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Antisocial Personality Disorder

Signs and symptoms


Characteristics of people with antisocial personality disorder may include:[2]

• Persistent lying or stealing


• Apparent lack of remorse[3] or empathy for others
• Cruelty to animals[4]
• Poor behavioral controls — expressions of irritability, annoyance, impatience,
threats, aggression, and verbal abuse; inadequate control of anger and temper
• A history of childhood conduct disorder
• Recurring difficulties with the law
• Tendency to violate the boundaries and rights of others
• Substance abuse
• Aggressive, often violent behavior; prone to getting involved in fights
• Inability to tolerate boredom
• Disregard for safety

DSM

The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR =
301.7, a widely used manual for diagnosing mental disorders, defines antisocial
personality disorder (in Axis II Cluster B) as:[1]

A) There is a pervasive pattern of disregard for and the rights of others occurring
since the age of 15, 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. deceitfulness, 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) The individual is at least 18 years of age.


C) There is evidence of Conduct disorder with onset before age 15.
D) The occurrence of antisocial behavior is not exclusively during the course of
schizophrenia or a manic episode.
Criticism

Researchers have heavily criticized the ASPD DSM-IV criteria because not enough
emphasis was placed on traditional psychopathic traits such as a lack of empathy,
superficial charm, and inflated self appraisal.[citation needed]

These latter traits are harder to assess than behavioral problems (like impulsivity and
acting out). Thus, the DSM-IV framers sacrificed validity for reliability. That is, the
ASPD diagnosis focuses on behavioral traits, but only limited emphasis is placed on
affective and unemotional interpersonal traits.

Researchers debate about whether psychopathy/sociopathy are incorrectly put together


under ASPD. These clinicians and researchers who believe that it was incorrect to label
the two in the same category are upset that an important distinction has been lost between
these two disorders. In other words, the DSM-IV-TR considers ASPD and psychopathy
to be the same, or similar. However, they are not the same since antisocial personality
disorder is diagnosed via behavior and social deviance, whereas psychopathy also
includes affective and interpersonal personality factors.[5]

Also, ASPD, unlike psychopathy, does not have biological markers confirmed to
underpin the disorder.[citation needed] Other criticisms of ASPD are that it is essentially
synonymous with criminality. Nearly 80%–95% of felons will meet criteria for ASPD —
thus ASPD predicts nothing in criminal justice populations. Whereas, psychopathy scores
(using the Hare Psychopathy Checklist-Revised (PCL-R)) is found in only ~20% of
inmates and PCL-R is considered one of the best predictors of violent recidivism.[citation
needed]
Also, the DSM-IV field trials never included incarcerated populations.

The official stance of the American Psychiatric Association as presented in the DSM-IV-
TR is that "psychopathy" and "sociopathy" are obsolete synonyms for antisocial
personality disorder. The World Health Organization takes a similar stance in its ICD-10
by referring to psychopathy, sociopathy, antisocial personality, asocial personality, and
amoral personality as synonyms for dissocial personality disorder.[citation needed]

• Description Common to All Personality Disorders


o Personality Disorders
 Personality Disorder Diagnostic Guidelines

Please see our separate note on Treatment, Mental Disorders and Basic Science for
important caveats on the role and definition of diagnostic criteria.
Personality Disorder Description Common to All
Personality Disorders
The following information is reproduced verbatim from the ICD-10 Classification of
Mental and Behavioural Disorders, World Health Organization, Geneva, 1992. (Since the
WHO updates the overall ICD on a regular basis, individual classifications within it may
or may not change from year to year; therefore, you should always check directly with
the WHO to be sure of obtaining the latest revision for any particular individual
classification.) It provides the common description and guidelines referenced by the
diagnostic criteria for each of the individual personalty disorders.

Personality Disorders

A personality disorder is a severe disturbance in the characterological constitution and


behavioural tendencies of the individual, usually involving several areas of the
personality, and nearly always associated with considerable personal and social
disruption. Personality disorder tends to appear in late childhood or adolescence and
continues to be manifest into adulthood. It is therefore unlikely that the diagnosis of
personality disorder will be appropriate before the age of 16 or 17 years. General
diagnostic guidelines applying to all personality disorders are presented below;
supplementary descriptions are provided with each of the subtypes.

Diagnostic Guidelines

Conditions not directly attributable to gross brain damage or disease, or to another


psychiatric disorder, meeting the following criteria:

a. markedly disharmonious attitudes and behaviour, involving usually several areas


of functioning, e.g. affectivity, arousal, impulse control, ways of perceiving and
thinking, and style of relating to others;
b. the abnormal behaviour pattern is enduring, of long standing, and not limited to
episodes of mental illness;
c. the abnormal behaviour pattern is pervasive and clearly maladaptive to a broad
range of personal and social situations;
d. the above manifestations always appear during childhood or adolescence and
continue into adulthood;
e. the disorder leads to considerable personal distress but this may only become
apparent late in its course;
f. the disorder is usually, but not invariably, associated with significant problems in
occupational and social performance.

