Antisocial personality disorder

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Jesus Rosario Hernandez, M.D. [2], Haleigh Williams, B.S., Irfan Dotani

Synonyms and keywords: APD; introverted personality disorder; sociopath; ASPD; antisocial behavior; sociopathic; sociopathic behavior; antisocial; antisocial tendency; antisocial tendencies

Overview

Antisocial personality disorder (ASPD) is a psychiatric condition characterized by a disregard for social rules, norms, and cultural codes, as well as impulsive behavior and indifference to the rights and feelings of others. People with ASPD may lie, endanger the wellbeing of others for their own benefit, and/or show a prominent lack of remorse for wrongdoing. Such behavior is often associated with criminal activity. Sufferers of ASPD may nonetheless be capable of behaving in a flattering, charming, or otherwise likeable and socially acceptable way in the interest of manipulating others and achieving their own ends. Incarcerated people are roughly ten times more likely to have antisocial personality disorder than members of the general population. During childhood, people who will go on to be diagnosed with ASPD may demonstrate pyromania, a prolonged period of bedwetting, and/or cruelty to animals; this set of symptoms is known as the Macdonald triad. Truancy, delinquency, hyperactivity, and conduct disorder are also common in young people with ASPD. "Antisocial personality disorder" is the terminology used by the American Psychiatric Association's Diagnostic and Statistical Manual, while the World Health Organization's ICD-10 uses the term Dissocial personality disorder. People with ASPD are sometimes referred to as "sociopaths."

Historical Perspective

• Prior to being defined cohesively, what we have come to know as ASPD was encapsulated under the categories of "psychopathy" and "sociopathy." The distinctions among these disorders remain somewhat ill-defined.
• The term antisocial personality disorder first appeared in the third edition of the DSM in 1980.

Classification

There is no established classification system for ASPD.

Pathophysiology

Neural Maldevelopment

• Individuals with cavum septum pellucidum (CSP), a marker of limbic neural maldevelopment, are significantly more likely to have ASPD than control populations.
• This relationship is observed even when researchers control for trauma and head injury.
• The early maldevelopment of limbic and septal structures appears to predispose individuals to antisocial behaviors.
• The presence of CSP is more closely related to the aggressive aspect of ASPD symptomology than the deceptive/irresponsible facet.

Common Comorbidities

Conditions that are commonly comorbid with ASPD include:

• Psychopathy (sometimes considered a particularly intense form of ASPD)
• Depression
• Substance abuse disorder
  • People who meet the DSM criteria for ASPD are 21 times more likely to develop alcohol abuse and dependence at some point throughout their lives than people who do not suffer from ASPD.

Causes

The cause of ASPD is unknown, though the disorder is commonly associated with both genetics and childhood tumult.

Differentiating antisocial personality disorder from other diseases

ASPD must be differentiated from disorders with similar symptomology, including:

• Substance abuse disorders
• Schizophrenia
• Bipolar disorder
• Narcissistic personality disorder
• Histrionic personality disorder
• Borderline personality disorder
• Criminal behavior

Epidemiology and Demographics

Prevalence

• Overall, 3% of men and 1% of women in the general population meet the criteria for ASPD.
• The 12-month prevalence of ASPD is 1.0% of the United States adult population.

Gender

• ASPD is more common in men than in women.
• The male to female ratio is 2 to 1.
• Boys with ASPD tend to develop symptoms earlier than girls, who may not show signs of ASPD until they reach puberty.
• Basal testosterone levels are positively related to incidence of antisocial behaviors.

Age

• Symptoms tend to be most severe in early adulthood and may diminish over time, as a person ages.
• This finding is consistent with arrest records, which show that arrests are most common among individuals in their late teens and early 20s, and then decline in subsequent age groups. This is a relevant finding because criminality is a common complication of ASPD.

Race

• No racial predilection is associated with ASPD.

Special Populations

• Approximately 1 in 2 male prisoners and 1 in 5 female prisoners suffer from ASPD.
• Prisoners are roughly ten times more likely to have antisocial personality disorder than members of the general population.

Risk Factors

Risk factors for the development of ASPD include:

• Male gender
• Genetics
• Family history of ASPD
• Antisocial/alcoholic parent
• Alcohol abuse
• Child abuse
• Drug abuse
• Incarceration
• Childhood hyperactivity or conduct disorder
  • Though people with ASPD commonly exhibited conduct disorder (CD) as children, most children with CD do not go on to develop ASPD. Accounting for the variety and severity of childhood behavioral issues is a more precise means of predicting whether a child with CD will later be diagnosed with ASPD.

Screening

Screening for ASPD, performed by a mental health specialist, is recommended for individuals who demonstrate antisocial behaviors, particularly as children, when complications may be easier to forestall. Screening for ASPD is also recommended for incarcerated people, who experience much higher rates of ASPD than the general population.

