Antisocial Personality Disorder

Antisocial Personality Disorder Joan Benefield, Frank Kilgore and Amy Simpson-Cullor SW 537

8/8/2008 template from www.brainybetty.com copyright 2006 2 Definition The essential feature for the diagnosis of APD is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood due to the lack of love and care for the child. It should be noted that Antisocial Personality Disorder is also sometimes referred to as psychopathy, sociopathy, or dyssocial personality disorder. (APA, p. 702, 1994)

8/8/2008 template from www.brainybetty.com copyright 2006 3 Diagnostic Criteria 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. deceitfulness, as indicated by repeated 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 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 (APA, p. 706, 1994)

8/8/2008 template from www.brainybetty.com copyright 2006 4 Diagnostic Criteria (cont d) B. The individual is at least 18 years of age. 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. (APA, p. 706, 1994)

8/8/2008 template from www.brainybetty.com copyright 2006 5 Symptoms 1. May repeatedly perform acts that are grounds for arrest 2. May repeatedly lie, use an alias or con others 3. Often fails to plan ahead 4. Decisions are often made on the spur of the moment 5. May be irritable or aggressive 6. May display a reckless disregard for the safety of themselves or others 7. May engage in risky sexual behavior or substance abuse 8. May neglect or fail to care for a child in a way that puts the child in danger 9. Tend to be consistently and extremely irresponsible 10. May be indifferent to, or provide a superficial rationalization for, having hurt, mistreated, or stolen from someone (APA, p. 703, 1994)

8/8/2008 template from www.brainybetty.com copyright 2006 6 Clinical Presentation of Symptoms Lacks empathy Arrogant Excessively opinionated Superficial charm Exploitative Attention Deficits Irresponsible May also experience dysphoria Complains of tension Unable to tolerate boredom Depressed mood (APA, p. 703, 1994) & (Fitzgerald & Demakis, p. 177, 2007)

8/8/2008 template from www.brainybetty.com copyright 2006 7 Risk Factors Harsh parental discipline with cruel punishment appears to play a causal role in the development of antisocial behavior in childhood, whereas the absence of parental supervision appears to be an important factor in antisocial behavior in late childhood or adolescence (Lahey, McBurnett, Loeber, & Hart, 1995). Early (perinatal) hormonal environment is assumed to play a role in shaping temperament and its development before the onset of important social influences such as peer interactions (van Goozen, H. M. et al., p. 149, 2007). Low fear of punishment and physiological under-activity may predispose antisocial individuals to seek out stimulation or take risks and may help to explain poor social conditioning and socialization (van Goozen, H. M. et al., p. 149, 2007).

8/8/2008 template from www.brainybetty.com copyright 2006 8 Risk Factors (cont d) Conduct problems are a major risk factor for adult disorders that are characterized by antisocial behavior, and aggression in general not only is predictive of antisocial outcomes in adulthood but also is stable across generations (Huesmann, Eron, Lefkowitz, & Walder, 1984; Lynam, 1996; Robins, 1966). A genetic predisposition toward aggressive or antisocial behavior may be expressed in adverse rearing environments in which the child receives harsh or inconsistent discipline, or is exposed to high levels of inter-parental conflict or marital breakdown (El-Sheikh & Harger, 2001; El-Sheikh, Harger, & Whitson, 2001). Some risk factors are prenatal, such as exposure to maternal smoking in utero (Silberg et al., 2003; Thapar et al., 2003) and low birth weight/gestational age. Even though antisocial personality disorder cannot be diagnosed before adulthood, the presence of three behavioral markers, known as the Macdonald triad, can be found in some children who go on to develop APD. The triad consists of bedwetting, a tendency to abuse animals, and pyromania (Macdonald, J. M., 1963).

8/8/2008 template from www.brainybetty.com copyright 2006 9 Prevalence The overall prevalence of Antisocial Personality Disorder in community samples is about 3% in males and about 1% in females (APA, p. 704, 1994). There are no marked differences in prevalence rates between different ethnic groups in the United States (Robins et al., 1991, pp. 271-276), although prevalence is generally higher in inner-city areas than in rural villages (Robins et al., 1984; Robins et al. 1991, pp. 280-283). 75% of inmates in a typical prison setting meet the criteria for APD (Reid, W. H & Gacono, C., p.648, 2000).

