Antisocial personality disorder From Wikipedia, the free encyclopedia Jump to navigationJump to search Not to be confused with Asociality or Anti-social behavior. "ASPD" redirects here. For the sleep disorder, see Advanced sleep phase disorder. For the former trade union, see Amalgamated Society of Painters and Decorators. For the institution formerly the Alaska State Program for the Deaf, see Alaska State School for the Deaf and Hard of Hearing. Antisocial personality disorder Other names Dissocial personality disorder (DPD), sociopathy Specialty Psychiatry Symptoms Pervasive deviance, deception, impulsivity, irritability, aggression, recklessness, manipulation and callous and unemotional traits Usual onset Childhood or early adolescence[1] Duration Long term[2] Risk factors Family history, poverty[2] Differential diagnosis Conduct disorder, Narcissistic personality disorder, Substance use disorder, bipolar disorder, borderline personality disorder, schizophrenia, criminal behavior[2] Frequency 1.8% during a year[2] Personality disorders Cluster A (odd) ParanoidSchizoidSchizotypal Cluster B (dramatic) AntisocialBorderlineHistrionicNarcissistic Cluster C (anxious) AvoidantDependentObsessive–compulsive Not otherwise specified Depressive DepressiveCyclothymic Others Passive–aggressiveMasochisticSadisticPsychopathyHaltloseImmaturePost-traumatic organic vte Antisocial personality disorder (ASPD or infrequently APD) is a personality disorder characterized by a long-term pattern of disregard for, or violation of, the rights of others as well as a difficulty sustaining long term relationships.[3] A weak or nonexistent conscience is often apparent, as well as a history of rule-breaking that can sometimes lead to law-breaking, a tendency towards substance abuse,[3] and impulsive and aggressive behaviour.[4][5] Antisocial behaviors often have their onset before the age of 8, and in nearly 80% of ASPD cases, the subject will develop their first symptoms by age 11.[6] The Prevalence of ASPD peaks in people age 24 to 44 years old, and often decreases in people age 45 to 64 years.[6] In the United States, the rate of antisocial personality disorder in the general population is estimated between 0.2 and 3.3 percent.[7] However, settings can greatly influence the prevalence of ASPD. In a study by Donald W. Black MD, a random sampling of 320 newly incarcerated offenders found ASPD was present in over 35 percent of those surveyed.[8] Antisocial personality disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), while the equivalent concept of dissocial personality disorder (DPD) is defined in the International Statistical Classification of Diseases and Related Health Problems (ICD); the primary theoretical distinction between the two is that antisocial personality disorder focuses on observable behaviours, while dissocial personality disorder focuses on affective deficits.[9] Otherwise, both manuals provide similar criteria for diagnosing the disorder.[10] Both have also stated that their diagnoses have been referred to, or include what is referred to, as psychopathy or sociopathy. However, some researchers have drawn distinctions between the concepts of antisocial personality disorder and psychopathy, with many researchers arguing that psychopathy is a disorder that overlaps with but is distinguishable from ASPD.[11][12][13][14][15] Contents 1 Signs and symptoms 1.1 Conduct disorder 1.2 Comorbidity 2 Causes 2.1 Genetic 2.2 Physiological 2.3 Environmental 2.4 ICD-10 2.5 Psychopathy 2.6 Other 3 Treatment 4 Prognosis 5 Epidemiology 6 History 7 See also 8 References 9 Further reading 10 External links 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.[4] Although behaviors vary in degree, individuals with this personality disorder will typically have limited compunction in exploiting others in harmful ways for their own gain or pleasure, and frequently manipulate and deceive other people. While some do so through a façade of superficial charm, others do so through intimidation and violence.[16] They may display arrogance, think lowly and negatively of others, and lack remorse for their harmful actions and have a callous attitude towards those they have harmed.[4][5] Irresponsibility is a core characteristic of this disorder; most 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.[4][5][17][18] 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, which can place both themselves and other people in danger.[4][5][19] They are often aggressive and hostile, with poorly regulated tempers, and can lash out violently with provocation or frustration.[4][18] Individuals are prone to substance use disorders and addiction, and the non-medical use of various psychoactive substances is common in this population. These behaviors can in some instances lead such individuals into frequent conflict with the law, and many people with ASPD have extensive histories of antisocial behavior and criminal infractions stemming back to adolescence or childhood.[4][5][17][18] Moderate to serious problems with interpersonal relationships are often seen in those with the disorder. People with antisocial personality disorder usually form poor or reduced attachments and emotional bonds, and interpersonal relationships often revolve around the exploitation and abuse of others.[4] They may have difficulties in sustaining and maintaining relationships, and some have difficulty entering them.[17] Conduct disorder Main article: Conduct disorder While antisocial personality disorder is a mental disorder diagnosed in adulthood, it has its precedent in childhood.[20] The DSM-5's criteria for ASPD require that the individual have conduct problems evident by the age of 15.[16] 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.[21] About 25–40% of youths with conduct disorder will be diagnosed with ASPD in adulthood.