|Antisocial personality disorder|
|Classification and external resources|
|Patient UK||Antisocial personality disorder|
|Cluster A (odd)|
|Cluster B (dramatic)|
|Cluster C (anxious)|
Antisocial personality disorder (also known as dissocial personality disorder, psychopathy, and sociopathy) is a personality disorder, characterized by a pervasive pattern of disregard for, or violation of, the rights of others. An impoverished moral sense or conscience is often apparent, as well as a history of crime, legal problems, and/or impulsive and aggressive behavior.
Antisocial personality disorder (ASPD) is the name of the disorder as defined in the Diagnostic and Statistical Manual (DSM). Dissocial personality disorder is the name of a similar or equivalent concept defined in the International Statistical Classification of Diseases and Related Health Problems (ICD), where it states that the diagnosis includes antisocial personality disorder. Both manuals have similar but not identical criteria for diagnosing the disorder. Both have also stated that their diagnoses have been referred to, or include what is referred to, as psychopathy or sociopathy, but distinctions have been made between the conceptualizations of antisocial personality disorder and psychopathy, with many researchers arguing that psychopathy is a disorder that overlaps with but is distinguishable from ASPD.
The APA's Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM IV-TR), defines antisocial personality disorder (Cluster B):
Antisocial Personality Disorder (ASPD) falls under the dramatic/erratic cluster of personality disorders, the so-called "Cluster B."
The WHO's International Statistical Classification of Diseases and Related Health Problems, tenth edition (ICD-10), has a diagnosis called dissocial personality disorder (F60.2):
The ICD states that this diagnosis includes "amoral, antisocial, asocial, psychopathic, and sociopathic personality". 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.
Psychopathy is commonly defined as a personality 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). "Psychopathy" is not the official title of any diagnosis in the DSM or ICD, but both have stated that their diagnoses have been referred to (or include what is referred to) as psychopathy or sociopathy.
American psychiatrist Hervey Cleckley's work on psychopathy formed the basis of the diagnostic criteria for ASPD, and the DSM has stated that ASPD has also been referred to as psychopathy. However, critics have argued that ASPD is not synonymous with psychopathy as the diagnostic criteria are not exactly the same, since criteria relating to personality traits are emphasized relatively less in the former. These differences exist in part because it was believed that such traits were difficult to measure reliably and it was "easier to agree on the behaviors that typify a disorder than on the reasons why they occur".
Although the diagnosis of ASPD covers two to three times as many prisoners than the diagnosis of psychopathy, Robert Hare believes that the PCL-R is better able to predict future criminality, violence, and recidivism than a diagnosis of ASPD. He 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. Additionally, 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.
Nonetheless, psychopathy has been proposed as a specifier under an alternative model for ASPD. In the DSM-5, under "Alternative DSM-5 Model for Personality Disorders", ASPD with psychopathic features is described as characterized by "a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviors (e.g., fraudulence)." Low levels of withdrawal and high levels of attention-seeking combined with low anxiety are associated with "social potency" and "stress immunity" in psychopathy.:765 Under the specifier, affective and interpersonal characteristics are comparatively emphasized over behavioral components.
|Nomadic (including schizoid and avoidant 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.||These individuals distance themselves from people and society. They are caught up in self-pity as well as being vacant and disconnected from self. They may seem harmless, but these individuals are impulsively violent and brutal towards victims who are weaker than them.|
|Malevolent (including sadistic and paranoid features)||Belligerent, mordant, rancorous, vicious, malignant, brutal, resentful; anticipates betrayal and punishment; desires revenge; truculent, callous, fearless; guiltless.||These individuals have had extremely terrible pasts, and are resentful. They want revenge and will ruthlessly secure their personal boundaries in cold blood. These are brutal and callous individuals who are extremely fearless.|
|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.||These individuals feel they haven't got their due and that society owes them something. They are deeply insecure about their status and power and could be petty thieves or business people. These individuals are very exploitative and greedy, and they belittle people who are vulnerable to manipulation. They also show off their money, valuables and assets.|
|Risk-taking (including histrionic features)||Dauntless, venturesome, intrepid, bold, audacious, daring; reckless, foolhardy, impulsive, heedless; unbalanced by hazard; pursues perilous ventures.||These individuals are easily bored and seek activities that will excite them. These could be brutal assaults, murders, sky diving, pranks, doing dares and putting one's life at risk. The violent activities, such as murder and assault, are not necessarily sadistic in nature but more of a rush or thrill for the perpetrator. These are reckless and bold individuals who have no regard for their own safety or the safety of others.|
|Reputation-defending (including narcissistic features)||Needs to be thought of as infallible, unbreakable, invincible, indomitable, formidable, inviolable; intransigent when status is questioned; overreactive to slights.||These individuals want to be portrayed as tough and fearless. If his or her reputation is questioned the individual becomes furious and explosive, leading to murders or brutal attacks on people.|
|Unprincipled (including narcissistic features)||Deficient conscience; unscrupulous, amoral, disloyal, fraudulent, deceptive, arrogant, exploitative; a conman and charlatan; dominating, contemptuous, vindictive.||Cocky, disrespectful, self-centered, smug and extremely arrogant, What characterizes this group of narcissists is that they seem to be devoid of a conscience, or sense of right and wrong. They are often unconcerned with the welfare of others and are amoral, unscrupulous, and deceptive in their dealings with others. They exude an arrogant sense of self-worth and grandiosity. They are driven by a need to outwit others, which proves that they are smarter than those they prey on. It’s not unusual to find this type of narcissist in jails, prisons, and drug rehabilitation centers although many unprincipled narcissists go through life without running afoul of the law.|
