251 Antisocial Personality Disorder

DSM-IV-TR criteria

• 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 groups for arrest
2. deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
3. impulsive behavior 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

• 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.

Associated Features

• Most essential diagnostic feature of ASPD is the pervasive disregard for and violation of the rights of others (SAMHSA, 2009).
• They appear deficient in their ability to experience shared or reciprocal emotions such as guilt or love (SAMHSA, 2009).
• They have a disdain for society’s rules. They know right from wrong, but they simply do not care (SAMHSA, 2009).
• Antisocial Personality Disorder (ASPD) is considered to be a chronic illness in which an individual’s manner of thinking, perceiving situations, and empathizing with others is deemed morally wrong in his or her society.
• Antisocial Personality disorder is also sometimes called psychopathy or sociopathic personality disorder. Normally, an individual suffering from Antisocial Personality Disorder will display a pattern of lying, stealing, running away from home, and having difficulty upholding the law. They also tend to have problems with the abuse of illicit drugs and alcohol.
  • The fearlessness hypothesis states they psychopaths have a higher fear threshold, or the frightening things for most people, like a burning building, or gunshots, have little effect on these individuals. It is possible there is no association with certain stimuli or cues with punishment or danger, such as an alarm going off.
  • Psychopaths do not show normal anxiety reactions when anticipating a punishment response and they were slow at learning how to stop responding when punishment was inevitable.
  • They were unable to avoid punishment because they have problems learning how to properly respond to anxiety-producing situations. Impulsive behaviors are unrestrained because the individuals do not successfully avoid punishment.
  • These inhibited responses that can be learned in the face of cues that signal upcoming punishment or also known as passive avoidance earning, and appears to be deficient in psychopaths and in individuals with ASPD.
  • A behavioral activation stem may, at the least, be normal, and at the most, be overactive in avoiding the punishment by any means necessary. Psychopaths are persistent in situations where failure is likely, so they set sites on a goal and very little if anything will stop him or her from attaining their goal.
• The majority of people who have a substance use disorder in conjuncture with ASPD are not sociopathic except as a result of their addiction.
• Most people that are diagnosed with ASPD are not true psychopaths.
• Individuals with ASPD violate the rights of others through deceit or aggression.
  • They will lie repeatedly or will con other people for profit or pleasure.
  • They are impulsive and lack the ability to plan ahead.
  • Their behavior will generally be irresponsible, they will often be irritable, and they will often get into physical fights.
  • An important criterion is that they will be indifferent to having hurt or mistreated another person, or they will rationalize this behavior.
• They are also unable to hold down a steady job and will often renege on financial commitments or steal from others.

Substance Use Among People with ASPD

They use substances in a polydrug pattern, meaning more than one drug at a time, involving alcohol, marijuana, heroin, cocaine, and methamphetamine.

The illicit drug culture can correspond with their view of the world as fast-paced and dramatic, which helps to support their need for a heightened self-image.

(SAMHSA, 2009)

Child vs. Adult Presentation

The disorder cannot be diagnosed until the age of 18, but symptoms must be present before the age of fifteen and diagnosed as Conduct Disorder. Studies show that 60% of all children who suffer from Conduct Disorder will later develop ASPD. It is when Conduct Disorder is left undiagnosed and untreated that it is most likely to develop into ASPD.

The rates of ASPD are much higher for young adults than for older adults.

A well known notion about ASPD is that these disorders begin early on in a child’s life. The greater the number of antisocial behaviors the child demonstrates, the more likely that child will develop ASPD later on in life. This is the single best predictor of developing ASPD or psychopathy. Conduct disorder is closely related in behaviors, such as theft, truancy, and school discipline problems.

