Antisocial personality disorder

Antisocial personality disorder
Synonyms Dissocial personality disorder (DPD), sociopathy
Specialty psychiatry

Antisocial personality disorder (ASPD), also known as sociopathy, is a personality disorder characterized by a long term 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, or impulsive and aggressive behavior.[1][2]

Antisocial personality disorder is the name of the disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Dissocial personality disorder (DPD) 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.[3] 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.[4][5][6][7][8]

Signs and symptoms

Antisocial personality disorder is defined by a pervasive and persistent disregard for morals, social norms, and the rights and feelings of others.[1] Individuals with this personality disorder will typically have no compunction in exploiting others in harmful ways for their own gain or pleasure, and frequently manipulate and deceive other people, achieving this through wit and a facade of superficial charm, or through intimidation and violence. They may display arrogance and think lowly and negatively of others, and lack remorse for their harmful actions and have a callous attitude to those they have harmed.[1][2] Irresponsibility is a core characteristic of this disorder: they can have significant difficulties in maintaining stable employment as well as fulfilling their social and financial obligations, and people with this disorder often lead exploitative, unlawful, or parasitic lifestyles.[1][2][9][10]

Those with antisocial personality disorder are often impulsive and reckless, failing to consider or disregarding the consequences of their actions. They may repeatedly disregard and jeopardize their own safety and the safety of others, and place themselves and others in danger.[1][2] They are often aggressive and hostile and display a disregulated temper, and can lash out violently with provocation or frustration.[1][10] Individuals are prone to substance abuse and addiction, and the abuse of various psychoactive substances is common in this population. These behaviors leads such individuals into frequent conflict with the law, and many people with ASPD have extensive histories of antisocial behavior and criminal infractions stemming back before adulthood.[1][2][9][10]

Serious problems with interpersonal relationships are often seen in those with the disorder. Attachments and emotional bonds are weak, and interpersonal relationships often revolve around the manipulation, exploitation and abuse of others.[1] While they generally have no problems in establishing relationships, they may have difficulties in sustaining and maintaining them.[9] Relationships with family members and relatives are often strained due to their behavior and the frequent problems that these individuals may get into.

Conduct disorder

While antisocial personality disorder is a mental disorder diagnosed in adulthood, it has its precedent in childhood. The DSM-5's criteria for ASPD require that the individual have conduct problems evident by the age of 15. Persistent antisocial behavior as well as a lack of regard for others in childhood and adolescence is known as conduct disorder, and is the precursor of ASPD.[11] About 25-40% of youths with conduct disorder will be diagnosed with ASPD in adulthood.[12]

Conduct disorder (CD) is a disorder diagnosed in childhood that parallels the characteristics found in ASPD, and is characterized by a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate norms are violated. Children with the disorder often display impulsive and aggressive behavior, may be callous and deceitful, and may repeatedly engage in petty crime such as stealing or vandalism or get into fights with other children and adults.[13] This behavior is typically persistent and may be difficult to deter with threat or punishment. Attention deficit hyperactivity disorder (ADHD) is common in this population, and children with the disorder may also engage in substance abuse."[14][15] CD is differentiated from oppositional defiant disorder (ODD) in that children with ODD do not commit aggressive or antisocial acts against other people, animals and property, though many children diagnosed with ODD are subsequently rediagnosed with CD.[16]

Two developmental courses for CD have been identified based on the age at which the symptoms become present. The first is known as the "childhood-onset type" and occurs when conduct disorder symptoms are present before the age of 10 years. This course is often linked to a more persistent life course and more pervasive behaviors, and children in this group express greater levels of ADHD symptoms, neuropsychological deficits, more academic problems, increased family dysfunction, and higher likelihood of aggression and violence.[17] The second is known as the "adolescent-onset type" and occurs when conduct disorder develops after the age of 10 years. Compared to the childhood-onset type, less impairment in various cognitive and emotional functions are present, and the adolescent-onset variety may remit by adulthood.[18] In addition to this differentiation, the DSM-5 provides a specifier for a callous and unemotional interpersonal style, which reflects characteristics seen in psychopathy and are believed to be a childhood precursor to this disorder. Compared to the adolescent-onset subtype, the childhood onset subtype, especially if callous and unemotional traits are present, tend to have a worse treatment outcome.[19]

Causes and pathophysiology

Personality disorders are seen to be caused by a combination and interaction of genetic and environmental influences. Genetically, it is the intrinsic temperamental tendencies as determined by their genetically influenced physiology, and environmentally, it is the social and cultural experiences of a person in childhood and adolescence encompassing their family dynamics, peer influences, and social values.[1]