|Tyrannical (including negativistic and sadistic features)||Relishes menacing and brutalising others, forcing them to cower and submit; verbally cutting and scratching, accusatory and destructive; intentionally surly, abusive, inhumane, unmerciful.||Tyrannical sadists are among the more frightening and cruel of the subtypes by appearing to relish menacing and brutalizing others; forcing their victims to cower and submit seems to provide them with a special sense of satisfaction. This subtype of SPD somewhat resembles the explosive sadist but more methodically use violence to terrorize and intimidate rather than release their frustration. Moreover, tyrannical sadists very carefully select their victims, ensuring that their choice will not resist, and they generally have low self-esteem and insecurities that they hide from others; by overwhelming others they can feel superior to them.|
|Spineless (including avoidant personality disorder features)||Basically Insecure, bogus, Spineless, venomous dominance is counterphobic, public swaggering, selects powerless scapegoats, is diminished with group support||They are typically deeply insecure and act like cowards. In anticipation of real danger, they project their hostile fantasies and strike first, hoping thereby to forestall their antagonist and ask questions later. They use aggressive hostility to send the message to others that they aren’t intimidated or fearful, so that they can control their inner feelings and display the exact opposite of how they actually feel. They seek out scapegoats to gang up on, which allows them to assault the exact things that exist within themselves that they want to deny.|
Elsewhere, Millon differentiates ten subtypes (partially overlapping with the above) – covetous, risk-taking, malevolent, tyrannical, malignant, disingenuous, 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."
The following conditions commonly coexist with ASPD:
Personality disorders seem to be caused by a combination of these genetic and environmental influences. Genetically, it is the temperament and the kind of personality a person is born with, and environmentally, it is the way in which a person grows up and the experiences they have had.
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. Aggressiveness and impulsivity are among the possible symptoms of ASPD. Testosterone is a hormone that plays an important role in aggressiveness in the brain. For instance, criminals who have committed violent crimes tend to have higher levels of testosterone than the average person. The effect of testosterone is counteracted by cortisol which facilitates the cognitive control on impulsive tendencies.
One of the neurotransmitters that have been discussed in individuals with ASPD is serotonin, also known as 5HT. A meta-analysis of 20 studies found significantly lower 5-HIAA levels (indicating lower serotonin levels), especially in those who are younger than 30 years of age.
J.F.W. Deakin of University of Manchester's Neuroscience and Psychiatry Unit has discussed additional evidence of a connection between 5HT (serotonin) and 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. 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.
Cavum septi pellucidi (CSP) is a marker for limbic neural maldevelopment, and its presence has been loosely associated with certain mental disorders, such as schizophrenia and post-traumatic stress disorder. One study found that those with CSP had significantly higher levels of antisocial personality, psychopathy, arrests and convictions compared with controls.
The socio-cultural perspective of clinical psychology views disorders as 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.
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.
Researchers have linked physical head injuries with antisocial behavior. Since the 1980s, scientists have associated 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.
ASPD is considered to be among the most difficult personality disorders to treat.[verification needed] 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.[verification needed] 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, which is extremely difficult considering the nature of the disorder, therapeutic techniques are focused on rational and utilitarian arguments against repeating past mistakes. These approaches would focus on the tangible, material value of prosocial behavior and abstaining from antisocial behavior. However, the impulsive and aggressive nature of those afflicted with this disorder may limit the effectiveness of even this form of therapy.
No medications have been approved by the FDA to treat ASPD, although certain psychiatric medications may alleviate conditions sometimes associated with the disorder and with symptoms such as aggression, including antipsychotic, antidepressant or mood-stabilizing medications. Antidepressants, specifically the tricyclic antidepressant, Nortriptyline has been found to help treat individuals with ASPD and substance abuse problems. Additionally, the anticonvulsant Phenytoin has been found to lessen impulsivity and aggressiveness individuals with ASPD.
According to Professor Emily Simonoff of the Institute of Psychiatry, Psychology and Neuroscience, "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."
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 (Hare 1983), suggesting a link between ASPD and AOD abuse and dependence.
A University of Colorado Colorado Springs study comparing personality disorders and Myers-Briggs Type Indicator types found that the disorder had a significant correlation with the Intuitive (N), Thinking (T), and Perceiving (P) preferences.
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 "rationalize" their behavior. 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 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 rationalize. The manual preface contains "special instructions" including "Antisocial personality should always be specified as mild, moderate, or severe." 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 to "dyssocial behavior" for individuals who are predatory and follow more or less criminal pursuits, such as racketeers, dishonest gamblers, prostitutes, and dope peddlers. (DSM-I classified this condition as sociopathic personality disorder, dyssocial type). It would later resurface as the name of a diagnosis in the ICD manual produced by the WHO, later spelled dissocial personality disorder and considered approximately 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 behaviors to enhance consistency in diagnosis between different psychiatrists ('inter-rater 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 behavioral 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 the same diagnosis of antisocial personality disorder. The Pocket Guide to the DSM-5 Diagnostic Exam suggests that a person with ASPD may present "with psychopathic features" if he or she exhibits "a lack of anxiety or fear and a bold, efficacious interpersonal style".
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