[22] 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.[23] 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 use.[24][25] 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 re-diagnosed with CD.[26] 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.[27] 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.[28] 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, tends to have a worse treatment outcome.[29] Comorbidity ASPD commonly coexists with the following conditions:[30] Anxiety disorders Depressive disorder Impulse control disorders Substance-related disorders Somatization disorder Attention deficit hyperactivity disorder Bipolar disorder Borderline personality disorder Histrionic personality disorder Narcissistic personality disorder Sadistic personality disorder When combined with alcoholism, people may show frontal function deficits on neuropsychological tests greater than those associated with each condition.[31] Alcohol Use Disorder is likely caused by lack of impulse and behavioral control exhibited by Antisocial Personality Disorder patients.[32] The rates of ASPD tends to register around 40-50% in male alcohol and opiate addicts.[33] However, it is important to remember this is not a causal relationship, but rather a plausible consequence of cognitive deficits as a result of ASPD. Causes Personality disorders are seen to be caused by a combination and interaction of genetic and environmental influences.[34] 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.[4] People with an antisocial or alcoholic parent are considered to be at higher risk. Fire-setting, and cruelty to animals during childhood are also linked to the development of antisocial personality. The condition is more common in males than in females, and among incarcerated populations.[34][16] Genetic Research into genetic associations in antisocial personality disorder suggests 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.[35] 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 monoamine neurotransmitters such as serotonin and Norepinephrine. Various studies examining the genes' 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 in men.[36][37] The association is also influenced by negative experience in early life, with children possessing a low-activity variant (MAOA-L) who experience such maltreatment being more likely to develop antisocial behavior than those with the high-activity variant (MAOA-H).[38][39] Even when environmental interactions (e.g. emotional abuse) are controlled for, a small association between MAOA-L and aggressive and antisocial behavior remains.[40] 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.[41] 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.[42] 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.[43] 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. Furthermore, the study found that those who carry 4 mutations on chromosome 6 are 50 percent more likely to develop antisocial personality disorder than those who do not.[44] 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.[45] Aggressiveness and impulsivity are among the possible symptoms of ASPD. Testosterone is a hormone that plays an important role in aggressiveness in the brain.[46] For instance, criminals who have committed violent crimes tend to have higher levels of testosterone than the average person.[47][citation needed] The effect of testosterone is counteracted by cortisol which facilitates the cognitive control of impulsive tendencies.[48] One of the neurotransmitters that has been discussed in individuals with ASPD is serotonin, also known as 5HT.[45] 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.[49] 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.[50] 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.[51][16] Some studies have found a relationship between monoamine oxidase A and antisocial behavior, including conduct disorder and symptoms of adult ASPD, in maltreated children.[52] Neurological Antisocial behavior may be related to head trauma.[53] 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.[54] Intellectual and cognitive ability is often found to be impaired or reduced in the ASPD population.[55] Contrary to stereotypes in popular culture of the "psychopathic genius", antisocial personality disorder is associated with both reduced overall intelligence and specific reductions in individual aspects of cognitive ability.[55][56] These deficits also occur in general-population samples of people with antisocial traits[57] and in children with the precursors to antisocial personality disorder.[58] People that exhibit antisocial behavior tend to demonstrate decreased activity in the prefrontal cortex. The association is more apparent in functional neuroimaging as opposed to structural neuroimaging.[59] The prefrontal cortex is involved in many executive functions, including behavior inhibitions, planning ahead, determining consequences of action, and differentiating between right and wrong. However, some investigators have questioned whether the reduced volume in prefrontal regions is associated with antisocial personality disorder, or whether they result from co-morbid disorders, such as substance use disorder or childhood maltreatment.[60] Moreover, it remains an open question whether the relationship is causal, i.e., whether the anatomical abnormality causes the psychological and behavioral abnormality, or vice versa.[60] 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.[61][62][63] One study found that those with CSP had significantly higher levels of antisocial personality, psychopathy, arrests and convictions compared with controls.[63] Environmental Family environment Many studies suggest that the social and home environment has contributed to the development of antisocial behavior.