For different cultures it may be necessary to develop specific sets of criteria with regard
to social norms, rules and obligations. For diagnosing most of the subtypes listed below,
clear evidence is usually required of the presence of at least three of the traits or
behaviours given in the clinical description.
The current criteria for ASPD, as described in DSM–IV, include a behavioral pattern that
begins before age 15 and comprises at least three of the following behaviors:

 Repeated criminal acts

 Deceitfulness

 Impulsiveness

 Repeated fights or assaults

 Disregard for the safety of others

 Irresponsibility

 Lack of remorse

This pattern of behavior has occurred since age 15 (although only adults 18 years or older can be
diagnosed with this disorder) and consists by the presence of the majority of these symptoms *:

 failure to conform to social norms with respect to lawful behaviors as indicated by


repeatedly performing acts that are grounds for arrest
 deceitfulness, as indicated by repeated lying, use of aliases, or conning others for
personal profit or pleasure
 impulsivity or failure to plan ahead

 irritability and aggressiveness, as indicated by repeated physical fights or assaults

 reckless disregard for safety of self or others

 consistent irresponsibility, as indicated by repeated failure to sustain consistent work


behavior or honor financial obligations
 lack of remorse, as indicated by being indifferent to or rationalizing having hurt,
mistreated, or stolen from another

The manual lists the following additional necessary criteria:

 The individual is at least 18 years of age.

 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.

Alternative names

Psychopathic personality; Sociopathic personality; Personality disorder - antisocial


Symptoms & Signs

The classic person with an antisocial personality is indifferent to the needs of others and
may manipulate through deceit or intimidation. He or she shows a blatant disregard for
what is right and wrong, may have trouble holding down a job, and often fails to pay
debts or fulfill parenting or work responsibilities. They are usually loners.

The diagnostic criteria for antisocial personality disorder are set forth in
table above. DSM-IV states that this disorder is 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." The antisocial features are reflected in
poor job performance, academic failure, participation in a wide variety of illegal
activities, recklessness, and impulsive behavior.

The patient with antisocial personality disorder also experiences a feeling of


subjective dysphoria, characterized by tension, depression, inability to tolerate boredom,
and a feeling of being victimized. There is also a diminished capacity for intimacy.

A substantial body of research has shown that only a minority of patients with
antisocial personality disorder have severe psychopathy, and this latter
group has a significantly poorer treatment prognosis than do patients with
nonpsychopathic antisocial personality disorder.

They appear to be incapable of any true emotions, from love to shame to guilt. They are
quick to anger, but just as quick to let it go, without holding grudges. No matter what
emotion they state they have, it has no bearing on their future actions or attitudes.

 Disregard for the feelings of others

 Impulsive and irresponsible decision-making

 Lack of remorse for harm done to others

 Lying, stealing, other criminal behaviors

 Disregard for the safety of self and others

Common countertransference reactions to the patient with antisocial personality disorder

1. Therapeutic nihilism (condemnation)


2. Illusory treatment alliance
3. Fear of assault or harm (sadistic control)
4. Denial and deception (disbelief)
5. Helplessness and guilt
6. Devaluation and loss of professional identity
7. Hatred and the wish to destroy
8. Assumption of psychological complexity
Natural History & Prognosis

Antisocial personality disorder tends to remit with time. After 21 years of age, the
remission rate is about 2% of all patients each year. As destructive social behavior
diminishes, patients tend to develop hypochondriacal and depressive disorders.

Epidemiology

Onset of antisocial personality disorder is before age 15, frequently around


puberty in girls and quite early in childhood for boys. The disorder is more prevalent in
men, with incidence being about 3% for men and 1% for women. Prevalence is increased
in lower socioeconomic groups. Family histories are often positive for antisocial
personality disorder, with increased incidence in the fathers of both male and female
patients with this disorder. Evidence suggests that this familial occurrence results from
both genetic and environmental causes; the relative contribution of each factor is
unknown. Antisocial personality disorder may be diagnosed in as many as 75% of prison
inmates.

Etiology & Pathogenesis

The exact causes of antisocial personality disorder are unknown, but experts
believe that both hereditary factors and environmental circumstances influence
development of the condition.

A. Genetic and Biological Factors: Robins (1966) found an increased incidence of


sociopathic characteristics and alcoholism in the fathers of individuals with antisocial
personality disorder. Within the families of these individuals, male relatives have
increased rates of antisocial personality disorder and substance abuse
disorders, whereas female relatives have increased rates of somatization disorder.
Adoption studies support the role of both genetic and environmental contributions to the
development of the disorder. In a retrospective study of this disorder, Raine et al (1990)
reported that indices of psychophysiological underarousal at age 15 were predictive of
criminality at age 24 years. Criminals had significantly lower heart rates and skin
conductance activity and more slow-frequency electroencephalographic activity than
noncriminals.