8/8/2008 template from www.brainybetty.com copyright 2006 10 Diversity Antisocial Personality Disorder appears to be associated with low economic status and urban settings. Native Americans are more likely and Asians and Hispanics were less likely to have APD and adult antisocial behavior (Compton, W. M. et al., p. 677, 2005). There are no marked differences in prevalence rates between different ethnic groups in the United States (Robins et al., 1991, pp. 271-276), although prevalence is generally higher in inner-city areas than in rural villages (Robins et al., 1984; Robins et al. 1991, pp. 280-283). No information was found on treatment effectiveness between subgroups.

8/8/2008 template from www.brainybetty.com copyright 2006 11 Comorbidity Individuals diagnosed with APD may have associated Anxiety Disorders, Depressive Disorders, Substance-Related Disorders, Somatization Disorder, Pathological Gambling, and other disorders of impulse control. Individuals with APD also often have personality features that meet criteria for other Personality Disorders, particularly Borderline, Histrionic, and Narcissistic Personality Disorders. In one study, virtually all of the associations between APD and adult antisocial behavior and specific substance use disorders were positive and statistically significant (p <.05) (Compton, W. M. et al., p. 677, 2005). (APA, p. 702, 1994)

8/8/2008 template from www.brainybetty.com copyright 2006 12 Etiology Young adults of lower socioeconomic status who carry the short 5HTTLPR (serotonin transporter linked polymorphic region) allele may be especially vulnerable to developing antisocial traits by young adulthood (Lyons et al., p. 339, 2007). Most researchers agree that this disorder stems from brain abnormalities, including the theories of frontal lobe dysfunction and differences in the autonomic nervous systems in individuals diagnosed with APD (Fitzgerald & Demakis, p. 177, 2007). Considerable evidence from twin and adoption studies indicates that both genetic and shared environmental factors play a substantial role in the liability to antisocial behavior (Maes et al., p. 136, 2007). Serotonergic functioning and stress regulating mechanisms, including the hypothalamic-pituitary adrenal (HPA) axis and the autonomic nervous system (ANS), are important in explaining individual differences in antisocial behavior (van Goozen, H. M. et al., p. 149, 2007).

8/8/2008 template from www.brainybetty.com copyright 2006 13 Etiology (cont d) Intergenerational transmission of antisocial behavior has been welldocumented (Huesmann et al., 1984). There have been a few studies that indicate low cortisol levels precede the onset of antisocial or aggressive behavior and can therefore be used to predict which individuals will exhibit a pervasive pattern of antisocial behavior throughout adolescence and into young adulthood (van Goozen, H. M. et al., p. 155, 2007). Low IQ was related to antisocial behavior at age 5 years and predicted relatively higher antisocial behavior scores at age 7 years when antisocial behavior at age 5 years was controlled. This association was significantly stronger among boys than among girls (Koenen, p. 787, 2006). Research on the etiology of antisocial behavior has focused almost exclusively on the role of dysfunctional family influences, such as economic problems, parental psychopathology, coercive parenting, physical abuse, and family conflict (Moffitt & Caspi, 2001).

8/8/2008 template from www.brainybetty.com copyright 2006 14 Assessment Measures 1. ASPD scale of the Personality Diagnostic Questionnaire-4 (PDQ-4; S. E. Hyler, 1994) In a trial, the PDQ-4 yielded poor sensitivity and low negative predictive power. 2. Personality Assessment Inventory (PAI; L. Morey, 1991, 2007) In contrast to the PDQ-4, the PAI was significantly more sensitive and less specific, which suggests that it would be a preferable measure compared with the PDQ-4 for identifying persons in need of more detailed assessment. 3. Structured Clinical Interview for DSM IV Axis II (SCID-II; M. B. First, R. L. Spitzer, M. Gibbon, J. B. W. Williams, & L. S. Benjamin, 1997) Guy et al. found that the SCID-II yielded a higher proportion of ASPD cases than did the PDQ-4. (Guy et al., p. 52, 2008)

