Antisocial Personality Disorder

• A personality disorder (PD) is a persistent pattern of internal experience and behavior that markedly differs from what people consider normal within the person's own culture.
• Mental health professionals group personality disorders into clusters A, B, and C based on the dominating symptoms.
• According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the antisocial personality disorder is a diagnosis that a mental health professional can only assign when the individual is 18 years of age or older and has an enduring pattern of disregarding and violating the rights of others with symptoms having been present since the age of 15 years. The diagnosis may include symptoms like breaking laws, repeated deceitfulness, starting fights, a lack of regard for their own safety or the safety of others, a lack of guilt and taking personal responsibility, a tendency toward impulsivity and irritability.
• Although not a formal diagnosis, psychopathy is a more severe form of antisocial personality disorder. Specifically, in order to be considered a psychopath, a person must have a complete lack of conscience, having absolutely no remorse or guilt about their actions, in addition to demonstrating antisocial behaviors.
• Psychopaths tend to be highly suspicious or paranoid, even in comparison to individuals with antisocial personality disorder, which tends to lead the psychopathic person to interpret all aggression toward them as being arbitrary and unfair.
• Antisocial personality disorder is likely the result of a combination of biologic/genetic and environmental factors.
• Some theories about the biological risk factors for antisocial personality disorder include the malfunction of certain genes, hormones, or parts of the brain.
• Diagnoses often associated with antisocial personality disorder include substance-related disorders, attention-deficit hyperactivity disorder (ADHD), and reading disorders.
• Theories regarding the life circumstances that increase the risk for developing antisocial personality disorder include a history of childhood physical, sexual, or emotional abuse; neglect, deprivation, or abandonment; associating with peers who engage in antisocial behavior; or having a parent who is either antisocial or alcoholic.
• Since there is no specific definitive test that can accurately diagnose antisocial personality disorder, health care professionals perform a mental health interview that assesses for the presence of antisocial symptoms. If the cultural context of the symptoms is not considered, medical professional often falsely diagnose antisocial personality disorder as being present.
• Research indicates that medical professionals tend to wrongly diagnose members of ethnic minorities with antisocial personality disorder, thereby inappropriately resulting in less treatment and more punishment for those individuals.
• While antisocial personality disorder can be quite resistant to treatment, the most effective interventions tend to be a combination of firm but fair behavior therapy and programming that emphasizes teaching the antisocial personality disorder individuals skills that can be used to live independently and productively within the rules and limits of society.
• While medications do not directly treat the behaviors that are associated with antisocial personality disorder, they can be useful in addressing conditions like depression, anxiety, and mood swings that often co-occur with this condition.
• If untreated, people with antisocial personality disorder are at risk for developing or worsening many other mental disorders, as well as for self-mutilation or dying from homicide or suicide.
• Many people with antisocial personality disorder experience a remission of symptoms by the time they are 50 years old.

Psychopathy and sociopathy, although not mental health disorders formally recognized by the American Psychiatric Association, are more severe forms of antisocial personality disorder. Specifically, in order for a medical professional to diagnose someone as a psychopath, a person must have a lack of remorse or guilt about their actions in addition to demonstrating antisocial behaviors. Other core symptoms of this condition include a severe lack of caring for others, a lack of emotion, overconfidence, selfishness, and a higher propensity for planned aggression compared to sociopaths or other people with antisocial personality disorder. They are more likely to be able to maintain steady employment and to seem to have normal relationships compared to sociopaths. Mental health providers believe psychopaths are born lacking the ability to feel guilt rather than being associated with a history of trauma (like abuse, neglect, or exposure to community violence). While statistics indicate that 50%-80% of incarcerated individuals have antisocial personality disorder, only 15% of those convicted criminals have been shown to have the more severe antisocial personality disorder type of psychopathy.

Psychopaths tend to be highly suspicious or paranoid, even compared to people with antisocial personality disorder. The implications of this suspicious stance can be dire, in that paranoid thoughts (ideations) tend to lead the psychopathic person to interpret all aggressive behaviors toward them, even those that are justified, as being arbitrary and unfair. A televised case study of a psychopath provided a vivid illustration of the resulting psychopathic anger. Specifically, the criminal featured in the story apparently abducted a girl and sexually abused her over the course of a number of days in an attempt to prove to investigating authorities that his stepdaughter's allegations that he sexually abused her were false.

Although people often use the terms psychopathy and sociopathy interchangeably, researchers describe sociopaths as having a higher tendency toward impulsive behaviors and angry outbursts and if they form any connection to other people it is usually with other sociopaths. They are also less likely to be able to maintain steady employment or to give the appearance of having normal relationships compared to psychopaths.

