motivator to the violence, but not as a direct provocation by the child, but rather as a kind of ‘provocation by proxy’ by another party (e.g., former partner, father to the child, social services) perceived as threatening. The reactive aspects could be better understood by including a broader spectrum of provocations, understood as factors motivating the violence. Such a suggestion aligns with previous arguments that human aggression, here violence, is complex and should be addressed rather than restricted (Anderson & Bushman, 2002; Bushman & Anderson, 2001). The pattern within the no-SMD group was more often characterized by perceived provocation concerning a male partner and acting out directly against the victim within the provoking situation. The no-SMD offender could, in some cases, be characterized by higher levels of psychopathy but for most of the no-SMD offenders, this was not the case.

Moreover, since this study exclusively builds on violent offenses, largely characterized by reactive aggression, in combination with a high prevalence of mental health issues and adverse experiences (see Trägårdh et al., 2023), it could indicate dominance of secondary rather than primary psychopathic features and emotional regulation difficulties rather than emotional detachment among those with relatively higher PCL-R levels (Hicks et al., 2010; Ireland et al., 2020; Pinheiro et al., 2020; Skeem et al., 2011). Nevertheless, such interpretation should be done with caution since prior research has focused on different samples (e.g., non-offending, non-lethal violence, high levels of psychopathy) compared to our study, and sometimes with other measures (e.g., self-reports).

Applying the current findings to distinguish common motives and risk scenarios could improve preventive work and risk management regarding female lethal violence. For example, in cases of severe mental illness, noticing rumination/planning, probably concerning a person or specific issue, in combination with high arousal, appears to be risk factors suited for further assessment with the potential for prevention. Females experiencing provocation within a destructive intimate partner relationship affecting them emotionally should also be in focus for assessments since offering support to reduce this provocation could reduce the risk of female lethal violence in close relations. In the same vein, preventive work regarding male violence against females in general (Carlsson et al., 2021), for example, providing affected females easy access to available options out of destructive relationships, could reduce the risk of female lethal violence.

Strengths and Limitations

The current cohort constitutes a large majority of Swedish female offenders charged with lethal/attempted lethal violence during the study period. The data sources used are clinically detailed, covering a broad array of information about these offenders and their criminal acts compiled by different professions. However, some limitations should be addressed. First, the criteria for inclusion were indictments of lethal/attempted lethal crime, rather than labels included in the final sentence, which ultimately rendered a wider range of offenses. Second, some individuals with similar crimes were not captured within the study since (a) some never took part in an FPI due to not being court-ordered to any (based on no indications of any mental health problems), and (b) committing homicide-suicide at the time of the crime, or (c) potential hidden/unsolved crimes. Further, because of the international diversity of legal codes involving lethal violence and the legal standards for forensic psychiatric care, instead of prison, the generalizability of the current findings should be done with prudence. This cautiousness is also warranted due to the modest effect sizes obtained within this study. Nevertheless, the present findings are considered to be of international interest, since similar legislation resembling the Swedish legal concept of SMD is found in many countries (e.g., Not Guilty by Reason of Insanity), and this kind of clinically relevant data about female offenders of lethal violence is sparse (Bennet et al., 2022; Pouls et al., 2022).

Conclusions and Further Directions

The current results are in line with previous studies on female offenders’ motives for lethal violence as based on relatively low levels of psychopathy (Carabellese, Felthous, Tegola et al., 2020; Klein Tuente et al., 2014), and more reactive incentives (Fridel & Zimmerman, 2022; Mosechkin, 2023; Vatnar et al., 2018). However, females with SMD showed a complex and somewhat unexpected pattern, where the reactive aspects, such as high arousal were combined with instrumental features in the form of some planning (<24 h). This planning was interpreted as short-term fixated rumination concerning conflictual situations/self-protection, often under high arousal, rather than long-term conventional planning. As for clinical implications, in the case of women with mental health problems who are experiencing stressful life situations, an opportunity for prevention is to investigate the thought content and whether they are ruminating/pondering a solution that includes violence. Consequently, factors behind female violence could not be reduced to a simple dichotomy of reactive/instrumental, either among those with SMD or as a rule of thumb dividing those with versus without an SMD. Research concerning this perspective is desirable since it has the potential to deepen our understanding of the driving forces behind female lethal violence and thus create more optimal preventive conditions for identifying females at risk. This would especially concern previously identified patterns concerning female offending taking place within close relationships, as this is the predominant circumstance for severe female violence. Further suggestions include comparing male and female offenders and collecting larger samples/cohorts studying different types of offenses (e.g., child victims, intimate partner victims). Also, it would be interesting to dive further into the co-variation of psychopathy and personality disorders, among female offenders of lethal violence. Since psychopathy appears to be of low frequency among female offenders of lethal violence in our country, and other studies often have had different focuses (e.g., non-offending samples, non-violent offenders, self-reported psychopathy), international collaborations would be desirable to assemble larger groups making it possible to study females committing lethal violence with/without higher levels of psychopathy.

Supplemental Material

sj-docx-1-fmh-10.1177_14999013251345496 - Supplemental material for Links Between Psychopathy, Type of Violence, and Severe Mental Disorder among Female Offenders of Lethal Violence in Sweden

Supplemental material, sj-docx-1-fmh-10.1177_14999013251345496 for Links Between Psychopathy, Type of Violence, and Severe Mental Disorder among Female Offenders of Lethal Violence in Sweden by Karin Trägårdh, Malin Hildebrand Karlén, Peter Andiné and Thomas Nilsson in International Journal of Forensic Mental Health

Footnotes

Acknowledgements

The authors express their gratitude to the Department of Forensic Psychiatry, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, for offering research time to KT. Appreciation to thank Kristina Börtz and Louise Parkdahl for their contribution to data collection and Johan Green for data transferring.

ORCID iD

Karin Trägårdh

Malin Hildebrand Karlén

Peter Andiné

Thomas Nilsson

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was financed by grants to TN and KT respectively, from the Swedish state under the agreement between the Swedish Government and the county councils, the ALF-agreement (ALFGBG-819681, and ALFGBG-983995), and to KT from the Local Research and Development Council of Gothenburg and South Bohuslän (VGFOUGSB-869731).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

Notes

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