8/8/2008 template from www.brainybetty.com copyright 2006 15 Assessment Measures (cont d) Antisocial Processes Screening Device Self-report version exists, which shows moderate correlations moderate correlations with parent ratings of psychopathic traits in youth (Munoz, L.C. & Frick, P. J., p. 299, 2007) Inventory of Interpersonal Problems, a self-report version of the Iowa Personality Disorder Screen and the Temperament and Character Inventory All three screeners highly correlated and no single screener stood out as clearly superior; each performed modestly in predicting the presence of PD (Morse, J. Q. & Pilkonis, P. A., p. 179, 2007) Guy et al. found that men had higher mean scores on the PDQ-4 and SCID-II than did women, which is consistent with research indicating that prevalence rates of ASPD are relatively higher among men (American Psychiatric Association, 1994).

8/8/2008 template from www.brainybetty.com copyright 2006 16 Interventions There is no study that suggests that any traditional inpatient program or voluntary milieu addresses the characterologic aspects of adults with antisocial personality. There are no styles of individual psychotherapy that are routinely associated with successful treatment of antisocial syndromes. Group psychotherapies are cost efficient and attractive to sponsoring agencies but they are not effective for changing antisocial behavior. Cognitive therapies, useful for many other symptoms and syndromes, have not been found to affect antisocial syndromes or character structure, although some nonpsychopathic APD patients can benefit from modified psychodynamic approaches that use cognitive behavioral techniques. Behavioral assessments, reinforcer strategies, and consistency can work together to change almost any behavior, including antisocial behavior. However, there is no controlled study which supports the premise that simple behavioral or conditioning paradigms have lasting benefit in APD. No controlled study suggests that medication improves antisocial character per se. However, lithium, citalopram, risperidone, carbamazepine, a combination of moclobemid and zuclopenthixol have been used to control certain symptoms. Interventions designed to reduce or prevent antisocial behavior often prove on average only modestly successful (van Goozen, H. M. et al., p. 173, 2007). (Reid, W. H. & Gacono, C., p. 651-653, 2000)

8/8/2008 template from www.brainybetty.com copyright 2006 17 Interventions (cont d) Many aspects of the treatment of primitive personality disorders, of which antisocial personality is an example, require that the clinician be flexible in his or her approach, while working from a consistent treatment philosophy. In the long run, the best behavioral program outcomes appear to come from those that are rigidly consistent, with little or no room for excuses or rationalizations. Antisocial personality is not a disorder in which the patient should guide his own treatment. If he can make things more comfortable, he will, and making things more comfortable is almost always counter-therapeutic. This sometimes means very strict training and supervision of staff, or rules that cannot be overridden by staff. Such rigidity may be misunderstood by family or other observers, including licensing agencies and the media (sometimes because of manipulation by the patients themselves). (Reid, W. H. & Gacono, C., p. 649, 2000)

