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Premediated aggression: Clinical

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Article in Personality and Individual Differences April 2003

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 Personality and Individual Differences 34 (2003) 773781
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Premeditated aggression: clinical assessment and

cognitive psychophysiology
Matthew S. Stanford*, Rebecca J. Houston,
Nicole R. Villemarette-Pittman, Kevin W. Greve
Department of Psychology, University of New Orleans, New Orleans, LA 70148, USA

Received 14 September 2001; received in revised form 17 January 2002; accepted 7 March 2002

Abstract
Aggressive behavior has traditionally been classied into two distinct subtypes: an aective, impulsive
aggressive display or a planned, predatory aggressive act. While a number of investigations have examined
the clinical and physiological correlates in impulsive aggressive individuals, very little research has been
conducted on those individuals engaging in predominantly premeditated aggressive acts. The present study
compared a group of premeditated aggressive psychiatric outpatients with a group of normal, non-
aggressive control subjects on personality, neuropsychological and cognitive psychophysiological mea-
sures. Consistent with previous work, premeditated aggressors did not dier signicantly from controls on
most measures of neuropsychological and psychophysiological function. Premeditated aggressors did show
signicant personality pathology scoring higher on measures of impulsivity, verbal and physical aggres-
sion, anger, hostility, psychoticism and neuroticism. Overall, these results suggest a distinctive personality
style that is associated with aggressive behavior. With respect to this and previous work, it is suggested that
the physiological aspects of behavioral control play a key role in the type of aggressive behavior displayed.
# 2002 Elsevier Science Ltd. All rights reserved.
Keywords: Event-related potentials; Neuropsychology; Personality; Aggression

Traditionally, the study of violence and aggression has recognized the importance of distin-
guishing between dierent types of destructive behavior. While a number of various physiological
and behavioral categories have been described, two distinct subtypes of aggressive behavior con-
sistently emerge: an aective or impulsive type of aggressive behavior and a predatory or pre-
meditated type. Impulsive aggression is typically described as a reactive or emotionally charged

* Corresponding author. Tel.: +1-504-280-5525; fax: +1-504-280-6049.

E-mail address: mstanfor@uno.edu (M.S. Stanford).

0191-8869/03/$ - see front matter # 2002 Elsevier Science Ltd. All rights reserved.
PII: S0191-8869(02)00070-3
774 M.S. Stanford et al. / Personality and Individual Dierences 34 (2003) 773781

aggressive response characterized by a loss of behavioral control (Barratt, 1991; Raine, Meloy,
Bihrle, Stoddard, LaCasse, & Buchsbaum, 1998). Premeditated aggression, however, is con-
sidered a purposeful, controlled aggressive display that is usually instrumental in nature. A
number of studies have attempted to delineate the abnormal clinical and neurological features
that characterize individuals engaging in impulsive violence (Coccaro, 1989; Houston & Stanford,
2001; Stanford, Houston, Mathias, Greve, Villemarette-Pittmann, & Adams, 2001). In addition,
previous work has indicated dierent treatment success depending upon the type of aggressive
behavior displayed (Barratt, Stanford, Felthous, & Kent, 1997). Few investigations, however,
have attempted to document or describe those features that might be clinically relevant in indi-
viduals that engage in premeditated violent acts.
According to Linnoila and Charney (1999), the perpetrators [of premeditated physical
aggression] are not thought to be dierent from nonviolent healthy volunteers on psycho-
biological variables. Despite the recency of this statement, it appears only three studies have
actually examined underlying biological substrates in premeditated violent oenders compared to
impulsive violent oenders and/or normal non-violent controls (Barratt, Stanford, Kent, & Fel-
thous, 1997; Linnoila, Virkkunen, Scheinin, Nuutila, Rimon, & Goodwin, 1983; Raine et al.,
1998). In general, impulsive aggressive subjects, as compared with premeditated aggressive sub-
jects, demonstrate lower levels of CSF 5HIAA (Linnoila et al., 1983), impaired prefrontal func-
tion (Raine et al., 1998), poorer verbal skills and lower P3 amplitude (Barratt, Stanford, Kent et
al., 1997). In contrast, premeditated aggressive subjects exhibit relatively normal prefrontal
function (Raine et al., 1998) and P3 amplitude (Barratt, Stanford, Kent et al., 1997b) when
compared with non-violent controls.
It is important, however, to note two methodological caveats in previous work related to pre-
meditated aggression. First, all three of the investigations mentioned here utilized oender sam-
ples. This population is associated with a multitude of potential confounding variables (e.g. low
IQ) that make generalization of any ndings to a psychiatric setting uncertain. Secondly, the lit-
erature is replete with investigations that imply some link between psychopathy and aggression,
particularly premeditated aggression (Hare, 1993). While individuals that meet criteria for
psychopathy may indeed engage in overt aggressive behavior (premeditated or impulsive), it is
not required or necessarily even a common characteristic of the classication. Therefore, accurate
study requires explicit identication of the type and degree of aggressive behavior exhibited. With
respect to these issues, the present study compared a group of premeditated aggressive psychiatric
outpatients with a group of non-aggressive control subjects on measures of personality, neuro-
psychological performance and cognitive psychophysiology.

