Antisocial personality disorder

Antisocial personality disorder (APD) is a mental disorder defined by the American Psychiatric Association's Diagnostic and Statistical Manual: "The essential feature for the diagnosis 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."^[1] Considered essential features of the disorder are deceit and manipulation. Therefore it is essential in making the diagnosis to collect material from sources other than the individual being diagnosed. Also, the individual must be age 18 or older as well as have a documented history of a conduct disorder before the age of 15.^[1]

Additional recommended knowledge

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Development

The criteria for the Antisocial Personality Disorder were derived from the Research Diagnostic Criteria developed by Spitzer, Endicott and Robbins (1978). There was concern in the development of the DSM-IV that there was too much emphasis on research data and not enough on the more traditional psychopathic traits such as a lack of empathy, superficial charm, and inflated self appraisal. However field trial data indicated that some of the traits of psychopathy derived from the Psychopathy Checklist developed by Hare et al., 1992, were difficult to assess reliably and thus were not included. Lack of remorse is an example. The antisocial person may express guilt or remorse or offer excuses and rationalizations. However, a history of criminal acts in itself suggests little remorse or guilt.^[2]

Diagnostic criteria

In addition to the above, three or more of the following is required:^[1]

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.

The antisocial behavior must not occur exclusively during an episode of Schizophrenia or a Manic Episode.^[3]

Sex differences: According to DSM-IV, Antisocial Personality disorder is diagnosed in approximately 3% of all males and 1% of all females.^[1]

Symptoms

Common characteristics of people with antisocial personality disorder include:^{[citation needed]}

• Persistent lying or stealing
• Recurring difficulties with the law
• Tendency to violate the rights and boundaries of others (property, physical, sexual, emotional, legal)
• Substance abuse
• Aggressive, often violent behavior; prone to getting involved in fights
• A persistent agitated or depressed feeling (dysphoria)
• Inability to tolerate boredom
• Disregard for the safety of self or others
• A childhood diagnosis of conduct disorders - this is not a symptom but "a history of"
• Lack of remorse for hurting others
• Superficial charm
• Impulsiveness
• A sense of extreme entitlement
• Inability to make or keep friends
• Lack of guilt
• Relentlessness^{[dubious – discuss]}
• Recklessness, impulsivity^[4][5]

People with a diagnosis of antisocial personality disorder often experience difficulties with authority figures.^[6]

Prevalence

The National Comorbidity Survey, which used DSM-III-R criteria, found that 5.8 percent of males and 1.2 percent of females showed evidence of a lifetime risk for the disorder.^[7] According to DSM-IV, Antisocial Personality disorder is diagnosed in approximately 3% of all males and 1% of all females.^[1]

In penitentiaries, the percentage is estimated to be as high as 75 percent.^{[citation needed]} Prevalence estimates within clinical settings have varied^{[weasel words]} from three to 30 percent, depending on the predominant characteristics of the populations being sampled. {Diagnostic and Statistical Manual of Mental Disorders} Perhaps not surprisingly^[who?], 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.^[8] David Korten also reports research that shows a high proportion of these traits amongst CEOs of major corporations ^[9].

Relationship with other mental disorders

Antisocial personality disorder is negatively correlated with all DSM-IV Axis I disorders except substance abuse disorders. Antisocial personality disorder is most strongly correlated with psychopathy as measured on the Psychopathy Checklist-Revised (PCL-R).

Potential markers

Although antisocial personality disorder cannot be formally diagnosed before age 18, three markers for the disorder, known as the MacDonald Triad, can be found in some children. These are, a longer-than-usual period of bedwetting, cruelty to animals, and pyromania^[10].

It is not known how many children who exhibit these signs grow up to develop antisocial personality disorder, but these signs are often found in the histories of diagnosed adults. Because it is unknown how many children have these symptoms and who do not develop antisocial personality disorder, the predictive value (ie, the usefulness of these symptoms for predicting future antisocial personality disorder) is unclear.

These three traits are now included in the Diagnostic and Statistical Manual of Mental Disorders IV-TR under conduct disorder.

A child who shows signs of antisocial personality disorder may be diagnosed as having either conduct disorder or oppositional defiant disorder. Not all of these children, however, will grow up to develop antisocial personality disorder.

Criticism of the DSM-IV criteria

The DSM-IV confound: some argue that an important distinction has been lost by including both sociopathy and psychopathy together under APD. As Hare et al write in their abstract, "The Axis II Work Group of the Task Force on DSM-IV has expressed concern that antisocial personality disorder (APD) criteria are too long and cumbersome and that they focus on antisocial behaviors rather than personality traits central to traditional conceptions", concluding, "... conceptual and empirical arguments exist for evaluating alternative approaches to the assessment of psychopathy ... our hope is that the information presented here will stimulate further research on the comparative validity of diagnostic criteria for psychopathy; although too late to influence DSM-IV."^[11]

Causes

The cause of this disorder is unknown, but biological or genetic factors may play a role. However, the statistical correlation between the disorder and biological factors is weak, leading many experts to believe otherwise.^{[citation needed]}

A family history of the disorder — such as having an antisocial parent — increases the chances of developing the condition. A number of environmental factors within the childhood home, school and community, such as an overly punitive home or school environment may also contribute, according to the Mayo Clinic Website.^[5]

Robins (1966) found an increased incidence of sociopathic characteristics and alcoholism in the fathers of individuals with antisocial personality disorder. He found that, within such a family, males had an increased incidence of APD, whereas females tended to show an increased incidence of somatization disorder instead.^[12]

Bowlby (1944) saw a connection between antisocial personality disorder and maternal deprivation in the first five years of life. Glueck and Glueck (1968) saw indications that the mothers of children who developed this personality disorder tended to display a lack of consistent discipline and affection, and an abnormal tendency to alcoholism and impulsiveness. These factors all contribute to a failure to create a stable and functional home with consistent structure and behavioral boundaries.^[12]

Adoption studies support the role of both genetic and environmental contributions to the development of the disorder. Twin studies also indicate an element of hereditability of antisocial behaviour in adults and have shown that genetic factors are more important in adults than in antisocial children or adolescents where shared environmental factors are more important. (Lyons et al., 1995)^[12]

See also

• Psychopathy
• The Mask of Sanity

References