[45] The parents of these children have been shown to display antisocial behavior, which could be adopted by their children.[45] A lack of parental stimulation and affection during early development leads to high levels of cortisol with the absence of balancing hormones such as oxytocin which disrupts and overloads the child's stress response systems, which is thought to lead to underdevelopment of the child's brain that deals with emotion, empathy and ability to connect to other humans on an emotional level. According to Dr. Bruce Perry in his book The Boy Who Was Raised as a Dog, "the [infant's developing] brain needs patterned, repetitive stimuli to develop properly. Spastic, unpredictable relief from fear, loneliness, discomfort, and hunger keeps a baby's stress system on high alert. An environment of intermittent care punctuated by total abandonment may be the worst of all worlds for a child."[64] Cultural influences The sociocultural perspective of clinical psychology views disorders as influenced by cultural aspects; since cultural norms differ significantly, mental disorders such as ASPD are viewed differently.[65] 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.[66]: 136 While the rise reported may be in part merely a byproduct of the widening use (and abuse) of diagnostic techniques,[67] 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[68] – it has been suggested that the erosion of collective standards may indeed serve to release the individual with latent ASPD from their previously prosocial behavior.[66]: 136–7 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.[69] Controversial clinical psychiatrist Pierre-Édouard Carbonneau suggested that the problem with legal forced admittance is the rate of failure when diagnosing ASPD. He contends that the possibility of diagnosing and coercing a patient into prescribing medication to someone without ASPD, but is diagnosed with ASPD, could be potentially disastrous. But the possibility of not diagnosing ASPD and seeing a patient go untreated because of a lack of sufficient evidence of cultural or environmental influences is something a psychiatrist must ignore; and in his words, "play it safe".[70] 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):[71][72] It is characterized by at least 3 of the following: Callous unconcern for the feelings of others; Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations; Incapacity to maintain enduring relationships, though having no difficulty in establishing them; Very low tolerance to frustration and a low threshold for discharge of aggression, including violence; Incapacity to experience guilt or to profit from experience, particularly punishment; 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.[72][73] 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.[72] Psychopathy Main article: 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.[15][74][75][76] Psychopathic traits are assessed using various measurement tools, including Canadian researcher Robert D. Hare's Psychopathy Checklist, Revised (PCL-R).[77] "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, however, state that their antisocial diagnoses are at times referred to (or include what is referred to) as psychopathy or sociopathy.[15][71][76][78][79] American psychiatrist Hervey Cleckley's work[80] on psychopathy formed the basis of the diagnostic criteria for ASPD, and the DSM states ASPD is often referred to as psychopathy.[11][15] However, critics argue ASPD is not synonymous with psychopathy as the diagnostic criteria are not the same, since criteria relating to personality traits are emphasized relatively less in the former. These differences exist in part because it was believed 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".[11][12][13][14][15] Although the diagnosis of ASPD covers two to three times as many prisoners than the diagnosis of psychopathy, Robert Hare believes the PCL-R is better able to predict future criminality, violence, and recidivism than a diagnosis of ASPD.[11][12] He suggests 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.[12][13] Additionally, Hare argued 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.[12][13] 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.[23]: 765 Under the specifier, affective and interpersonal characteristics are comparatively emphasized over behavioral components.[81] Other Theodore Millon suggested 5 subtypes of ASPD.[82][83] However, these constructs are not recognized in the DSM and ICD. Subtype Features Nomadic antisocial (including schizoid and avoidant features) Drifters; roamers, vagrants; adventurer, itinerant vagabonds, tramps, wanderers; they typically adapt easily in difficult situations, shrewd and impulsive. Mood centers in doom and invincibility. Malevolent antisocial (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 criminals, including serial killers. Covetous antisocial (including negativistic features) Rapacious, begrudging, discontentedly yearning; hostile and domineering; envious, avaricious; pleasures more in taking than in having. Risk-taking antisocial (including histrionic features) Dauntless, venturesome, intrepid, bold, audacious, daring; reckless, foolhardy, heedless; unfazed by hazard; pursues perilous ventures. Reputation-defending antisocial (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."[66]:
Antisocial personality disorder
| Antisocial personality disorder | |
|---|---|
| Other names | Dissocial personality disorder (DPD), sociopathy |
| Specialty | Psychiatry |
| Symptoms | Pervasive deviance, deception, impulsivity, irritability, aggression, recklessness, manipulation and callous and unemotional traits |
| Usual onset | Childhood or early adolescence[1] |
