Antisocial personality disorder

Antisocial personality disorder (ASPD) is described by the American Psychiatric Association's Diagnostic and Statistical Manual, fourth edition (DSM-IV-TR), as an Axis II personality disorder characterized by "... a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood."^[1] They have an "impoverished moral sense or conscience" and may have a "history of crime, legal problems, impulsive and aggressive behaviour." The antisocial personality disorder falls under the dramatic/erratic cluster of personality disorders.^[2]

The World Health Organization's International Statistical Classification of Diseases and Related Health Problems', tenth edition (ICD-10), defines a conceptually similar disorder to antisocial personality disorder called (F60.2) Dissocial personality disorder.^[3]

Though the diagnostic criteria for ASPD were based in part on Hervey Cleckley's pioneering work on psychopathy, ASPD is not synonymous with psychopathy and the diagnostic criteria are different.^[4]

Diagnosis [edit]

ICD-10 [edit]

The World Health Organization's International Statistical Classification of Diseases and Related Health Problems, tenth edition (ICD-10), defines a conceptually similar disorder to antisocial personality disorder called (F60.2) Dissocial personality disorder.^[5]

It is characterized by at least 3 of the following:

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

There may be persistent irritability as an associated feature.

The diagnosis includes what may be referred to as amoral, antisocial, psychopathic, or sociopathic personality (disorder.)

The criteria specifically rule out conduct disorders.^[6] Dissocial personality disorder criteria differ from those for antisocial personality disorders.^[7]

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

DSM-IV-TR [edit]

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM IV-TR), defines antisocial personality disorder (in Axis II Cluster B) as:^[1]

A) 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:

1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;
2. deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
3. impulsiveness or failure to plan ahead;
4. irritability and aggressiveness, as indicated by repeated physical fights or assaults;
5. reckless disregard for safety of self or others;
6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another;

B) The individual is at least age 18 years.

C) There is evidence of conduct disorder with onset before age 15 years.

D) The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode.

Further diagnostic considerations [edit]

Psychopathy [edit]

Although there are behavioral similarities, ASPD and psychopathy are not synonymous. A diagnosis of ASPD using the DSM criteria is based on behavioral patterns, whereas psychopathy measurements also include more indirect personality characteristics. The diagnosis of antisocial personality disorder covers two to three times as many prisoners as are rated as psychopaths. Most offenders scoring high on the PCL-R also pass the ASPD criteria but most of those with ASPD do not score high on the PCL-R.^[4]

Theodore Millon's subtypes [edit]

Theodore Millon identified five subtypes of antisocial personality disorder:^[8][9]

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".^[10]

Comorbidity [edit]

The following conditions commonly coexist with antisocial personality disorder:^[11]

When combined with alcoholism, people may show frontal function deficits on neuropsychological tests greater than those associated with each condition.^[12]

Causes and pathophysiology [edit]

Hormones and neurotransmitters [edit]

Antisocial personality disorder 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.^[13] 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)^[14]

J.F.W. Deakin of University of Manchester's Neuroscience and Psychiatry Unit has discussed additional evidence of 5HT's connection with antisocial personality disorder. 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.^[15] 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 cortisol responses, which correlated to decreased serotonin levels.^[16] Correspondingly, The Diagnostic and Statistical Manual of Mental Disorders classifies "impulsiveness or failure to plan ahead" and "irritability and aggressiveness" as two of the seven criteria in diagnosing someone with 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 [edit]

Cavum septum pellucidum (CSP) is a marker for limbic neural maldevelopment.^[17] One study found that those with CSP had significantly higher levels of antisocial personality, psychopathy, arrests and convictions compared with controls.^[17]

Cultural influences [edit]

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.^[18]Robert D. Hare has suggested that the rise in antisocial personality disorder that has been reported in the United States may be linked to changes in cultural mores, the latter serving to validate the behavioural tendencies of many individuals with ASPD.^[19] While the rise reported may be in part merely a byproduct of the widening use (and abuse) of diagnostic techniques,^[20] 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^[21] - 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 behaviour.^[22]

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.^[23]

Environment [edit]

Some studies suggest that the social and home environment has contributed to the development of antisocial behaviour.^[24] The parents of these children have been shown to display antisocial behavior, which could be adopted by their children.^[24]

Treatment [edit]

ASPD is considered to be the most difficult personality disorder to treat.^[25][26] Individuals with ASPD can be seductively charming and dishonest. They declare a commitment to change, but they often lack sufficient motivation and fail to see the costs associated with antisocial acts. 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.^[25]

When in inpatient treatment, individuals with ASPD may manipulate and exploit staff and fellow patients.^[27] 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.^[28]

There has been some research on the treatment of ASPD that indicated positive results for therapeutic interventions.^[29] Some studies have found that the presence of ASPD does not significantly interfere with treatment for other disorders, such as substance abuse,^[30] although others have reported contradictory findings.^[31] Schema Therapy is being investigated as a treatment for antisocial personality disorder.^[32] 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.^[33]

Therapists of individuals with ASPD may have considerable negative feelings toward clients with extensive histories of aggressive, exploitative, and abusive behaviors.^[25] 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.^[34]

Prognosis [edit]

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."^[35]

Epidemiology [edit]

Antisocial personality disorder is seen in 3% to 30% of psychiatric outpatients.^[1][11] The prevalence of the disorder is even higher in selected populations, like prisons, where there is a preponderance of violent offenders.^[36] A 2002 literature review of studies on mental disorders in prisoners stated that 47% of male prisoners and 21% of female prisoners had antisocial personality disorder.^[37] Similarly, the prevalence of ASPD is higher among patients in alcohol or other drug (AOD) abuse treatment programs than in the general population (Hare 1983), suggesting a link between ASPD and AOD abuse and dependence.^[38]

See also [edit]

References [edit]

Further reading [edit]

T. Millon and R. Davis, 'Ten Subtypes of Psychopathy', in T. Millon et al. eds., Psychopathy: Antisocial, Criminal and Violent Behavior (New York 1998)

External links [edit]

Look up antisocial in Wiktionary, the free dictionary.

• "Into the Abyss." Article on street crime referencing the roots and consequences of sociopathic behavior
• DSM IV-TR Criteria for Antisocial personality disorder
• Psychopathy and Antisocial Personality Disorder: A Case of Diagnostic Confusion
• Recent Studies Implicate Slow Monoamine Oxidase Enzyme/High Circulating T3 in Antisocial Behavior/Aggression/Violence 2007