B. Psychological Factors: Bowlby (1944) correlated antisocial personality


disorder with maternal deprivation in the child's first 5 years of life. Glueck and
Glueck (1968) reported that the mothers of children who developed this personality
disorder show a lack of consistent discipline, a lack of affection, and an increased
incidence of alcoholism and impulsiveness. These qualities contribute to failure to
create a cohesive home environment with consistent structure and behavioral boundaries.
In the prospective study, children found to be at risk by age 6 frequently showed features
of antisocial personality at 18 years.
Differential Diagnosis

The diagnosis of Antisocial Personality Disorder is not given to individuals under age 18
years and is given only if there is a history of some symptoms of Conduct Disorder
before age 15 years. For individuals over age 18 years, a diagnosis of Conduct Disorder
is given only if the criteria for Antisocial Personality Disorder are not met.

When antisocial behavior in an adult is associated with a Substance-Related Disorder,


the diagnosis of Antisocial Personality Disorder is not made unless the signs of
Antisocial Personality Disorder were also present in childhood and have continued into
adulthood. When substance use and antisocial behavior both began in childhood and
continued into adulthood, both a Substance-Related Disorder and Antisocial Personality
Disorder should be diagnosed if the criteria for both are met, even though some antisocial
acts may be a consequence of the Substance-Related Disorder (e.g., illegal selling of
drugs or thefts to obtain money for drugs). Antisocial behavior that occurs exclusively
during the course of Schizophrenia or a Manic Episode should not be diagnosed as
Antisocial Personality Disorder.

Prevalence

The National Comorbidity Survey, which used DSM-III-R criteria, found that 5.8% of
males and 1.2% of females showed evidence of a lifetime risk for the disorder.
Prevalence estimates within clinical settings have varied from 3% to 30%, depending on
the predominant characteristics of the populations being sampled. Perhaps not
surprisingly, the prevalence of the disorder is even higher in selected populations, such as
people in prisons (who include many violent offenders) (Hare 1983). 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.

Complications

People with antisocial personality disorder are at an increased risk of:

 Dying from a physical trauma, such as an accident

 Drug and alcohol abuse

 Suicide

 Homicide

 Other mental disorders such as depression, bipolar disorder and anxiety

 Other personality disorders, particularly borderline and narcissistic personality disorders

 Committing serious crimes that may result in imprisonment


Treatment

The most important goals of treating antisocial behavior are to measure and describe the
individual child's or adolescent's actual problem behaviors and to effectively teach him or
her the positive behaviors that should be adopted instead. In severe cases, medication will
be administered to control behavior, but it should not be used as a substitute for therapy.

In a review of the effectiveness of treatments for antisocial personality


disorder Garrido et al (1995) concluded that treatment is more effective with those
subjects who are not currently abusing drugs, who have less serious histories of
criminality, and who are treated in an institutional setting such as an inpatient unit or a
prison rather than in an outpatient setting. As an example Dolan (1998) describes a
therapeutic community program for antisocial patients and those with other violent
personality disorders that is successful in reducing not only impulsive behaviors but also
physical health problems, rates of incarceration for criminal offenses, and core features of
personality disorder.

Effective psychotherapy treatment for this disorder is limited. It is likely, though, that
intensive, psychoanalytic approaches are inappropriate for this population. Approaches
the reinforce appropriate behaviors and attempting to make connections between the
person's actions and their feelings may be more beneficial. Emotions are usually a key
aspect of treatment of this disorder. Patients often have had little or no significant
emotionally-rewarding relationships in their lives. The therapeutic relationship, therefore,
can be one of the first ones. This can be very scary for the client, initially, and it may
become intolerable. A close therapeutic relationship can only occur when a good and
solid rapport has been established with the client and he or she can trust the therapist
implicitly.

Antisocial Personality Disorder in Medical Practice

The relationship between a physician and a patient with antisocial personality


disorder is characterized by mutual feelings of suspicion and, at times, hostility. The
antisocial person's mistrust of the physician stems from unwarranted generalizations
about physicians that are based in part on early abusive experiences at the hands of
parental caretakers, particularly during the formative periods of childhood and
adolescence. The physician's mistrust of the antisocial patient may well be grounded in
unpleasant personal experience. Persons with antisocial personality disorder
may feign physical symptoms to obtain narcotic analgesics for substance abuse, may
attempt to defraud third-party health care payment sources by seeking reimbursement for
services not rendered, or may be delinquent in payment for services they have actually
received. Unfortunately, individuals with antisocial personalities are at least as vulnerable
to physical illness as any other type of patient and are in fact at higher risk for illnesses
associated with substance abuse and stress because of their chronic unstable interpersonal
and occupational adjustments. The physician is therefore challenged to find a way to
create an effective therapeutic alliance. A firm, no-nonsense approach that is not punitive
but conveys a streetwise awareness of the patient's potential for manipulation will
encourage respect without aggravating the patient's hostility against authority.