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''Antisocial personality disorder'' (ASPD) is the name of the disorder as defined in the ''[[Diagnostic and Statistical Manual]]'' (DSM). ''Dissocial personality disorder'' is the name of a similar or equivalent concept defined in the ''[[International Statistical Classification of Diseases and Related Health Problems]]'' (ICD), where it states that the diagnosis includes antisocial personality disorder. Both manuals have similar but not identical criteria.<ref>
''Antisocial personality disorder'' (ASPD) is the name of the disorder as defined in the ''[[Diagnostic and Statistical Manual]]'' (DSM). ''Dissocial personality disorder'' is the name of a similar or equivalent concept defined in the ''[[International Statistical Classification of Diseases and Related Health Problems]]'' (ICD), where it states that the diagnosis includes antisocial personality disorder. Both manuals have similar but not identical criteria.<ref>
{{cite book |date=2003-06-16 |author= David P. Farrington, Jeremy Coid |title= Early Prevention of Adult Antisocial Behavior |url=http://books.google.com/?id=KtXU8R8oZYwC&pg=PA82&lpg=PA82&dq=dissocial+personality+disorder |publisher=Cambridge University Press |accessdate=2008-01-12 |page = 82 |isbn=978-0-521-65194-3 }}</ref> Both have stated that their diagnoses have been referred to, or include what is referred to, as [[psychopathy or sociopathy]], though the criteria are different to some other commonly used assessments; for example, certain personality assumptions may be excluded.<ref name="Handbook of Psychopathy">{{cite book |last=Patrick |first=Christopher |title=Handbook of Psychopathy |url=http://books.google.co.uk/books/about/Handbook_of_Psychopathy.html?id=OuNdrmHcJlgC&redir_esc=y |accessdate=18 July 2013 |year=2005 |publisher= Guilford Press}}</ref><ref name="Hare1996">[http://www.psychiatrictimes.com/dsm-iv/content/article/10168/54831 "Psychopathy and Antisocial Personality Disorder: A Case of Diagnostic Confusion"]. Robert D. Hare, Ph.D. ''Psychiatric Times''. Vol. 13 No. 2. February 1, 1996.</ref><ref name="HareHarpur">Hare, R.D., Hart, S.D., Harpur, T.J. [http://www.psych.utoronto.ca/~peterson/psy430s2001/Hare%20RD%20Psychopathy%20JAP%201991.pdf Psychopathy and the DSM—IV Criteria for Antisocial Personality Disorder] (PDF).</ref><ref name="Semple">{{cite book | first=David | last= Semple | year= 2005 | title= The Oxford Handbook of Psychiatry |url=http://books.google.co.uk/books/about/Oxford_Handbook_of_Psychiatry.html?id=1MeRuoTs0loC&redir_esc=y | edition=| publisher=Oxford University Press | location=USA| pages= 448–449 | isbn=0-19-852783-7}}</ref><ref name="gap"/> ASPD falls under the dramatic/erratic cluster of personality disorders.<ref name= Psychology>Schacter, Daniel L., Daniel T. Gilbert, and Daniel M. Wegner. Psychology. Worth Publishers, 2010. Print.</ref>
{{cite book |date=2003-06-16 |author= David P. Farrington, Jeremy Coid |title= Early Prevention of Adult Antisocial Behavior |url=http://books.google.com/?id=KtXU8R8oZYwC&pg=PA82&lpg=PA82&dq=dissocial+personality+disorder |publisher=Cambridge University Press |accessdate=2008-01-12 |page = 82 |isbn=978-0-521-65194-3 }}</ref> Both have stated that their diagnoses have been referred to, or include what is referred to, as [[psychopathy or sociopathy]], though the criteria are different to some other commonly used assessments; for example, certain personality assumptions may be excluded.<ref name="Handbook of Psychopathy">{{cite book |last=Patrick |first=Christopher |title=Handbook of Psychopathy |url=http://books.google.com/?id=OuNdrmHcJlgC |accessdate=18 July 2013 |year=2005 |publisher= Guilford Press |isbn=9781606238042}}</ref><ref name="Hare1996">[http://www.psychiatrictimes.com/dsm-iv/content/article/10168/54831 "Psychopathy and Antisocial Personality Disorder: A Case of Diagnostic Confusion"]. Robert D. Hare, Ph.D. ''Psychiatric Times''. Vol. 13 No. 2. February 1, 1996.</ref><ref name="HareHarpur">Hare, R.D., Hart, S.D., Harpur, T.J. [http://www.psych.utoronto.ca/~peterson/psy430s2001/Hare%20RD%20Psychopathy%20JAP%201991.pdf Psychopathy and the DSM—IV Criteria for Antisocial Personality Disorder] (PDF).</ref><ref name="Semple">{{cite book | first=David | last= Semple | year= 2005 | title= The Oxford Handbook of Psychiatry |url=http://books.google.com/?id=1MeRuoTs0loC | edition=| publisher=Oxford University Press | location=USA| pages= 448–449 | isbn=0-19-852783-7}}</ref><ref name="gap"/> ASPD falls under the dramatic/erratic cluster of personality disorders.<ref name= Psychology>Schacter, Daniel L., Daniel T. Gilbert, and Daniel M. Wegner. Psychology. Worth Publishers, 2010. Print.</ref>