1. Methods

1.1. Subjects

Over a 4-year period, 80 patients were referred from local outpatient psychiatric clinics for
assessment due to problems with aggressive behavior. Using a semi-structured aggression interview
(Barratt & Stanford, 2001), 15 patients (19%) were identied as exhibiting predominately pre-
meditated aggressive behaviors. This interview has been used in previous studies which have shown
 M.S. Stanford et al. / Personality and Individual Dierences 34 (2003) 773781 775

signicant personality, neuropsychological and psychophysiological dierences between impul-

sive and premeditated aggressive individuals (Baratt, Stanford, Felthous et al., 1997; Baratt, Stan-
ford, Kent et al., 1997). Interrater reliability for the interview has been shown to be high
(kappa=0.79).
One of the 15 premeditated individuals received an Axis II diagnosis of mental retardation and
was therefore excluded from further analysis. This premeditated aggressor group (n=14, 12M/
2F, M age=35.50, SD=13.45) was compared with a non-aggressive normal control group
(n=14, 12M/2F, M age=30.50, SD=7.89). Non-aggressive controls were primarily recruited via
newspaper advertisement and excluded for any of the following: aggression problems, head
injury, psychoactive medications or psychiatric illness. Primary psychiatric diagnoses for the
premeditated subjects were as follows: Axis I: Depression n=3; Dysthymia n=2; Axis II: Anti-
social Personality Disorder n=9; Borderline Personality Disorder n=2; Narcissistic Personality
Disorder n=1; Axis I & II comorbidity n=4. Five of the premeditated subjects were presently
taking psychoactive medications: Wellbutrin n=2; Serax n=1; Tranxene n=1; Sinequan n=1;
Risperdal n=1; Desyrel n=1; Trazadone n=1.

1.2. Personality and neuropsychological measures

All subjects completed the following battery of personality and neuropsychological tests: Bar-
ratt Impulsiveness Scale (BIS-11; Patton, Stanford, & Barratt, 1995), Eysenck Personality Ques-
tionnaire (Eysenck & Eysenck, 1975), BussPerry Aggression Questionnaire (Buss & Perry, 1992),
BrownGoodwin Lifetime History of Aggression Questionnaire (Brown, Goodwin, Ballenger,
Goyer, & Major, 1979), Peabody Picture Vocabulary Test-Revised (Dunn & Dunn, 1981), Trail
Making Test (Reitan & Wolfson, 1985), Benton Facial Recognition (Benton, Sivan, Hamsher,
Varney, & Spreen, 1994), Ru Figural Fluency (Ru, 1988), Controlled Oral Word Association
Test (Lezak, 1995), and the Wisconsin Card Sorting Test (WCST; Heaton, Chelune, Talley, Kay,
& Curtiss, 1993). The WCST was administered and scored in accordance with Heaton et al.
(1993) except that all 128 cards were sorted rather than discontinuing administration after the
completion of six categories.

