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Antisocial personality disorder

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Antisocial personality disorder or ASPD, is a psychiatric diagnosis that encompasses the formerly separated diagnoses of Psychopathy and Sociopathy. The diagnosis is established in a patient who is over the age of 18, who exhibited conduct disorder before the age of 15, where the behavior cannot be traced to schizophrenia or a manic episode and the patient exhibits at least three of the following behaviors:

  • Failure to conform to social norms, particularly engaging in repeated criminal behavior;
  • Skilled in the arts of deception or lying, particularly when done to hurt others for pleasure, staying out of trouble, personal gain or profit;
  • Skilled with charm;
  • Impulsiveness and failure to plan ahead;
  • Irritability or aggression, particularly getting into fights;
  • Reckless disregard for the safety of themselves or others;
  • Constant irresponsibility, particularly with respect to employment or financial obligations;
  • Lack of remorse characterized by rationalization or indifference to the damage caused to others;
  • Constant blaming of others;
  • Early sexual promiscuity.

The disorder has a combination of both genetic and environmental causes. It is about three times more likely to be observed in males than females.

Theodore Millon has broken down the types of behaviors exhibited by individuals with the order into five broad types: covetous, reputation-defending, risk-taking, nomadic and malevolent.

A psychiatrist attempting to make the diagnosis must go through a careful differential to rule out similar conditions. Anxiety, clinical depression, addiction, sleep disorders, borderline personality disorder, histrionic personality disorder and narcissism can all masquerade as antisocial personality disorder.

There is no effective treatment for antisocial personality disorder. Physicians and others merely attempt to control the behavior of the individual through diligence and exploiting the patient's behavior. Psychotherapy and other behavioral therapies are commonly used with mixed effectiveness.

No direct cause has been established for the development of ASPD. However, it has been shown that many psychopaths suffered extreme abuse during childhood. Though a fictional character, Valerie developed ASPD after suffering domestic abuse by her father. Real life mass murderer Eric Harris, who was posthumously diagnosed a psychopath, had suffered four years of school bullying at the hands of school athletes, whom he declared revenge on.

Antisocial (Dissocial) Personality Disorder is a personality disorder characterized by a pervasive pattern of disregard for, or violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. There may be an impoverished moral sense or conscience and a history of crime, legal problems, impulsive and aggressive behavior.

The American Psychiatric Association's Diagnostic and Statistical Manual (DSM) and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems' (ICD) Dissocial personality disorder have similar but not identical criteria. Both have stated that their diagnosis has also been known as psychopathy or sociopathy, though the criteria are different to other commonly used assessments, and the DSM-5 now has psychopathy as an optional 'specifier' of the main diagnosis.

Diagnosis

DSM-IV-TR

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV-TR), defines ASPD as:

  • There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three or more of the following:
    • failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;
    • deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
    • impulsivity or failure to plan ahead;
    • irritability and aggressiveness, as indicated by repeated physical fights or assaults;
    • reckless disregard for safety of self or others;
    • consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
    • lack of remorse]], as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another;
  • The individual is at least age 18 years.
  • There is evidence of conduct disorder with onset before age 15 years.
  • The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode.

Further considerations

Similar concepts

Psychopathy

Psychopathy is a personality or mental disorder characterized partly by antisocial behavior, a diminished capacity for remorse, and poor behavioral controls. Psychopathic traits are assessed using various measurement tools, including Canadian researcher Robert D. Hare's Psychopathy Checklist, Revised (PCL-R)

American psychiatrist Hervey Cleckley's work on psychopathy formed the basis of the diagnostic criteria for ASPD, and the DSM states that ASPD is also known as psychopathy. However, critics have argued that ASPD is not synonymous with psychopathy as the diagnostic criteria are different. A diagnosis of ASPD is based on behavioral patterns, whereas the PCL-R also relies on subjective judgments of personality traits.