Genetic

Research into genetic associations in antisocial personality disorder is suggestive that ASPD has some or even a strong genetic basis. Prevalence of ASPD is higher in people related to someone afflicted by the disorder. Twin studies, which are designed to discern between genetic and environmental effects have reported significant genetic influences on antisocial behavior and conduct disorder,[20]

In the specific genes that may be involved, one gene that has seen particular interest in its correlation with antisocial behavior is the gene that encodes for Monoamine oxidase A (MAO-A), an enzyme that breaks down monomamine neurotransmitters such as serotonin and norephinephrine. Various studies examining the gene's relationship to behavior have suggested that variants of the gene that results in less MAO-A being produced, such as the 2R and 3R alleles of the promoter region have associations with aggressive behavior.[21][21][22] The association is also found influenced by negative experience in early life, with children possessing a low-activity variant (MAOA-L) with who experienced such maltreatment being more likely to develop antisocial behavior than those with the high-activity variants (MAOA-H).[23][24] Even when environmental interactions (e.g. emotional abuse) are controlled for, a small association between MAOA-L and aggressive and antisocial behavior remains.[25]

The gene that encodes for the serotonin transporter (SCL6A4), a gene that is heavily researched for its associations with other mental disorders, is another gene of interest in antisocial behavior and personality traits. Genetic associations studies have suggested that the short "S" allele is associated with impulsive antisocial behavior and ASPD in the inmate population.[26] However, research into psychopathy find that the long "L" allele is associated with the Factor 1 traits of psychopathy, which describes its core affective (e.g. lack of empathy, fearlessness) and interpersonal (e.g. grandiosity, manipulativeness) personality disturbances.[27] This is suggestive of two different forms, one associated more with impulsive behavior and emotional dysregulation, and the other with predatory aggression and affective disturbance, of the disorder.[28]

Various other gene candidates for ASPD have been identified by a genome-wide association study published in 2016. Several of these gene candidates are shared with attention-deficit hyperactivity disorder, with which ASPD is comorbid.[29]

Physiological

Hormones and neurotransmitters

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.[30] Aggressiveness and impulsivity are among the possible symptoms of ASPD. Testosterone is a hormone that plays an important role in aggressiveness in the brain.[31] For instance, criminals who have committed violent crimes tend to have higher levels of testosterone than the average person.[31] The effect of testosterone is counteracted by cortisol which facilitates the cognitive control of impulsive tendencies.[31]

One of the neurotransmitters that have been discussed in individuals with ASPD is serotonin, also known as 5HT.[30] 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.[32]

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.[33] 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.[34]

Some studies have found a relationship between monoamine oxidase A and antisocial behavior, including conduct disorder and symptoms of adult ASPD, in maltreated children.[35]

Neurological

Researchers have linked physical head injuries with antisocial behavior.[36][37][38] 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.[36][38] 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."[36][37] 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.[36] Antisocial behavior is associated with decreased grey matter in the right lentiform nucleus, left insula, and frontopolar cortex. Increased volumes have been observed in the right fusiform gyrus, inferior parietal cortex, right cingulate gyrus, and post central cortex.[39]

People that exhibit antisocial behavior demonstrate decreased activity in the prefrontal cortex. The association is more apparent in functional neuroimaging as opposed to structural neuroimaging.[40] The prefrontal cortex is involved in many executive functions, including behavior inhibitions, planning ahead determining consequences of action and differentiating between right and wrong.

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.[41][42][43] One study found that those with CSP had significantly higher levels of antisocial personality, psychopathy, arrests and convictions compared with controls.[43]

Environmental

Family environment

Some studies suggest that the social and home environment has contributed to the development of antisocial behavior.[44] The parents of these children have been shown to display antisocial behavior, which could be adopted by their children.[44]

Cultural influences

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.[45] 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.[46] While the rise reported may be in part merely a byproduct of the widening use (and abuse) of diagnostic techniques,[47] 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[48] – 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.[49]

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.[50]

Diagnosis

DSM IV-TR

The APA's Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM IV-TR), defines antisocial personality disorder (Cluster B):[34]

A) 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. impulsivity 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) There is evidence of conduct disorder with onset before age 15 years.
C) The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode.

Antisocial Personality Disorder (ASPD) falls under the dramatic/erratic cluster of personality disorders, the so-called "Cluster B."