1.3. Psychophysiological measures

Psychophysiological recordings were taken in the afternoon (13:0016:00 h) to control for

hourly variations in scalp patterns. Subjects were seated in a comfortable chair in a sound and
light attenuated room. The scalp was prepared by application of rubbing alcohol and a mildly
abrasive gel (OmniPrep). An electrocap (International 1020 system) was tted onto each sub-
jects head and midline scalp electrodes (Fz, Cz, Pz) were examined. Electrodes were referenced to
linked ears, and an EOG electrode was axed below the left eye to facilitate dierentiation of
artifact and allow for removal of data contaminated by eye movements.
Trial rejection due to artifact contamination was determined by a bin selection technique. Trials
were placed into one of ve bins according to the level of artifact present in the trial. Bin ve contained
all trials and thus the highest level of artifact. Bins four to one contained decreasing levels of artifact in
conjunction with decreasing number of trials. Bin ve was utilized for peak identication in 42.9% of
stimuli. Bin four was utilized in 14.3%, bin 3 in 3.6%, bin two in 21.4% and bin one in 17.9%.
776 M.S. Stanford et al. / Personality and Individual Dierences 34 (2003) 773781

Impedance for each electrode was less than 5 Kohms. EEGs and EOGs were digitized every 4
ms for a 1000 ms interval beginning 100 ms prior to stimulus onset. Physiological data were
recorded using QND 3.1 (Neurodata, Inc., 1997) running on a Power Macintosh 8600/300.
Signal amplication was conducted using the NE-3 amplier. The lter bandpass was set at 0.5
to 35 Hz.

1.4. Auditory oddball task

The auditory oddball task consisted of one block of 200 trials. The stimuli were two randomly
sequenced tones, a frequent 1000 Hz tone and a rare 2000 Hz tone. Tones were presented in a
ratio of 80/20 and were presented at a comfortable level of 70 dB through stereo headphones at a
rate of one tone every 2 s, with a 5 ms rise/fall and a 50 ms sustain. Subjects were asked to sit with
their eyes closed and silently count the rare 2000 Hz tones. If subjects did not report the correct
count ( 5 tones), they were asked to repeat the task. In the present sample, one subject in the
premeditated aggressor group was asked to repeat the task due to an incorrect count.

1.5. Statistical analyses

Univariate ANOVAs were conducted to examine group dierences on personality and neuro-
psychological measures. Age and education corrected scores were utilized on neuropsychological
measures where available. Event-related potential amplitude and latency were examined using
repeated measures ANOVAs with group serving as the between subjects variable and electrode
site serving as the within subjects variable. P3 was dened as the most positive deection 250+
ms after stimulus presentation. P3 peak amplitude and latency were determined from baseline
(dened as the 100 ms prior to stimulus onset) using a graphical user interface program. For
analysis of amplitude, the mV deection from the baseline to the peak served as the dependent
variable. In latency analysis, the dependent variable was the average milliseconds from stimulus
presentation to the peak.

2. Results

2.1. Personality measures

Analyses of age indicated no signicant group dierence [F(1, 26)=1.44, P=0.24]. In terms of
personality measures, univariate ANOVAs revealed a signicant group dierence on the BIS-11
[F(1, 26)=5.63, P=0.025] indicating higher impulsiveness scores in the premeditated aggressor
group (Table 1). Analyses of the EPQ indicated signicant group dierences on both the
Psychoticism [F(1, 26)=10.34, P=0.003] and Neuroticism [F(1, 26)=17.69, P<0.001] Scales with
the premeditated aggressor group scoring higher than non-aggressive controls (Table 1). Analysis
of the BPAQ also indicated signicantly higher scores on the Physical Aggression [F(1, 26) =32.33,
P<0.001], Verbal Aggression [F(1, 26)=8.84, P=0.006], Anger [F(1, 26)=30.60, P<0.001] and
Hostility [F(1, 26)=13.51, P=0.001] subscales as well as the Total Aggression Score
[F(1,26)=29.06, P<0.001] in the premeditated aggressor group (Table 1). Finally, analysis of the
 M.S. Stanford et al. / Personality and Individual Dierences 34 (2003) 773781 777

Table 1
Personality measures

Measure Premeditated aggressors Non-aggressive controls

n=14 n=14

M S.D. M S.D.