Although the diagnosis of ASPD covers two to three times as many prisoners as are rated as psychopaths, Hare believes that the PCL-R is better able to predict future criminality, violence, and recidivism than a diagnosis of ASPD. Hare suggests that there are differences between PCL-R-diagnosed psychopaths and non-psychopaths on "processing and use of linguistic and emotional information", while such differences are potentially smaller between those diagnosed with ASPD and without. Hare argued that confusion regarding how to diagnose ASPD, confusion regarding the difference between ASPD and psychopathy, as well as the differing future prognoses regarding recidivism and treatability, may have serious consequences in settings such as court cases where psychopathy is often seen as aggravating the crime.

The DSM-V working party has recommended a revision of ASPD to be called antisocial/dyssocial personality disorder. There is also a suggestion to include a subtype "Antisocial/Psychopathic Type".

Dissocial personality disorder

The World Health Organization's International Statistical Classification of Diseases and Related Health Problems, tenth edition (ICD-10), defines a conceptually similar disorder to ASPD called Dissocial personality disorder, "usually coming to attention because of a gross disparity between behavior and the prevailing social norms".

It is characterized by at least 3 of the following:

  • Callous unconcern for the feelings of others;
  • Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations;
  • Incapacity to maintain enduring relationships, though having no difficulty in establishing them;
  • Very low tolerance to frustration and a low threshold for discharge of aggression, including violence;
  • Incapacity to experience guilt or to profit from experience, particularly punishment;
  • Marked readiness to blame others or to offer plausible rationalizations for the behavior that has brought the person into conflict with society.

The diagnosis includes what may be referred to as amoral, antisocial, asocial, psychopathic, or sociopathic personality (disorder). Although the disorder is not synonymous with conduct disorder, presence of conduct disorder during childhood or adolescence may further support the diagnosis of dissocial personality disorder. There may also be persistent irritability as an associated feature. Dissocial personality disorder criteria differ from those for ASPD.

It is a requirement of the ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Theodore Millon's subtypes

Theodore Millon suggested five subtypes of ASPD:

Subtype Features
Nomadic (including Schizoid personality disorder and Avoidant personality disorder features) Feels jinxed, ill-fated, doomed, and cast aside; peripheral, drifters; gypsy-like roamers, vagrants; dropouts and misfits; itinerant vagabonds, tramps, wanderers; impulsively not benign.
Malevolent (including Sadistic personality disorder and Paranoid personality disorder features) Belligerent, mordant, rancorous, vicious, malignant, brutal, resentful; anticipates betrayal and punishment; desires revenge; truculent, callous, fearless; guiltless.
Covetous (variant of "pure" pattern) Feels intentionally denied and deprived; rapacious, begrudging, discontentedly yearning; envious, seeks retribution, and avariciously greedy; pleasure more in taking than in having.
Risk-taking (including Histrionic personality disorder features) Dauntless, venturesome, intrepid, bold, audacious, daring; reckless, foolhardy, impulsive, heedless; unbalanced by hazard; pursues perilous ventures.
Reputation-defending (including Narcissistic personality disorder features) Needs to be thought of as infallible, unbreakable, invincible, indomitable, formidable, inviolable; intransigent when status is questioned; over-reactive to slights.

Elsewhere, Millon differentiates ten subtypes (partially overlapping with the above) – covetous, risk-taking, malevolent, tyrannical, malignant, unprincipled, disingenuous, spineless, explosive, and abrasive – but specifically stresses that "the number 10 is by no means special ... Taxonomies may be put forward at levels that are more coarse or more fine-grained."

Comorbidity

The following conditions commonly coexist with ASPD:

When combined with alcoholism, people may show frontal function deficits on neuropsychological tests greater than those associated with each condition.

Causes and pathophysiology

Hormones and neurotransmitters

ASPD is said to be genetically based but typically has environmental factors, such as family relations, that trigger its onset. Traumatic events can lead to a disruption of the standard development of the central nervous system, which can generate a release of hormones that can change normal patterns of development. One of the neurotransmitters that have been discussed in individuals with ASPD is serotonin.

A recent meta-analysis of 20 studies showed a correlation between ASPD and serotonin metabolic 5-hydroxyindoleacetic acid (5-HIAA). The study found a reasonable effect size (5-HIAA levels in antisocial groups were 0.45 standard deviation lower than in non-antisocial groups).