ICD-10

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):[51][52]

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.

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.[52][53]

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.[52]

Psychopathy

Psychopathy is commonly defined as a personality disorder characterized partly by antisocial behavior, a diminished capacity for empathy and remorse, and poor behavioral controls.[8][54][55][56] Psychopathic traits are assessed using various measurement tools, including Canadian researcher Robert D. Hare's Psychopathy Checklist, Revised (PCL-R).[57] "Psychopathy" is not the official title of any diagnosis in the DSM or ICD; nor is it an official title used by other major psychiatric organizations. The DSM and ICD have, however, stated that they have antisocial diagnoses that have been referred to (or include what is referred to) as psychopathy or sociopathy.[8][51][56][58][59]

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.[4][8] 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".[4][5][6][7][8]

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.[4][5] 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.[5][6] 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.[5][6]

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.[13]:765 Under the specifier, affective and interpersonal characteristics are comparatively emphasized over behavioral components.[60]

Other

Theodore Millon suggested 5 subtypes of ASPD.[61][62] However, these constructs are not recognized in the DSM and ICD.

Subtype Features
Nomadic (including schizoid and avoidant features) drifters; roamers, vagrants; Adventurer, itinerant vagabonds, tramps, wanderers; they typically easy to adapt in difficult situations, shrewd and impulsive.
Malevolent (including sadistic and paranoid features) Belligerent, mordant, rancorous, vicious, sadistic, malignant, brutal, resentful; anticipates betrayal and punishment; desires revenge; truculent, callous, fearless; guiltless; many dangerous criminal fits this criteria.
Covetous (including negativistic features) rapacious, begrudging, discontentedly yearning; envious, seek more profit, and avariciously greedy; pleasure more in taking than in having.
Risk-taking (including histrionic features) Dauntless, venturesome, intrepid, bold, audacious, daring; reckless, foolhardy,heedless; unfazed by hazard; pursues perilous ventures.
Reputation-defending (including narcissistic features) Needs to be thought of as infallible, unbreakable, indomitable, formidable, inviolable; intransigent when status is questioned; overreactive to slights.

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."[63]

Comorbidity

ASPD commonly coexists with the following conditions:[64]

When combined with alcoholism, people may show frontal function deficits on neuropsychological tests greater than those associated with each condition.[65]

Treatment

ASPD is considered to be among the most difficult personality disorders to treat.[66][67] 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.[66] 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.[68] Studies have shown that outpatient therapy is not likely to be successful, but the extent to which persons with ASPD are entirely unresponsive to treatment may have been exaggerated.[69]

Those with ASPD may stay in treatment only as required by an external source, such as parole conditions. Residential programs that provide a carefully controlled environment of structure and supervision along with peer confrontation have been recommended.[66] There has been some research on the treatment of ASPD that indicated positive results for therapeutic interventions.[70] Psychotherapy also known as talk therapy is found to help treat patients with ASPD.[71]Schema therapy is also being investigated as a treatment for ASPD.[72] 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.[73] Some studies have found that the presence of ASPD does not significantly interfere with treatment for other disorders, such as substance abuse,[74] although others have reported contradictory findings.[75]

Therapists working with individuals with ASPD may have considerable negative feelings toward patients with extensive histories of aggressive, exploitative, and abusive behaviors.[66] 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 with this disorder may limit the effectiveness of even this form of therapy.[76]

The use of medications in treating antisocial personality disorder is still poorly explored, and no medications have been approved by the FDA to specifically treat ASPD.[77] A 2010 Cochrane review of studies that explored the use of pharmaceuticals in ASPD patients, of which 8 studies met the selection criteria for review, concluded that the current body of evidence was inconclusive for recommendations concerning the use of pharmaceuticals in treating the various issues of ASPD.[78] Nonetheless psychiatric medications such as antipsychotics, antidepressants, and mood stabilizers can be used to control symptoms such as aggression and impulsivity, as well as treat disorders that may co-occur with ASPD for which medications are indicated.[77]

Prognosis

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."[79]

Epidemiology

ASPD is seen in 3% to 30% of psychiatric outpatients.[64] The prevalence of the disorder is even higher in selected populations, like prisons, where there is a preponderance of violent offenders.[80] A 2002 literature review of studies on mental disorders in prisoners stated that 47% of male prisoners and 21% of female prisoners had ASPD.[81] 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.[82]

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.[83]

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 "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.[84] 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.[85]

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".[86] 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.[87]

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".[60]

See also

References

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