| Antisocial personality disorder | |
|---|---|
| Classification and external resources | |
| ICD-10 | F60.2 |
| ICD-9 | 301.7 |
| MeSH | D000987 |
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]
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.[2]
The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders incorporated various concepts of psychopathy/sociopathy/antisocial personality in early versions but, starting with the DSM-III in 1980, used instead a diagnosis of antisocial personality disorder. This was based on some of the criteria put forward by Cleckley but operationalized in behavioral terms and more specifically related to conduct and criminality. The World Health Organization's ICD incorporates a similar diagnosis of Dissocial Personality Disorder. Both the DSM and the ICD state that psychopathy (or sociopathy) are synonyms of their diagnosis.
Psychopathy and sociopathy are terms related to ASPD. ASPD replaced psychopathy as a diagnosis in the DSM but the terms are not identical. Psychopathy is now (like sociopathy) usually seen as a subset of ASPD.[3][4] Many people with this disorder are not violent unless significantly and specifically provoked.
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The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM IV-TR), defines antisocial personality disorder (in Axis II Cluster B) as:[1]
New evidence points to the possibility that children often develop antisocial personality disorder as a result of environmental as well as genetic influence. The individual must be at least 18 years of age to be diagnosed with this disorder (Criterion B), but those commonly diagnosed with ASPD as adults were diagnosed with conduct disorder as children. The prevalence of this disorder is 3% in males and 1% from females, as stated in the DSM IV-TR.
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.[2]
It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
Theodore Millon identified five subtypes of antisocial behavior.[7][8] Any antisocial individual may exhibit none, one or more than one of the following:
The following conditions commonly coexist with antisocial personality disorder:[9]
When combined with alcoholism, people may show frontal function deficits on neuropsychological tests greater than those associated with each condition.[10]
Serotonin Levels: Anti-Social Personality Disorder (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.[11] 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, (p=-0.45), suggesting that 5-HIAA levels in antisocial individuals were about half a standard deviation lower than those who did not have antisocial characteristics [12]
J.F.W. Deakin of University of Manchester's Neuroscience and Psychiatry Unit has discussed additional evidence of 5HT's connection with anti social 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. [13] 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. [14] 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.
Antisocial personality disorder is seen in 3% to 30% of psychiatric outpatients.[1][9] The prevalence of the disorder is even higher in selected populations, like prisons, where there is a preponderance of violent offenders.[15] A 2002 literature review of studies on mental disorders in prisoners stated that 47% of male prisoners and 21% of female prisoners had anti-social personality disorder.[16] 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.[17]
To date there have been no controlled studies reported which found an effective treatment for ASPD, although contingency management programs, or a reward system, has been shown moderately effective for behavioral change.[18] Some studies have found that the presence of ASPD does not significantly interfere with treatment for other disorders, such as substance abuse,[19] although others have reported contradictory findings.[20] Schema Therapy is being investigated as a treatment for antisocial personality disorder.[21]
Psychopathy and sociopathy are terms related to ASPD. ASPD replaced psychopathy as a diagnosis in the DSM but the terms are not identical. Psychopathy is now (like sociopathy) usually seen as a subset of ASPD.
Psychopathy (/saɪˈkɒpəθi/[22]) was, until 1980, the term used for a personality disorder characterized by an abnormal lack of empathy combined with strongly amoral conduct but masked by an ability to appear outwardly normal. The publication of DSM-III changed the name of this mental disorder to Antisocial Personality Disorder and also broadened the diagnostic criteria considerably by shifting from clinical inferences to behavioral diagnostic criteria.[3] The ICD-10 diagnostic criteria of the World Health Organization also lacks psychopathy as a personality disorder, its 1992 manual including Dissocial (Antisocial) Personality Disorder, which encompasses amoral, antisocial, asocial, psychopathic, and sociopathic personalities.[4]
Psychopathy is normally seen as a subset of the antisocial personality disorder, but Blair believes that the antisocial personality disorder and psychopathy may be separate conditions altogether.[23]
Some researchers are critical of the changed diagnostic criteria. Antisocial personality disorder is diagnosed via behavior and social deviant behaviors, whereas a diagnosis of psychopathy also includes affective and interpersonal personality factors. The Hare Psychopathy Checklist is better able to predict future criminality, violence, and recidivism than the diagnosis of ASPD using the DSM-III-R. Robert D. Hare writes that there are also differences between psychopaths and others on "processing and use of linguistic and emotional information" while such differences are small between those diagnosed with ASPD and not.[3][24] However, the Hare Psychopathy Checklist requires the use of a rather long interview and availability of considerable additional information[24] as well as depending in part on judgements of character rather than observed behavior. Hare writes that the field trials for the DSM-IV found personality traits judgements to be as reliable as those diagnostic criteria relying only on behavior but that the personality traits criteria were dropped in part because it was feared that the average clinician would not use them correctly. Hare criticizes the instead used DSM-IV criteria for being poorly empirically tested. In addition, the introductory text description describes the personality characteristics typical of psychopathy, which Hare argues make the manual confusing and actually containing two different sets of criteria. He also argues 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.[3]
The DSM-V working party is recommending a revision of Antisocial Personality Disorder to include "Antisocial/Psychopathic Type", with the diagnostic criteria having a greater emphasis on character than on behavior.[25]
Hare writes that the difference between sociopathy and psychopathy may "reflect the user's views on the origins and determinates of the disorder." The term sociopathy may be preferred by sociologists that see the causes as due to social factors. The term psychopathy may be preferred by psychologists who see the causes as due to a combination of psychological, genetic, and environmental factors.[26]
David T. Lykken proposed psychopathy and sociopathy are two distinct kinds of antisocial personality disorder. He believed psychopaths are born with temperamental differences such as impulsivity, cortical underarousal, and fearlessness that lead them to risk-seeking behavior and an inability to internalize social norms. On the other hand, he claimed that sociopaths have relatively normal temperaments; their personality disorder being more an effect of negative sociological factors like parental neglect, delinquent peers, poverty, and extremely low or extremely high intelligence. Both personality disorders are the result of an interaction between genetic predispositions and environmental factors, but psychopathy leans towards the hereditary whereas sociopathy tends towards the environmental.[27]
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