J.F.W. Deakin of the University of Manchester's Neuroscience and Psychiatry Unit has discussed additional evidence of 5HT's connection with ASPD. Deakin suggests that low cerebrospinal fluid concentrations of 5-HIAA, and hormone responses to 5HT, have displayed that the two main ascending 5HT pathways mediate adaptive responses to post and current conditions. He states that impairments in the posterior 5HT cells can lead to low mood functioning, as seen in patients with ASPD. It is important to note that the dysregulated serotonergic function may not be the sole feature that leads to ASPD but it is an aspect of a multifaceted relationship between biological and psychosocial factors.

While it has been shown that lower levels of serotonin may be associated with ASPD, there has also been evidence that decreased serotonin function is highly correlated with impulsiveness and aggression across a number of different experimental paradigms. Impulsivity is not only linked with irregularities in 5HT metabolism but may be the most essential psychopathological aspect linked with such dysfunction. In a study looking at the relationship between the combined effects of central serotonin activity and acute testosterone levels on human aggression, researchers found that aggression was significantly higher in subjects with a combination of high testosterone and high cortical responses, which correlated to decreased serotonin levels. Correspondingly, the DSM classifies "impulsivity or failure to plan ahead" and "irritability and aggressiveness" as two of seven sub-criteria in category A of the diagnostic criteria of ASPD.

Some studies have found a relationship between monoamine oxidase A and antisocial behavior, including conduct disorder and symptoms of adult ASPD, in maltreated children.

Limbic neural maldevelopment

Cavum septum pellucidum (CSP) is a marker for limbic neural maldevelopment. One study found that those with CSP had significantly higher levels of antisocial personality, psychopathy, arrests and convictions compared with controls.

Cultural influences

The Socio-cultural perspective of clinical psychology view disorders as being influenced by cultural aspects, since cultural norms differ significantly, mental disorders such as ASPD are viewed differently. Robert D. Hare has suggested that the rise in ASPD that has been reported in the United States may be linked to changes in cultural mores, the latter serving to validate the behavioral tendencies of many individuals with ASPD. While the rise reported may be in part merely a byproduct of the widening use (and abuse) of diagnostic techniques, given Eric Berne's division between individuals with active and latent ASPD – the latter keeping themselves in check by attachment to an external source of control like the law, traditional standards, or religion – it has been plausibly suggested that the erosion of collective standards may indeed serve to release the individual with latent ASPD from their previously prosocial behavior.

There is also a continuous debate as to the extent to which the legal system should be involved in the identification and admittance of patients with preliminary symptoms of ASPD.

Environment

Some studies suggest that the social and home environment has contributed to the development of antisocial behavior. The parents of these children have been shown to display antisocial behavior, which could be adopted by their children.

Head injuries

Researchers have linked physical head injuries with antisocial behavior. Since the 1980s, scientists have correlated traumatic brain injury, including damage to the prefrontal cortex, with an inability to make morally and socially acceptable decisions. Children with early damage in the prefrontal cortex may never fully develop social or moral reasoning and become "psychopathic individuals ... characterized by high levels of aggression and antisocial behavior performed without guilt or empathy for their victims." Additionally, damage to the amygdala may impair the ability of the prefrontal cortex to interpret feedback from the limbic system, which could result in uninhibited signals that manifest in violent and aggressive behavior.

Treatment

ASPD is considered to be among the most difficult personality disorders to treat. Because of their very low or absent capacity for remorse, individuals with ASPD often lack sufficient motivation and fail to see the costs associated with antisocial acts. They may only simulate remorse rather than truly commit to change: they can be seductively charming and dishonest, and may manipulate staff and fellow patients during treatment. Studies have shown that outpatient therapy is not likely to be successful, however the extent to which persons with ASPD are entirely unresponsive to treatment may have been exaggerated.

Those with ASPD may stay in treatment only as required by an external source, such as a parole. Residential programs that provide a carefully controlled environment of structure and supervision along with peer confrontation have been recommended. There has been some research on the treatment of ASPD that indicated positive results for therapeutic interventions. Schema Therapy is also being investigated as a treatment for ASPD. A review by Charles M. Borduin features the strong influence of multisystemic therapy (MST) that could potentially improve this imperative issue. However this treatment requires complete cooperation and participation of all family members. Some studies have found that the presence of ASPD does not significantly interfere with treatment for other disorders, such as substance abuse, although others have reported contradictory findings.

