Antisocial personality disorder

For the sleep disorder, see Advanced sleep phase disorder

Antisocial personality disorder
Classification and external resources
ICD-10	F60.2
ICD-9	301.7
MeSH	D000987

Personality disorders
Cluster A (odd)
Paranoid Schizoid Schizotypal
Cluster B (dramatic)
Antisocial Borderline Histrionic Narcissistic
Cluster C (anxious)
Avoidant Dependent Obsessive-compulsive
Not specified
Depressive Passive–aggressive Sadistic Self-defeating
v t e

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 the term Antisocial Personality Disorder and focused on earlier behavior instead of using personality judgements. The World Health Organization's ICD incorporates a similar diagnosis of Dissocial Personality Disorder. Both the DSM and the ICD state that psychopathy and sociopathy are synonyms of their diagnosis.

Psychopathy and its synonym, sociopathy, are terms related to ASPD. ASPD replaced psychopathy as a diagnosis in the DSM but the terms are not identical. Psychopathy is now usually seen as a subset of ASPD.^[3][4]

Diagnosis

ICD-10

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. Markedly prone 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, asocial, psychopathic, and sociopathic personality (disorder).

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

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.

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.

Further diagnostic considerations

Theodore Millon's subtypes

Theodore Millon identified five subtypes of Anti-Social Personality Disorder.^[8][9] exhibiting all of the following:

• covetous antisocial – variant of the pure pattern where individuals feel that life has not given them their due.
• reputation-defending antisocial – including narcissistic features
• risk-taking antisocial – including histrionic features
• nomadic antisocial – including schizoid, avoidant features
• malevolent antisocial – including sadistic, paranoid features.

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]

Differential diagnosis

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]

Antisocial Personality Disorder and Hormones

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, (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 ^[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.

Serotonin Impulsivity and Aggression

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.

Prognosis

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."^[17]

Epidemiology

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.^[18] 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.^[19] 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.^[20]

Treatment

This section requires expansion.

There has been some research on the treatment of ASPD that showed positive results for therapeutic interventions. ^[21] Some studies have found that the presence of ASPD does not significantly interfere with treatment for other disorders, such as substance abuse,^[22] although others have reported contradictory findings.^[23]Schema Therapy is being investigated as a treatment for antisocial personality disorder.^[24]

Psychopathy and sociopathy

Psychopathy and sociopathy are terms related to ASPD. ASPD was used rather than 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

Psychopathy (/saɪˈkɒpəθi/^[25]) was not used as the official term but referred to 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 DSM-III used the term Antisocial Personality Disorder and changed the diagnostic criteria considerably by shifting from clinical judgements about personality to behavioral diagnostic criteria.^[3] The ICD-10 diagnostic criteria of the World Health Organization its 1992 manual has the similar diagnosis 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.^[26]

Some researchers are critical of the official 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][27] However, the Hare Psychopathy Checklist requires the use of a rather long interview and availability of considerable additional information^[27] 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.^[28]

Sociopathy

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 who consider social factors to be the cause, while the term psychopathy may be preferred by psychologists who consider psychological, biological and genetic factors to also play a role.^[29]

David T. Lykken proposed psychopathy and sociopathy are two distinct kinds of antisocial personality disorder. Lykken reasoned that the different temperaments of people mark how likely that one is to develop antisocial personality disorders; some people are placid and very easy to socialize that, even with moderately incompetent parents, their integration into society is almost automatic; some people are very difficult to integrate and are impulsive, aggressive, and fearless and only the settings of very skillful parents and the right environment, peers, and mentors can socialize the difficult; most people, Lykken said, are of average temperament, between those two extremes. ^[30]. 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; sociopaths are born with average temperaments^[30], their personality disorder being more an effect of negative sociological factors like parental neglect, delinquent peers, poverty, and extremely low or extremely high intelligence. In other words, psychopathy leans towards the hereditary whereas sociopathy tends towards the environmental.^[30]

However, most modern psychologists now use the terms "psychopathy" and "sociopathy" interchangeably. The DSM-5 is proposed to include a new subtype of ASPD referred to as "psychopathic subtype." ^[31]

Cultural influences

Robert 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 many of the individual with ASPD's behavioural tendencies.^[32] While the rise reported may be in part merely a byproduct of the widening use (and abuse) of diagnostic techniques,^{[citation needed]} 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^[33] - 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.^[34]

See also

References

Further Reading

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

Look up antisocial in Wiktionary, the free dictionary.

• Interview with Dr. Martha Stout, author of The Sociopath Next Door on the Living Hero podcast, November 2010.
• "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
• Sociopathic – Research into personality disorders A collaborative to better understand personality disorders such as sociopathy, borderline, paranoid.
• The Unreal World of Narcissists and Sociopaths, with host Jari Chevalier for Living Hero. Numerous experts, including Nina W. Brown, Linda Martinez-Lewi, Gabor Mate, Martha Stout, Philip Zimbardo
• The short film "The Uncommitted Man (1968)" is available for free download at the Internet Archive [more]

v t e DSM personality disorders DSM-III-R only Sadistic · Self-defeating (masochistic) DSM-IV Cluster A (odd) Paranoid · Schizoid · Schizotypal Cluster B (dramatic) Antisocial · Borderline · Histrionic · Narcissistic Cluster C (anxious) Avoidant · Dependent · Obsessive-compulsive Personality disorder not otherwise specified Appendix B (proposed) Depressive · Negativistic (passive-aggressive)

v t e ICD-10 personality disorders Schizotypal Schizotypal Specific Anankastic · Anxious (avoidant) · Dependent · Dissocial · Emotionally unstable · Histrionic · Paranoid · Schizoid · Other Eccentric · Haltlose type · Immature · Narcissistic · Passive-aggressive · Psychoneurotic Unspecified Unspecified Mixed and other Mixed and other