One of the most frequently asked questions about antisocial personality disorder by both professionals and laypeople is whether it is genetic. Many wonder if it is hereditary, just as much as hair, eye, or skin color; if this were the case, children of antisocial people would be highly expected to become antisocial themselves, whether or not they live with the antisocial parent. Fortunately, human beings are just not that simple. Like all personality disorders, and most mental disorders, antisocial personality disorder tends to be the result of a combination of biologic/genetic and environmental factors.

Although there are no clear biological causes for this disorder, studies on the possible neurodevelopmental risk factors for developing antisocial personality disorder reveal that, in those with the illness, the part of the brain that is primarily responsible for learning from one's mistakes and for responding to sad and fearful facial expressions (the amygdala) tends to be smaller and respond less robustly to the happy, sad, or fearful facial expressions of others. That lack of response may have something to do with the lack of empathy that antisocial individuals tend to have with the feelings, rights, and suffering of others. While some individuals may be more vulnerable to developing antisocial personality disorder because of their particular genetic background, that is thought to be a factor only when the person is also exposed to life events such as abuse or neglect that tend to put the person at risk for development of the disorder. Similarly, while there are some theories about the role of premenstrual syndrome (PMS) and other hormonal fluctuations in the development of antisocial personality disorder, the disorder cannot be explained as the direct result of such problems.

Other conditions that are risk factors for antisocial personality disorder include substance abuse, attention-deficit hyperactivity disorder (ADHD), reading disorder, or conduct disorder, which is diagnosed in children. People who experience a temporary or permanent brain dysfunction, often also called organic brain damage, are at risk for developing violent or otherwise criminal behaviors. Theories about the life experiences that increase the risk for developing antisocial symptoms in teenagers and adults provide important clues for its prevention. Examples of such life experiences include a history of prenatal drug exposure or malnutrition, childhood physical, sexual, or emotional abuse; neglect; deprivation or abandonment; associating with peers who engage in antisocial behavior; or a parent who is either antisocial or alcoholic.

To understand antisocial personality disorder (ASPD or APD), it is necessary to learn what having any personality disorder involves. As defined by the Diagnostic and Statistical Manual for Mental Disorders (DSM-V, 2013), a personality disorder (PD) is a consistent, enduring pattern of inner experiences and behaviors that is significantly different from what is thought to be consistent with the individual's own social and cultural norms.

Mental health professionals group personality disorders based on a commonality of symptoms.

Cluster A personality disorders are those that include symptoms of social isolation, and/or strange, eccentric behavior. These disorders include

• paranoid personality disorder,
• schizotypal personality disorder,
• schizoid personality disorder.

Cluster B personality disorders are those that involve dramatic or erratic behaviors (counter-social behaviors). These personality disorders include

• antisocial personality disorder,
• borderline personality disorder,
• histrionic personality disorder,
• narcissistic personality disorder.

Cluster C personality disorders have difficulties with anxiety and inhibited behavior. These disorders include

• avoidant personality disorder,
• dependent personality disorder,
• obsessive compulsive personality disorder (OCD).

Antisocial personality disorder is specifically a persistent pattern of disregarding and violating the rights of others. Called dissocial personality disorder internationally, the United States-based Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) describes antisocial personality disorder as having diagnostic criteria of a pattern of inner experiences and behaviors that must include at least three of the following specific signs and symptoms:

• Repeatedly breaking laws, as evidenced by repeatedly engaging in behaviors that are grounds for arrest (for example, stealing, fire-setting, other destruction of property, assaults)
• Repeated deceitfulness in relationships with others, such as telling lies, using false names, or conning others for profit or pleasure
• Failure to think or plan ahead (impulsivity)
• Tendency to irritability, hostility, anger, and aggressiveness, as shown by repeatedly assaulting others or getting into frequent physical fights
• Disregard for their own safety or the safety of others, such that they have a lack of self-control and are prone to repeatedly engaging in risk-taking behaviors
• Persistent lack of taking responsibility, such as failing to establish a pattern of good work habits or keeping financial obligations
• A disregard for other people such that there is a lack of feeling guilty about wrongdoing

Other important characteristics of this disorder include that medical professionals do not diagnose this disorder in children (individuals younger than 18 years of age), but the affected person must have shown symptoms of this diagnosis (conduct disorder) at least since 15 years of age. Additionally, a medical professional cannot diagnose antisocial personality disorder if the person only shows symptoms of antisocial personality disorder at the same time they are suffering from symptoms of schizophrenia or of bipolar disorder. Describing bipolar disorder as one of the exclusion criteria (diagnoses whose presence means that the diagnosis of antisocial personality disorder cannot be assigned) is a change from how this disorder was described in the previous diagnostic manual in the United States, the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision). The DSM-IV described having a manic episode as the exclusion criterion with schizophrenia, not having the depressive aspect of bipolar disorder as an exclusion criterion.