Barratt Impulsiveness Scale 74.50* 17.69 61.21 11.21

Eysenck Personality Questionnaire

Psychoticism 6.64* 4.36 2.43 2.24
Extraversion 11.79 4.49 14.50 5.37
Neuroticism 17.21* 5.85 9.43 3.72

BussPerry Aggression Questionnaire

Physical 35.07* 9.66 17.07 6.86
Verbal 19.36* 5.51 13.86 4.19
Anger 26.00* 7.98 12.36 4.63
Hostility 26.50* 9.51 15.21 6.45
Total 106.93* 29.00 58.50 17.00

BrownGoodwin Lifetime History of Aggression 17.57* 7.45 4.21 3.51

*Denotes signicant group dierence at the < 0.05 level.

BrownGoodwin Lifetime History of Aggression scores indicated a signicantly greater history

of aggressive behavior in the premeditated aggressor group [F(1, 26)=36.82, P< 0.001; Table 1].
No other signicant dierences were found on personality measures.

2.2. Neuropsychological measures

On neuropsychological measures, no signicant group dierences were detected with the

exception of WCST failure to maintain set [F(1, 26)=5.98, P=0.022]. Premeditated subjects
exhibited more failures to maintain set. A comprehensive list of neuropsychological performance
in these two groups is provided in Table 2.

2.3. Psychophysiological measures

Repeated measures analysis of P3 amplitude indicated a signicant main eect for site [F(2, 50)
=53.07, P<0.001]. Main comparisons indicated normal P3 topography (Ant <Post) with lower
amplitude at Fz as compared with both Cz [F(1, 25)=41.13, P <0.001] and Pz [F(1, 25)=77.11,
P<0.001]. P3 amplitude at Cz was lower than that at Pz [F(1, 25)=16.35, P<0.001].
Repeated measures analysis of group dierences in P3 latency approached signicance [F(1, 25)
=3.85, P=0.061] suggesting longer latency in the premeditated aggressor group as compared
with non-aggressive controls (Fig. 1). Analyses yielded no other signicant dierences for P3
amplitude or latency.
778 M.S. Stanford et al. / Personality and Individual Dierences 34 (2003) 773781

Table 2
Neuropsychological measures

Measure Premeditated aggressors Non-aggressive controls

n=14 n=14

M S.D. M S.D.

Peabody Picture Vocabulary Testa 100.14 14.91 108.07 13.04

Trail Making Testb

Trails A 42.43 8.86 47.07 10.19
Trails B 49.71 6.89 49.21 12.85

Benton Facial Recognition 46.21 4.49 45.00 7.25

Ru Figural Fluency Testb

Number of Designs 34.60 12.92 41.93 13.54
Number of Perseverations 47.71 5.61 47.65 13.44

Controlled Oral Word Association Testb

FAS 42.16 8.87 46.66 9.86
Animals 48.02 18.55 41.96 8.46

Wisconsin Card Sorting Testc

Total Correct 92.50 15.40 96.00 20.45
Total Errors 35.50 15.40 33.71 18.47
Perseverative Responses 21.14 11.59 21.07 13.09
Peseverative Errors 19.00 10.40 18.79 10.71
Nonperseverative Errors 16.29 7.43 14.64 8.56
Conceptual Level of Response (%) 64.79 18.90 60.77 25.88
Number of Categories 6.07 3.12 7.29 3.20
Trials to First Category 11.50 1.95 17.79 14.92
Failure to Maintain Set 1.57* 1.40 0.50 0.85

* Denotes signicant group dierence at < 0.05 level.

a
Scores reported are standard scores.
b
Scores reported are t scores.
c
Scores reported are raw scores from 128 card version.