==Diagnosis==
==Diagnosis==
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* [[Sadistic personality disorder]]
* [[Sadistic personality disorder]]
}}
}}
When combined with [[alcoholism]], people may show frontal function deficits on [[neuropsychological tests]] greater than those associated with each condition.<ref>{{cite journal |author=Oscar-Berman M|coauthors=Valmas M, Sawyer K, Kirkley S, Gansler D, Merritt D, Couture A|date=|year=2009 |month= April|title=Frontal brain dysfunction in alcoholism with and without antisocial personality disorder|journal=Neuropsychiatric Disease and Treatment |volume=2009 |issue=5 |pages=309–326 |pmid=19557141 |pmc=2699656}}</ref>
When combined with [[alcoholism]], people may show frontal function deficits on [[neuropsychological tests]] greater than those associated with each condition.<ref>{{cite journal |author=Oscar-Berman M|coauthors=Valmas M, Sawyer K, Kirkley S, Gansler D, Merritt D, Couture A|date=|year=2009 |month= April|title=Frontal brain dysfunction in alcoholism with and without antisocial personality disorder|journal=Neuropsychiatric Disease and Treatment |volume=2009 |issue=5 |pages=309–326 |pmid=19557141 |pmc=2699656 |doi=10.2147/NDT.S4882}}</ref>


== Causes and pathophysiology ==
== Causes and pathophysiology ==
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=== Hormones and neurotransmitters ===
=== Hormones and neurotransmitters ===
Traumatic events can lead to a disruption of the standard development of the central nervous system, which can generate a release of hormones that can change normal patterns of development.<ref name="What causes ASPD?">{{cite web|last=Black|first=D|title=What Causes Antisocial Personality Disorder?|url=http://psychcentral.com/lib/2006/what-causes-antisocial-personality-disorder/|publisher=Psych Central|accessdate=1 November 2011}}</ref>
Traumatic events can lead to a disruption of the standard development of the central nervous system, which can generate a release of hormones that can change normal patterns of development.<ref name="What causes ASPD?">{{cite web|last=Black|first=D|title=What Causes Antisocial Personality Disorder?|url=http://psychcentral.com/lib/2006/what-causes-antisocial-personality-disorder/|publisher=Psych Central|accessdate=1 November 2011}}</ref>
Aggressiveness and impulsivity are among the possible symptoms of ASPD. [[Testosterone]] is a hormone that plays an important role in aggressiveness in the brain.<ref name="Batrinos">{{cite journal | url=http://endometabol.com/?page=article&article_id=3661 | title=Testosterone and Aggressive Behavior in Man | author=Menelaos L. Batrinos | journal=Int J Endocrinol Metab. | year=2012 | volume=10 | issue=3 | pages=563–568 | doi=10.5812/ijem.3661}}</ref> For instance, criminals who have committed violent crimes have higher levels of testosterone.<ref name="Batrinos"/> The effect of testosterone is counteracted by [[cortisol]] which facilitates the cognitive control on impulsive tendencies.<ref name="Batrinos"/>
Aggressiveness and impulsivity are among the possible symptoms of ASPD. [[Testosterone]] is a hormone that plays an important role in aggressiveness in the brain.<ref name="Batrinos">{{cite journal | url=http://endometabol.com/?page=article&article_id=3661 | title=Testosterone and Aggressive Behavior in Man | author=Menelaos L. Batrinos | journal=Int J Endocrinol Metab. | year=2012 | volume=10 | issue=3 | pages=563–568 | doi=10.5812/ijem.3661 | pmid=23843821 | pmc=3693622}}</ref> For instance, criminals who have committed violent crimes have higher levels of testosterone.<ref name="Batrinos"/> The effect of testosterone is counteracted by [[cortisol]] which facilitates the cognitive control on impulsive tendencies.<ref name="Batrinos"/>