| Duration | Long term[2] |
| Risk factors | Family history, poverty[2] |
| Differential diagnosis | Conduct disorder, Narcissistic personality disorder, Substance use disorder, bipolar disorder, borderline personality disorder, schizophrenia, criminal behavior[2] |
| Frequency | 1.8% during a year[2] |
| Personality disorders |
|---|
| Cluster A (odd) |
| Cluster B (dramatic) |
| Cluster C (anxious) |
| Not otherwise specified |
| Depressive |
| Others |
Antisocial personality disorder (ASPD or infrequently APD) is a personality disorder characterized by a long-term pattern of disregard for, or violation of, the rights of others as well as a difficulty sustaining long term relationships.[3] A weak or nonexistent conscience is often apparent, as well as a history of rule-breaking that can sometimes lead to law-breaking, a tendency towards substance abuse,[3] and impulsive and aggressive behaviour.[4][5] Antisocial behaviors often have their onset before the age of 8, and in nearly 80% of ASPD cases, the subject will develop their first symptoms by age 11.[6] The Prevalence of ASPD peaks in people age 24 to 44 years old, and often decreases in people age 45 to 64 years.[6] In the United States, the rate of antisocial personality disorder in the general population is estimated between 0.2 and 3.3 percent.[7] However, settings can greatly influence the prevalence of ASPD. In a study by Donald W. Black MD, a random sampling of 320 newly incarcerated offenders found ASPD was present in over 35 percent of those surveyed.[8]
Antisocial personality disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), while the equivalent concept of dissocial personality disorder (DPD) is defined in the International Statistical Classification of Diseases and Related Health Problems (ICD); the primary theoretical distinction between the two is that antisocial personality disorder focuses on observable behaviours, while dissocial personality disorder focuses on affective deficits.[9] Otherwise, both manuals provide similar criteria for diagnosing the disorder.[10] Both have also stated that their diagnoses have been referred to, or include what is referred to, as psychopathy or sociopathy. However, some researchers have drawn distinctions between the concepts of antisocial personality disorder and psychopathy, with many researchers arguing that psychopathy is a disorder that overlaps with but is distinguishable from ASPD.[11][12][13][14][15]
Signs and symptoms[edit]
Antisocial personality disorder is defined by a pervasive and persistent disregard for morals, social norms, and the rights and feelings of others.[4] Although behaviors vary in degree, individuals with this personality disorder will typically have limited compunction in exploiting others in harmful ways for their own gain or pleasure, and frequently manipulate and deceive other people. While some do so through a façade of superficial charm, others do so through intimidation and violence.[16] They may display arrogance, think lowly and negatively of others, and lack remorse for their harmful actions and have a callous attitude towards those they have harmed.[4][5] Irresponsibility is a core characteristic of this disorder; most 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.[4][5][17][18]
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, which can place both themselves and other people in danger.[4][5][19] They are often aggressive and hostile, with poorly regulated tempers, and can lash out violently with provocation or frustration.[4][18] Individuals are prone to substance use disorders and addiction, and the non-medical use of various psychoactive substances is common in this population. These behaviors can in some instances lead such individuals into frequent conflict with the law, and many people with ASPD have extensive histories of antisocial behavior and criminal infractions stemming back to adolescence or childhood.[4][5][17][18]
Moderate to serious problems with interpersonal relationships are often seen in those with the disorder. People with antisocial personality disorder usually form poor or reduced attachments and emotional bonds, and interpersonal relationships often revolve around the exploitation and abuse of others.[4] They may have difficulties in sustaining and maintaining relationships, and some have difficulty entering them.[17]
Conduct disorder[edit]
While antisocial personality disorder is a mental disorder diagnosed in adulthood, it has its precedent in childhood.[20] The DSM-5's criteria for ASPD require that the individual have conduct problems evident by the age of 15.[16] 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.[21] About 25–40% of youths with conduct disorder will be diagnosed with ASPD in adulthood.[22]
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.[23] 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 use.[24][25] 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 re-diagnosed with CD.[26]
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.[27] 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.[28] 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, tends to have a worse treatment outcome.[29]
Comorbidity[edit]
ASPD commonly coexists with the following conditions:[30]
When combined with alcoholism, people may show frontal function deficits on neuropsychological tests greater than those associated with each condition.[31] Alcohol Use Disorder is likely caused by lack of impulse and behavioral control exhibited by Antisocial Personality Disorder patients.[32] The rates of ASPD tends to register around 40-50% in male alcohol and opiate addicts.[33] However, it is important to remember this is not a causal relationship, but rather a plausible consequence of cognitive deficits as a result of ASPD.