Gender and Cultural Differences in Presentation

• Men are more likely than women to be diagnosed with ASPD. Studies show that about 3% of males and about 1% of females receive this diagnosis.
  • Women are more likely to be misdiagnosed as Borderline Personality Disorder (SAMHSA, 2009).
  • Determining the type and extent of antisocial symptoms for women is not easy, but it is important due to the high prevalence of neglectful parenting in women with substance use disorders and ASPD (SAMHSA, 2009).
• Studies also show that in clinical settings, the prevalence rate of ASPD ranges anywhere from 3 to 30 percent of the clinical population, with an increased prevalence with substance abuse facilities and prisons.
• ASPD rates are much higher among young adults than older adults.
• Culture seems to play a large role in the prevalence rates of Antisocial Personality Disorder.
  • For example, in Taiwan the prevalence rate is 0.14% while in Canada it is 3.7%. The only reasonable explanation for the lower rate in Taiwan is that the Taiwanese report antisocial behaviors more often than other countries.
  • In contrast, Taiwan has a lower prevalence rate than the countries surrounding it. Studies show that rates in Hong Kong and South Korea are similar to those in the U.S. and Europe; studies also show that the countries with high rates in ASPD also have high rates in other disorders with which there is typically co-morbidity. This disorder is more common among individuals with a relatively low socioeconomic status within their culture.

Epidemiology

• 3% of males and about 1% of females in community samples show Antisocial Personality Disorder. Clinical settings can have between a 3% to 30% prevalence rate depending on the characteristics of the populations being sampled.
• Higher rates are seen with substance abuse treatment settings and forensic or prison setting. In the male prison populations, 20% or more have Antisocial PD (SAMHSA, 2009).
• Most recent epidemiology studies put prevalence rates in the general population between 1% and 4%, and prevalence in an outpatient psychiatric setting at around 3% to 4%.
• The course is chronic, but the disorder may become less evident or remit with age, especially about age 40. This remission tends to be particularly evident regarding criminal behavior, though there is likely a decrease in the full spectrum of behavior.
• 10 to 20% of homeless women, and 20 to 25% of homeless men receive diagnosis of Antisocial PD (SAMHSA, 2009).
• 34.7% of alcoholics, 27% of heroin addicts, 30.4% of cocaine addicts have Antisocial Personality Disorder
  • The percentage is in the mid 40s for those addicted to 2 of the 3 drugs listed above.
  • 59.8% of those addicted to all 3 of the drugs have Antisocial Personality Disorder

(SAMHSA, 2009)

Etiology

• Little is known about the causes of Antisocial Personality Disorder. There are several factors which complicate detecting the cause.
  • First, most individuals with this disorder do not perceive any fault within themselves and, therefore, will not seek out clinical assistance.
  • Another reason is because many of the disorders dealing with personality are similar to one another, making it difficult to differentiate one disorder from another.
• There seems to be a strong genetic link to ASPD development and criminality.
• Although researchers aren’t entirely sure, they do believe that genetics have something to do with the development of Antisocial Personality Disorder.
  • Even though some researchers believe that genetics has some to do with a person developing ASPD, they mainly believe that a person’s environment is the main cause.
  • One perspective looks at the parents for answers. Studies have shown that parents who passively give in to their children’s whims and do not take disciplinary action can aid in the development of antisocial personalities. Their children may perceive their parents behavior as uncaring and will continue to behave poorly because they have not been conditioned to behave otherwise.
• They often exhibit signs of antisocial behavior from 15 to 18 years of age, such as unlawful behavior, deceitfulness, consistent irresponsibility, and lack of remorse.
  • Evidence of similar behaviors even before the age of 15.
  • When antisocial behavior occurs without any signs of it during adolescence, the DSM-IV diagnosis is Adult Antisocial Behavior.
• A history of childhood abuse, including harsh and neglectful care giving, is believed to result in the adult individual with ASPD neglecting others’ needs and feelings.
• Some suggest that individuals with ASPD exhibited difficult temperaments in childhood, eliciting hostile reactions in caregivers and reinforcing withdrawal from others.
• Developmental examinations of ASPD suggest that children who are repeatedly rejected by their normative peer group and who are more involved in deviant peer groups are more likely to develop ASPD.
• Also, the under-arousal hypothesis is given credit in that it states that individuals with personality disorders, in general, including ASPD have low levels of arousal in their brain’s cortex and is one reason why these individuals exhibit antisocial behaviors.
• More research has been conducted on ASPD than any other Personality Disorder.
• Environmental factors help to influence the development of psychopathy, criminal behavior and other conditions.
• The fearlessness hypothesis states they psychopaths have a higher fear threshold, or the frightening things for most people, like a burning building, or gunshots, have little effect on these individuals. It is possible there is no association with certain stimuli or cues with punishment or danger, such as an alarm going off.
• Psychopaths do not show normal anxiety reactions when anticipating a punishment response and they were slow at learning how to stop responding when punishment was inevitable.
• Inability to avoid punishment because of problems learning how to properly respond to anxiety-producing situations.
• Impulsive behaviors are unrestrained because the individuals do not successfully avoid punishment.
• These inhibited responses that can be learned in the face of cues that signal upcoming punishment or also known as passive avoidance learning, and appears to be deficient in psychopaths and in individuals with ASPD.