One of the neurotransmitters that have been discussed in individuals with ASPD is [[serotonin]].<ref name="What causes ASPD?" /> A meta-analysis of 20 studies found significantly lower [[5-HIAA]] levels (indicating lower serotonin levels), especially in those who are younger than 30 years of age.<ref>{{cite journal | title=A meta-analysis of serotonin metabolite 5-HIAA and antisocial behavior. | author=Moore TM, Scarpa A, Raine A. | journal=Aggressive Behavior. | year=2002 | volume=28 | pages=299–316 | doi=10.1002/ab.90027}}</ref>
One of the neurotransmitters that have been discussed in individuals with ASPD is [[serotonin]].<ref name="What causes ASPD?" /> A meta-analysis of 20 studies found significantly lower [[5-HIAA]] levels (indicating lower serotonin levels), especially in those who are younger than 30 years of age.<ref>{{cite journal | title=A meta-analysis of serotonin metabolite 5-HIAA and antisocial behavior | author=Moore TM, Scarpa A, Raine A. | journal=Aggressive Behavior. | year=2002 | volume=28 | pages=299–316 | doi=10.1002/ab.90027 | issue=4}}</ref>


J.F.W. Deakin of [[University of Manchester]]'s Neuroscience and Psychiatry Unit has discussed additional evidence of 5HT's connection with ASPD. Deakin suggests that low [[cerebrospinal fluid]] concentrations of 5-HIAA, and hormone responses to 5HT, have displayed that the two main ascending 5HT pathways mediate adaptive responses to post and current conditions. He states that impairments in the posterior 5HT cells can lead to low mood functioning, as seen in patients with ASPD. It is important to note that the dysregulated serotonergic function may not be the sole feature that leads to ASPD but it is an aspect of a multifaceted relationship between biological and psychosocial factors.{{Citation needed|date=July 2013}}
J.F.W. Deakin of [[University of Manchester]]'s Neuroscience and Psychiatry Unit has discussed additional evidence of 5HT's connection with ASPD. Deakin suggests that low [[cerebrospinal fluid]] concentrations of 5-HIAA, and hormone responses to 5HT, have displayed that the two main ascending 5HT pathways mediate adaptive responses to post and current conditions. He states that impairments in the posterior 5HT cells can lead to low mood functioning, as seen in patients with ASPD. It is important to note that the dysregulated serotonergic function may not be the sole feature that leads to ASPD but it is an aspect of a multifaceted relationship between biological and psychosocial factors.{{Citation needed|date=July 2013}}