8/8/2008 template from www.brainybetty.com copyright 2006 18 References Baker, L. A., Bezdjian, S., & Raine, A. (2006). Behavioral genetics: the science of antisocial behavior. Law and Contemporary Problems, 69(1-2), 7-46. Caspi, A., Henry, B., McGee, R. O., Moffitt, T. E., & Silva, P. A. (1995). Temperamental origins of child and adolescent behavior problems: From age three to age fifteen. Child Development, 66, 55 68. Caspi, A., McClay, J., Moffitt, T. E., Mill, J., Martin, J., Craig, I. W., et al. (2002, August 2). Role of the genotype in the cycle of violence in maltreated children. Science, 297, 851 854. Caspi, A., & Moffitt, T. E. (1995). The continuity of maladaptive behavior: From description to understanding in the study of antisocial behavior. In D. Cicchetti & D. Cohen (Eds.), Manual of Developmental Pychopathology (pp. 472 511). New York: Wiley. Colman, A. M., & Wilson, J. C. (1997). Antisocial personality disorder: An evolutionary game theory analysis. Legal and Criminological Psychology, 2, 23-34. Diagnostic and statistical manual of mental disorders (DSM-IV). (1994). Washington, D.C.: American Psychiatric Association. El-Sheikh, M., & Harger, J. (2001). Appraisals of marital conflict and children s adjustment, health, and physiological reactivity. Developmental Psychology, 37, 875 885. El-Sheikh, M., Harger, J., & Whitson, S. (2001). Exposure to interparental conflict and children s adjustment and physical health: The moderating role of vagal tone. Child Development, 72, 1617 1636. Fitzgerald, K. L. & Demakis, G. J. (2007). The neuropsychology of antisocial personality disorder. Disease-a-Month, 53(3), 177-183. Foley, D. L., Eaves, L. J., Wormley, B., Silberg, J. L., Maes, H. H., Kuhn, J., et al. (2004). Childhood adversity, monoamine oxidase A genotype, and risk for conduct disorder. Archives of General Psychiatry, 61, 738 744. Guy, L. S. et al. (2008). Correspondence between self-report and interview-based assessment of antisocial personality disorder. Psychological Assessment, 20(1), 47-54. Hirose, S. (2001). Effective treatment of aggression and impulsivity in antisocial personality disorder with risperidone. Psychiatry and Clinical Neurosciences, 55, 161-162.

References (cont d) Huesmann, L. R., Eron, L. D., Lefkowitz, M. M., & Walder, L. O. (1984). Stability of aggression over time and generations. Developmental Psychology, 20, 1120 1134. Koenen, K. C. et al. (2006). Genetic influences on the overlap between low IQ and antisocial behavior in young children. Journal of Abnormal Psychology, 115(4), 787-797. Lyons, M. J., True, W. R., Eisen, S. A., Goldberg, J., Meyer, J. M., Faraone, S. V., et al. (1995). Differential heritability of adult and juvenile antisocial traits. Archives of General Psychiatry, 52, 906 915. Lyons-Ruth, K. et al. (2007). Serotonin transporter polymorphism and borderline or antisocial traits among lowincome young adults. Psychiatric Genetics, 17(6), 339-343. Lahey, B. B., McBurnett, K., Loeber, R., & Hart, E. L. (1995). Psychobiology. In G. Perooz Sholevar (Ed.), Conduct disorders in children and adolescents (pp. 27 44). Washington, DC: American Psychiatric Press. Larsson, H. et al. (2006). A genetic factor explains most of the variation in the psychopathic personality. Journal of Abonormal Psychology, 115(2), 221-230. MacDonald, J. M. (1963). The threat to kill. American Journal of Psychiatry, 125-130. Maes, H. H. et al. (2007). Genetic and cultural transmission of antisocial behavior: an extended twin parent model. Twin Research and Human Genetics, 10(1), 136-150. Moffitt, T. E. (2005). The new look of behavioral genetics in developmental psychopathology: Gene-environment interplay in antisocial behaviors. Psychological Bulletin, 131, 533 554. Morse, J. Q. & Pilkonis, P. A. (2007). Screening for personality disorders. Journal of Personality Disorders, 21(2), 179-198. Munoz, L. C. & Frick, P. J. (2007). The reliability, stability, and predictive utility of the self-report version of the Antisocial Process Screening Device. Scandanavian Journal of Psychology, 48(4), 299-312. Reid, W. H. & Gacono, C. (2000). Treatment of antisocial personality, psychopathy, and other characterologic antisocial syndromes. Behavioral Sciences and the Law, 18, 647-662. Robins, L. N., Tipp, J., & Przybeck, T. (1991). Antisocial personality. In L. N. Robins & D. A. Regier (Eds), Psychiatric Disorders in America: The Epidemiologic Catchment Area Study (pp. 258-290). New York: Free Press. Van Goozen, H. M. et al. (2007). The evidence for a neurobiological model of childhood antisocial behavior. Psychological Bulletin, 133(1), 149-182. 8/8/2008 template from www.brainybetty.com copyright 2006 19