Causes[edit]
Personality disorders are seen to be caused by a combination and interaction of genetic and environmental influences.[34] 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.[4] People with an antisocial or alcoholic parent are considered to be at higher risk. Fire-setting, and cruelty to animals during childhood are also linked to the development of antisocial personality. The condition is more common in males than in females, and among incarcerated populations.[34][16]
Genetic[edit]
Research into genetic associations in antisocial personality disorder suggests 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.[35]
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 monoamine neurotransmitters such as serotonin and Norepinephrine. Various studies examining the genes' 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 in men.[36][37] The association is also influenced by negative experience in early life, with children possessing a low-activity variant (MAOA-L) who experience such maltreatment being more likely to develop antisocial behavior than those with the high-activity variant (MAOA-H).[38][39] Even when environmental interactions (e.g. emotional abuse) are controlled for, a small association between MAOA-L and aggressive and antisocial behavior remains.[40]
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.[41] 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.[42] 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.[43]
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. Furthermore, the study found that those who carry 4 mutations on chromosome 6 are 50 percent more likely to develop antisocial personality disorder than those who do not.[44]
Physiological[edit]
Hormones and neurotransmitters[edit]
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.[45] Aggressiveness and impulsivity are among the possible symptoms of ASPD. Testosterone is a hormone that plays an important role in aggressiveness in the brain.[46] For instance, criminals who have committed violent crimes tend to have higher levels of testosterone than the average person.[47][citation needed] The effect of testosterone is counteracted by cortisol which facilitates the cognitive control of impulsive tendencies.[48]
One of the neurotransmitters that has been discussed in individuals with ASPD is serotonin, also known as 5HT.[45] 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.[49]
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.[50] 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.[51][16]
Some studies have found a relationship between monoamine oxidase A and antisocial behavior, including conduct disorder and symptoms of adult ASPD, in maltreated children.[52]
Neurological[edit]
Antisocial behavior may be related to head trauma.[53] 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.[54]
Intellectual and cognitive ability is often found to be impaired or reduced in the ASPD population.[55] Contrary to stereotypes in popular culture of the "psychopathic genius", antisocial personality disorder is associated with both reduced overall intelligence and specific reductions in individual aspects of cognitive ability.[55][56] These deficits also occur in general-population samples of people with antisocial traits[57] and in children with the precursors to antisocial personality disorder.[58]
People that exhibit antisocial behavior tend to demonstrate decreased activity in the prefrontal cortex. The association is more apparent in functional neuroimaging as opposed to structural neuroimaging.[59] The prefrontal cortex is involved in many executive functions, including behavior inhibitions, planning ahead, determining consequences of action, and differentiating between right and wrong. However, some investigators have questioned whether the reduced volume in prefrontal regions is associated with antisocial personality disorder, or whether they result from co-morbid disorders, such as substance use disorder or childhood maltreatment.[60] Moreover, it remains an open question whether the relationship is causal, i.e., whether the anatomical abnormality causes the psychological and behavioral abnormality, or vice versa.[60]
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.[61][62][63] One study found that those with CSP had significantly higher levels of antisocial personality, psychopathy, arrests and convictions compared with controls.[63]
Environmental[edit]
Family environment[edit]
Many studies suggest that the social and home environment has contributed to the development of antisocial behavior.[45] The parents of these children have been shown to display antisocial behavior, which could be adopted by their children.[45] A lack of parental stimulation and affection during early development leads to high levels of cortisol with the absence of balancing hormones such as oxytocin which disrupts and overloads the child's stress response systems, which is thought to lead to underdevelopment of the child's brain that deals with emotion, empathy and ability to connect to other humans on an emotional level. According to Dr. Bruce Perry in his book The Boy Who Was Raised as a Dog, "the [infant's developing] brain needs patterned, repetitive stimuli to develop properly. Spastic, unpredictable relief from fear, loneliness, discomfort, and hunger keeps a baby's stress system on high alert. An environment of intermittent care punctuated by total abandonment may be the worst of all worlds for a child."[64]