Therapists of individuals with ASPD may have considerable negative feelings toward clients with extensive histories of aggressive, exploitative, and abusive behaviors. Rather than attempt to develop a sense of conscience in these individuals, therapeutic techniques should be focused on rational and utilitarian arguments against repeating past mistakes. These approaches would focus on the tangible, material value of prosocial behavior.

Prognosis

According to Professor Emily Simonoff, Institute of Psychiatry, "childhood hyperactivity and conduct disorder showed equally strong prediction of antisocial personality disorder (ASPD) and criminality in early and mid-adult life. Lower IQ and reading problems were most prominent in their relationships with childhood and adolescent antisocial behaviour."

Epidemiology

ASPD is seen in 3% to 30% of psychiatric outpatients. The prevalence of the disorder is even higher in selected populations, like prisons, where there is a preponderance of violent offenders. A 2002 literature review of studies on mental disorders in prisoners stated that 47% of male prisoners and 21% of female prisoners had ASPD. Similarly, the prevalence of ASPD is higher among patients in alcohol or other drug (AOD) abuse treatment programs than in the general population, suggesting a link between ASPD and AOD abuse and dependence.

History

The first version of the DSM in 1952 listed "sociopathic personality disturbance". Individuals to be placed in this category were said to be "...ill primarily in terms of society and of conformity with the prevailing milieu, and not only in terms of personal discomfort and relations with other individuals". There were four subtypes, referred to as 'reactions'; antisocial, dyssocial, sexual and addiction. The antisocial reaction was said to include people who were 'always in trouble' and not learning from it, maintaining 'no loyalties', frequently callous and lacking responsibility, with an ability to 'rationalise' their behaviour. The category was described as more specific and limited than the existing concepts of 'constitutional psychopathic state' or 'psychopathic personality' which had had a very broad meaning; the narrower definition was in line with criteria advanced by Hervey M. Cleckley from 1941, while the term sociopathic had been advanced by George E. Partridge. The DSM-II in 1968 rearranged the categories and 'antisocial personality' was now listed as one of ten personality disorders but still described similarly, to be applied to individuals who are: "basically unsocialized", in repeated conflicts with society, incapable of significant loyalty, selfish, irresponsible, unable to feel guilt or learn from prior experiences, and who tend to blame others and rationalise. The DSM-II warned that a history of legal or social offenses was not by itself enough to justify the diagnosis, and that a 'group delinquent reaction' of childhood or adolescence or 'social maladjustment without manifest psychiatric disorder' should be ruled out first. The dyssocial personality type was relegated in the DSM-II, though would later resurface as the name of a diagnosis in the ICD manual produced by the World Health Organisation, later spelled Dissocial Personality Disorder and equivalent to the ASPD diagnosis.

The DSM-III in 1980 included the full term Antisocial Personality Disorder and, as with other disorders, there was now a full checklist of symptoms focused on observable behaviours to enhance inter-operator reliability. The ASPD symptom list was based on the Research Diagnostic Criteria developed from the so-called Feighner Criteria from 1972, and in turn largely credited to influential research by sociologist Lee Robins published in 1966 as 'Deviant Children Grown Up'. However, Robins has previously clarified that while the new criteria of prior childhood conduct problems came from her work, she and co-researcher psychiatrist Patricia O'Neal got the diagnostic criteria they used from Lee's husband the psychiatrist Eli Robins, one of the authors of the Feighner criteria who had been using them as part of diagnostic interviews.

The DSM-IV maintained the trend for behavioural antisocial symptoms while noting "This pattern has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder" and re-including in the 'Associated Features' text summary some of the underlying personality traits from the older diagnoses. The DSM-5 has criteria for an overall diagnosis of Antisocial (Dissocial) Personality Disorder and then an optional specifier for "psychopathic features" where there is a lack of anxiety/fear accompanied by a bold and efficacious interpersonal style.

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