Natural History, Complications and Prognosis

Natural History

• People who suffer from ASPD are generally less likely to seek treatment for any medical problems or to adhere to treatment regimens set forth by their physicians.
• This can lead to myriad physical and psychological complications, including suicide attempts.
• Antisocial tendencies in childhood are also strongly predictive of future economic issues, diminished educational achievement, long-term unemployment, and unsatisfying familial relationships in later years.
• Patients who experience an early onset of symptoms progress more quickly to a severe form of ASPD than do people with later ages of onset.
• In a comparison between patients with ASPD and patients with schizophrenia, members of the former group were more likely to be married and to have secured their own housing, but they were equally likely to struggle at work and to be debilitated by psychiatric symptoms (though not the same symptoms as the schizophrenic patients).
• Married people with ASPD were found to be more likely to coalesce over time than their unmarried counterparts.

Complications

Complications of ASPD can include:

• Law-breaking or imprisonment
• Drug abuse
  • ASPD patients who are alcoholics are more likely to experience alcohol-related consequences than non-ASPD alcoholics.
• Violence
• Inability to sustain employment
• Tumultuous or unhappy family life
• Homelessness
• Self-harm or suicide
• Traumatic injury
• HIV
• Hepatitis C infection

Prognosis

• Without treatment, the prognosis of ASPD is varied.
  • Symptoms commonly peak in the late teenage years and the early 20s.
  • Sometimes, symptoms improve on their own as the patient nears middle age.
  • The median age for improvement seems to be 35 years.
  • Among ASPD patients, heavy alcohol usage and low socioeconomic status are predictive of poor neuropsychological outcomes.

• With treatment, the prognosis is improved, though concrete data are unavailable.
  • Though behavior may improve with treatment, the elements of personality that are central to ASPD, such as an inability to empathize with others, often remain.
  • Successfully treated individuals may no longer pose a threat to society or themselves, but they often continue to exhibit irritability and hostility, and may still have difficulty sustaining interpersonal relationships.

Diagnosis

Diagnostic Criteria

DSM-V Diagnostic Criteria for Antisocial Personality Disorder

“

A. 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: 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. AND B. The individual is at least age 18 years. AND C. There is evidence of conduct disorder with onset before age 15 years. AND D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

”

ICD-10 Diagnostic Criteria

Chapter V of the tenth revision of the International Classification of Diseases offers a set of criteria for diagnosing the related construct of dissocial personality disorder.

Dissocial Personality Disorder (F60.2), usually coming to a gross disparity between behavior and the prevailing social norms, and characterized by:

• Callous unconcern for the feelings of others
• 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 proneness to blame others, or to offer plausible rationalizations, for the behavior that has brought the patient into conflict with society

There may also be persistent irritability as an associated feature. Conduct disorder during childhood and adolescence, though not invariably present, may further support the diagnosis.

History and Symptoms

Common symptoms of ASPD include:

• Persistent lying or stealing
• Recurring difficulties with the law
• Tendency to violate the rights 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
• Lack of remorse for hurting others
• Superficial charm
• Impulsivity or recklessness
• A sense of extreme entitlement
• Inability to make or keep friends or maintain long-term, healthy relationships
• Lack of remorse for wrongdoing
• Persistent difficulty interacting with authority figures
• Macdonald triad in childhood
  • Longer-than-normal period of bedwetting
  • Cruelty to animals
  • Pyromania

Physical Examination

• ASPD is diagnosed based on the results of a psychiatric evaluation, during which the clinician will consider the nature of the patient’s symptoms, how long they have been present, and how severe they are.
• For a diagnosis of ASPD to be made, the patient must have exhibited behavioral and emotional problems during childhood.

Laboratory Findings

• A diagnosis of ASPD is supported by clinical evaluation rather than laboratory tests.

Imaging Findings

• Commonly impaired regions of the brain in ASPD patients include:

• • Prefrontal cortex (particularly orbitofrontal and dorsolateral prefrontal cortex)
  • Superior temporal gyrus
  • Amygdala-hippocampal complex
  • Anterior cingulate cortex

Treatment

Medical Therapy

• ASPD is often regarded among mental health professionals as one of the most difficult personality disorders to treat effectively, largely because individuals with this disorder are unlikely to seek treatment on their own and might do so only on the orders of a court or at the urging of a loved one.

• Behavioral treatments or talk therapy (CBT or MBT), as well as patient support groups, may be useful for some patients.

• • It is also important to treat patients for any comorbid conditions, including substance abuse disorder or mood disorder.
  • Relatively little evidence exists to support the use of medication to treat ASPD. Carbamazepine or lithium may be useful for minimizing aggressive behavior, while SSRIs can help improve disposition issues.

Surgery

• Surgery is not recommended for the treatment of ASPD.

Primary Prevention

• Early intervention in children with conduct disorder who display antisocial tendencies may prevent the development of ASPD throughout adolescence and adulthood and, consequently, can result in improved academic performance.

Secondary Prevention

• No effective strategies for the secondary prevention of ASPD have been established.