3. Discussion

Consistent with previous work, premeditated aggressors did not dier signicantly from normal
controls on most measures of neuropsychological and psychophysiological function (Barratt,
Stanford, Kent et al., 1997). In contrast, there were pronounced dierences on several measures
of personality. The premeditated group scored higher on measures of impulsivity, verbal and
physical aggression, anger, hostility, psychoticism and neuroticism. It is not surprising that indi-
viduals displaying premeditated aggressive behavior would show signicant personality patho-
logy. Individuals displaying chronic aggression problems, regardless of the type of aggressive
M.S. Stanford et al. / Personality and Individual Dierences 34 (2003) 773781 779

Fig. 1. Comparison of grand average waveforms across groups.

780 M.S. Stanford et al. / Personality and Individual Dierences 34 (2003) 773781

behavior, tend to score higher on these personality constructs (Stanford, Greve, Mathias, &
Houston, 1998).
High impulsivity and psychoticism scores are related to antisocial traits and behaviors (Amer-
ican Psychiatric Association, 1994; Eysenck & Eysenck, 1975), which would be expected in an
aggressive sample, particularly those whose aggressive displays are typically premeditated in
nature. Additionally, the high neuroticism scores suggest greater emotional lability and respon-
siveness in the premeditated aggressors. Again, this nding can easily be interpreted within the
context of aggressive behavior, greater emotional lability may lead to more extreme behavioral
expressions as a method of coping (e.g. physical harm). Thus, these results indicate that the
individual who habitually engages in controlled aggressive acts can clearly be dierentiated from
normal, non-aggressive controls on measures of personality.
Analysis of neuropsychological measures yielded only one signicant result. The premeditated
aggressors exhibited signicantly more failures to maintain set on the WCST. The lack of other
dierences in neuropsychological performance of this group suggests that this dierence is the
result of an impulsive personality style rather than any signicant cognitive decit.
Psychophysiological analyses indicated no signicant P3 amplitude or latency dierences
between premeditated aggressors and normal controls. This is consistent with previous work
(Barratt, Stanford, Kent et al., 1997) that demonstrated no signicant P3 dierences between
incarcerated premeditated aggressors and non-aggressive controls. However, in terms of P3
latency, the present analysis did approach signicance (P=0.06) suggesting a trend toward a
longer P3 latency in the premeditated aggressive group. As with the neuropsychological nding,
this result might best be interpreted with regard to the personality style of these premeditated
aggressors. Prolonged P3 latency has been linked to increased attitudinal hostility (Bond & Sur-
guy, 2000). Thus, the high levels of anger/hostility evidenced in the premeditated aggressive group
may have played a role in the latency trend observed in this sample.
The present results indicate a clear pattern of personality dierences between premeditated
aggressors and non-aggressive controls with few dierences on neuropsychological and psycho-
physiological variables. These results in conjunction with previous work (Barratt, Stanford, Kent
et al., 1997; Stanford et al., 1998), suggest a distinctive personality style that may be associated
with chronic aggressive behavior, regardless of the type of aggression displayed (premeditated or
impulsive). Considering these ndings, it is hypothesized that the individuals capacity to control
his behavior plays a key role in the manifestation of aggressive behavior. Those who display
predominately impulsive aggressive behavior are characterized by a host of cognitive and psy-
chophysiological decits that seem to contribute to their loss of behavioral control. Conversely,
the individual engaging in predominately premeditated aggressive acts appears to have an intact
behavioral control system. Thus these results provide some insight as to the underlying mechan-
isms of dierent aggressive subtypes, and allow for more accurate evaluation and treatment of
such problem behavior.

Acknowledgements

This research was supported by the Dreyfus Health Foundation, The Rogosin Institute, New
York HospitalCornell Medical Center.
 M.S. Stanford et al. / Personality and Individual Dierences 34 (2003) 773781 781

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