Cultural influences[edit]
The sociocultural perspective of clinical psychology views disorders as influenced by cultural aspects; since cultural norms differ significantly, mental disorders such as ASPD are viewed differently.[65] 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.[66]: 136 While the rise reported may be in part merely a byproduct of the widening use (and abuse) of diagnostic techniques,[67] 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[68] – it has been suggested that the erosion of collective standards may indeed serve to release the individual with latent ASPD from their previously prosocial behavior.[66]: 136–7
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.[69] Controversial clinical psychiatrist Pierre-Édouard Carbonneau suggested that the problem with legal forced admittance is the rate of failure when diagnosing ASPD. He contends that the possibility of diagnosing and coercing a patient into prescribing medication to someone without ASPD, but is diagnosed with ASPD, could be potentially disastrous. But the possibility of not diagnosing ASPD and seeing a patient go untreated because of a lack of sufficient evidence of cultural or environmental influences is something a psychiatrist must ignore; and in his words, "play it safe".[70]
ICD-10[edit]
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):[71][72]
- It is characterized by at least 3 of the following:
- Callous unconcern for the feelings of others;
- Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations;
- Incapacity to maintain enduring relationships, though having no difficulty in establishing them;
- Very low tolerance to frustration and a low threshold for discharge of aggression, including violence;
- Incapacity to experience guilt or to profit from experience, particularly punishment;
- 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.[72][73]
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.[72]
Psychopathy[edit]
Psychopathy is commonly defined as a personality disorder characterized partly by antisocial behavior, a diminished capacity for empathy and remorse, and poor behavioral controls.[15][74][75][76] Psychopathic traits are assessed using various measurement tools, including Canadian researcher Robert D. Hare's Psychopathy Checklist, Revised (PCL-R).[77] "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, however, state that their antisocial diagnoses are at times referred to (or include what is referred to) as psychopathy or sociopathy.[15][71][76][78][79]
American psychiatrist Hervey Cleckley's work[80] on psychopathy formed the basis of the diagnostic criteria for ASPD, and the DSM states ASPD is often referred to as psychopathy.[11][15] However, critics argue ASPD is not synonymous with psychopathy as the diagnostic criteria are not the same, since criteria relating to personality traits are emphasized relatively less in the former. These differences exist in part because it was believed 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".[11][12][13][14][15]
Although the diagnosis of ASPD covers two to three times as many prisoners than the diagnosis of psychopathy, Robert Hare believes the PCL-R is better able to predict future criminality, violence, and recidivism than a diagnosis of ASPD.[11][12] He suggests 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.[12][13] Additionally, Hare argued 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.[12][13]
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.[23]: 765 Under the specifier, affective and interpersonal characteristics are comparatively emphasized over behavioral components.[81]
Other[edit]
Theodore Millon suggested 5 subtypes of ASPD.[82][83] However, these constructs are not recognized in the DSM and ICD.
| Subtype | Features |
|---|---|
| Nomadic antisocial (including schizoid and avoidant features) | Drifters; roamers, vagrants; adventurer, itinerant vagabonds, tramps, wanderers; they typically adapt easily in difficult situations, shrewd and impulsive. Mood centers in doom and invincibility. |
| Malevolent antisocial (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 criminals, including serial killers. |
| Covetous antisocial (including negativistic features) | Rapacious, begrudging, discontentedly yearning; hostile and domineering; envious, avaricious; pleasures more in taking than in having. |
| Risk-taking antisocial (including histrionic features) | Dauntless, venturesome, intrepid, bold, audacious, daring; reckless, foolhardy, heedless; unfazed by hazard; pursues perilous ventures. |
| Reputation-defending antisocial (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."[66]:
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