Empirically supported treatments

• There is currently no permanent treatment for Antisocial Personality Disorder.
• As stated above, individuals with ASPD rarely see themselves as having a problem and are not motivated to enter treatment willingly.
• Many therapists do not see significant improvement throughout the course of counseling, as the patients tend to be manipulative and uncooperative.
• The patients have also been known to fake improvement in order to end their treatment.
• Even if treatment is successful for a patient, relapse is very likely to occur shortly after treatment sessions have ceased.
• ASPD is still not completely understood, so the use of medications is not yet a safe treatment option.
• Also, since ASPD is resistant to treatment; suicide, alcoholism, vagrancy, and social isolation are very common among these patients.
• Antisocial personality disorder is highly unresponsive to any form of treatment, in part because persons with APD rarely seek treatment voluntarily. If they do seek help, it is usually in an attempt to find relief from depression or other forms of emotional distress. Although there are medications that are effective in treating some of the symptoms of the disorder, noncompliance with medication regimens or abuse of the drugs prevents the widespread use of these medications.
• The most successful treatment programs for APD are long-term structured residential settings in which the patient systematically earns privileges as he or she modifies behavior. In other words, if a person diagnosed with APD is placed in an environment in which they cannot victimize others, their behavior may improve. It is unlikely, however, that they would maintain good behavior if they left the disciplined environment.
• If some form of individual psychotherapy is provided along with behavior modification techniques, the therapist’s primary task is to establish a relationship with the patient, who has usually had very few healthy relationships in his or her life and is unable to trust others. The patient should be given the opportunity to establish positive relationships with as many people as possible and be encouraged to join self-help groups or prosocial reform organizations.
• Unfortunately, these approaches are rarely if ever effective. Many persons with APD use therapy sessions to learn how to turn “the system” to their advantage. Their pervasive pattern of manipulation and deceit extends to all aspects of their life, including therapy. Generally, their behavior must be controlled in a setting where they know they have no chance of getting around the rules.

Counseling Tips for Clients with Antisocial Personality Disorders (SAMHSA, 2009)

Prognosis

APD usually follows a chronic and unremitting course from childhood or early adolescence into adult life. The impulsiveness that characterizes the disorder often leads to a jail sentence or an early death through accident, homicide or suicide . There is some evidence that the worst behaviors that define APD diminish by midlife; the more overtly aggressive symptoms of the disorder occur less frequently in older patients. This improvement is especially true of criminal behavior but may apply to other antisocial acts as well.

Prevention

Measures intended to prevent antisocial personality disorder must begin with interventions in early childhood, before youths are at risk for developing conduct disorder. Preventive strategies include education for parenthood and other programs intended to lower the incidence of child abuse; Big Brother/Big Sister and similar mentoring programs to provide children at risk with adult role models of responsible and prosocial behavior; and further research into the genetic factors involved in APD.