Intermittent explosive disorder is a recognized diagnosis whose symptoms involve aggression that is excessive in response to its trigger. People may mistake its symptoms for those of antisocial personality disorder. Misophonia, a newly described diagnosis not recognized in the DSM-V, has symptoms that include the sufferer responding to being provoked to anger and impulsive aggression by sights or sounds that are innocuous to most people. The aggression of this disorder may also be mistaken for antisocial personality disorder.

Antisocial personality disorder tends to occur in about 1% of women and 3% of men in the United States. Antisocial personality symptoms in women tend to include self-harm and more of the other symptoms of borderline personality disorder (BPD) than in men.

There is no specific definitive test, such as a blood test, that can accurately assess whether a person has antisocial personality disorder. Mental health practitioners like psychiatrists, psychoanalysts, or clinical psychologists conduct a mental health interview that gathers information to look for the presence of the symptoms previously described. Due to the use of a mental health interview in making the diagnosis and the fact that this disorder can be quite resistant to treatment, it is important that the mental health practitioner know to assess the symptoms in the context of the person's culture so the individual is not assessed as having antisocial personality disorder when he or she does not. Unfortunately, research shows that many practitioners lack the knowledge, experience, and sometimes the willingness to factor cultural context into their assessments.

Another very common question asked is, can antisocial personality disorder be cured? While it can be quite resistant to change, research shows there are a number of effective treatments for this disorder. For example, teenagers who receive therapy that helps them change the thinking that leads to their maladaptive behavior (cognitive behavioral psychotherapy) experience a significant decrease the incidence of engaging in repeat antisocial behaviors.

On the other hand, attempting to treat antisocial personality disorder like other conditions is not often effective. For example, programs that have tried to use a purely reflective (insight-oriented talk therapy) approach to treating depression or eating disorders in people with antisocial personality disorder often worsen rather than improve outcomes in those individuals. In those cases, firm but fair behavior therapy to reward appropriate actions and programming that emphasizes teaching individuals with antisocial personality disorder the skills that one can use to live independently and productively within the rules and limits of society has been the more effective treatment for this condition. Family therapy that helps loved ones of people with antisocial personality disorder appropriately cope with the negative behaviors and promote the positive behaviors of the antisocial personality disorder sufferer can also be an important part of treatment for this condition.

While clinical trials indicate that medications do not directly treat the behaviors that characterize antisocial personality disorder, they can be useful in addressing conditions that co-occur with this condition. Specifically, depressed or anxious individuals who also have antisocial personality disorder may benefit from antidepressants like fluoxetine (Prozac), escitalopram (Lexapro), or duloxetine (Cymbalta), and those who exhibit impulsive anger may improve when given mood stabilizers like lithium, divalproex (Depakote), or lamotrigine (Lamictal).

Some long-term societal costs of antisocial personality disorder, like the suffering endured by victims of the crimes committed by people with this disorder, are clear. However, when people with ASPD are the charismatic leaders of religious cults, the devastation they can create is often not known unless and until a catastrophe occurs. The multiple murders orchestrated by Charles Manson and the mass suicide that occurred at the command of the Reverend Jim Jones in Guyana in 1978 are just two such examples.

Individuals who suffer from antisocial personality disorder have a higher risk of abusing alcohol and other drugs and repeatedly committing crimes. Imprisonment is a potential consequence. People with antisocial personality disorder are also vulnerable to mood problems, such as major depression, anxiety, and bipolar disorder; having other personality disorders, especially borderline (BPD) and narcissistic personality disorders; self-mutilation and other forms of self-harm, as well as dying from homicide, suicide, or accident.

Antisocial personality disorder tends to make the prognosis of virtually any other condition more problematic. Having antisocial personality disorder makes the treatment for problems of substance abuse or emotional or physical substance dependence more difficult. People who have both antisocial personality disorder and schizophrenia are less likely to comply with treatment programs and are more likely to remain institutionalized in a prison or a hospital. These risks amplify if antisocial personality disorder is not treated. Statistics indicate that many people with antisocial personality disorder experience a remission of symptoms by the time they reach 50 years of age.

To find information on specialists who treat ASPD, visit

National Alliance on Mental Illness
http://www.nami.org

National Institute of Mental Health
http://www.nimh.nih.gov