ASPD and Brain Structures

• There is a subtle structural deficit in the prefrontal cortex of uninstitutionalized antisocial, violent persons with psychopathic-like behavior who live in community settings
• There is a much less observable volume reductions specific to the prefrontal gray matter that is associated with APD
  • APD had a 11% reduction in prefrontal gray matter when compared to a control group, a 13.9% reduction when compared to a substance-dependent group, and a 14% reduction when compared to a psychiatric control group
• APD also have reduced autonomic activity during social stressors
  • Those with APD who also had reduced prefrontal gray matter volume also had lower skin conductance activity during social stressors
• Prefrontal cortex is part of a neural circuit that plays a central role in fear conditioning and stress responsivity
  • Poor conditioning is theorized to be associated with poor development of the conscience, and those who are less autonomically responsive to aversive stimuli such as social criticism during childhood would be less susceptible to socializing punishments, and hence become predisposed to antisocial behavior
  • Antisocial groups show poor fear conditioning
• Prefrontal cortex is involved in the regulation of arousal, and deficits in autonomic and central nervous system arousal in antisocial persons have been viewed as facilitating a stimulation-seeking, antisocial behavioral response to compensate for such under arousal
• Patients with prefrontal damage fail to give anticipatory autonomic response to choice options that are risky, and make bad choices even when they are aware of the more advantageous response option
  • Inability to reason and decide advantageously in risky situations is likely to contribute to the impulsivity, rule breaking, and reckless, irresponsible behavior that make up 4 of the 7 traits of APD
• Previous research has shown that patients with major damage to the prefrontal cortex show dysregulation of cognition, emotion, and behavior, which predisposes to antisociality
• Those who are antisocial have visually imperceptible but meaningful and significant reductions in prefrontal gray matter volume in addition to psycho-physiological deficits in emotion reacitivity
• It is unlikely that only one brain mechanism is compromised in APD
  • Functional imaging has indicated multiple cortical and subcortical deficits in violent offenders
• Limitations
  • It is possible that it is only those substance abusers who also have APD who show the prefrontal deficit since substance abusers have been shown to have lower than normal prefrontal gray matter volumes
  • No study of gray matter volume loss in schizophrenia has controlled for crime and violence
  • Only men were assessed, so cannot be generalized to women
  • Only an association has been shown, not any causality
  • Does not delineate which subregion of the prefrontal cortex is particularly reduced in volume
    • It is predicted that the orbitofrontal region would be the most impaired and the dorsolateral region relatively spared

(Raine, Lencz, Bihrle, LaCasse, & Colletti, 2000)

Portrayed in Popular Culture

• The Silence of the Lambs (1991)
• American Psycho (2000)
• The Joker from Batman
  • Anarchy is his guiding philosophy
• Lord Voldemort from Harry Potter
  • He is a classic model of a conduct disorder case developing into Antisocial Personality Disorder

DSM-V Changes

• Reformulated as the Antisocial/Psychopathic Type
• Individuals who match this personality disorder type are arrogant and self-centered, and feel privileged and entitled. They have a grandiose, exaggerated sense of self-importance and they are primarily motivated by self-serving goals.
• They seek power over others and will manipulate, exploit, deceive, con, or otherwise take advantage of others, in order to inflict harm or to achieve their goals.
• They are callous and have little empathy for others’ needs or feelings unless they coincide with their own. They show disregard for the rights, property, or safety of others and experience little or no remorse or guilt if they cause any harm or injury to others.
• They may act aggressively or sadistically toward others in pursuit of their personal agendas and appear to derive pleasure or satisfaction from humiliating, demeaning dominating, or hurting others.
• They also have the capacity for superficial charm and ingratiation when it suits their purposes.
• They profess and demonstrate minimal investment in conventional moral principles and they tend to disavow responsibility for their actions and to blame others for their own failures and shortcomings.
• Individuals with this personality type are temperamentally aggressive and have a high threshold for pleasurable excitement. They engage in reckless sensation-seeking behaviors, tend to act impulsively without fear or regard for consequences, and feel immune or invulnerable to adverse outcomes of their actions.
• Their emotional expression is mostly limited to irritability, anger, and hostility; acknowledgment and articulation of other emotions, such as love or anxiety, are rare.
• They have little insight into their motivations and are unable to consider alternative interpretations of their experiences.
• Individuals with this disorder often engage in unlawful and criminal behavior and may abuse alcohol and drugs. Extremely pathological types may also commit acts of physical violence in order to intimidate, dominate, and control others.
• They may be generally unreliable or irresponsible about work obligations or financial commitments and often have problems with authority figures.

(APA, 2010)

For More Information, Please Read

• Luntz, B.K., & Widom, C.S. (1994). Antisocial personality disorder in abused and neglected children grown up. American Journal of Psychiatry, 151(5), 670-675.

Links

• Antisocial Personality Disorder
• All Things Considered on NPR covers a story on the brain of a psycopathic person.