While it has been shown that lower levels of serotonin may be associated with ASPD, there has also been evidence that decreased serotonin function is highly correlated with impulsiveness and aggression across a number of different experimental paradigms. Impulsivity is not only linked with irregularities in 5HT metabolism but may be the most essential psychopathological aspect linked with such dysfunction.<ref>{{cite journal|last=Brown|first=Serena-Lynn|coauthors=Botsis, Alexander; Van Praag; Herman M.|title=Serotonin and Aggression|journal=Journal of Offender Rehabilitation|year=1994|volume=21|series=3–4|pages=27–39|doi=10.1300/J076v21n03_03}}</ref> Correspondingly, the DSM classifies "impulsivity or failure to plan ahead" and "irritability and aggressiveness" as two of seven sub-criteria in category A of the diagnostic criteria of ASPD.<ref name="DSM-IV-TR ASPD" />
While it has been shown that lower levels of serotonin may be associated with ASPD, there has also been evidence that decreased serotonin function is highly correlated with impulsiveness and aggression across a number of different experimental paradigms. Impulsivity is not only linked with irregularities in 5HT metabolism but may be the most essential psychopathological aspect linked with such dysfunction.<ref>{{cite journal|last=Brown|first=Serena-Lynn|coauthors=Botsis, Alexander; Van Praag; Herman M.|title=Serotonin and Aggression|journal=Journal of Offender Rehabilitation|year=1994|volume=21|series=3–4|pages=27–39|doi=10.1300/J076v21n03_03|issue=3}}</ref> Correspondingly, the DSM classifies "impulsivity or failure to plan ahead" and "irritability and aggressiveness" as two of seven sub-criteria in category A of the diagnostic criteria of ASPD.<ref name="DSM-IV-TR ASPD" />


Some studies have found a relationship between [[monoamine oxidase A]] and antisocial behavior, including [[conduct disorder]] and symptoms of adult ASPD, in maltreated children.{{Citation needed|date=July 2013}}
Some studies have found a relationship between [[monoamine oxidase A]] and antisocial behavior, including [[conduct disorder]] and symptoms of adult ASPD, in maltreated children.{{Citation needed|date=July 2013}}


=== Limbic neural maldevelopment ===
=== Limbic neural maldevelopment ===
[[Cavum septum pellucidum]] (CSP) is a marker for [[limbic system|limbic]] neural maldevelopment.<ref name = Raine>{{cite journal |author=Adrian Raine, Lydia Lee, Yaling Yang, Patrick Colletti |title=Neurodevelopmental marker for limbic maldevelopment in antisocial personality disorder and psychopathy |journal=BJPsych. The British Journal of Psychiatry|volume=197 |pages=186–192 |year=2010 |doi=10.1192/bjp.bp.110.078485 }}</ref> One study found that those with CSP had significantly higher levels of antisocial personality, [[psychopathy]], arrests and convictions compared with controls.<ref name = Raine />
[[Cavum septum pellucidum]] (CSP) is a marker for [[limbic system|limbic]] neural maldevelopment.<ref name = Raine>{{cite journal |author=Adrian Raine, Lydia Lee, Yaling Yang, Patrick Colletti |title=Neurodevelopmental marker for limbic maldevelopment in antisocial personality disorder and psychopathy |journal=BJPsych. the British Journal of Psychiatry|volume=197 |pages=186–192 |year=2010 |doi=10.1192/bjp.bp.110.078485 |issue=3 }}</ref> One study found that those with CSP had significantly higher levels of antisocial personality, [[psychopathy]], arrests and convictions compared with controls.<ref name = Raine />


===Cultural influences===
===Cultural influences===
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==Treatment==
==Treatment==
ASPD is considered to be among the most difficult personality disorders to treat.<ref name="Gabbard">Gabbard, Glen O., Gunderson John G. (2000) ''Psychotherapy for Personality Disorders. First Edition.'' American Psychiatric Publishing. ISBN 978-0-88048-273-8.</ref><ref>Stone, Michael H. (1993) ''Abnormalities of Personality. Within and Beyond the Realm of Treatment.'' Norton. ISBN 978-0-393-70127-2</ref>{{Verify source|date=July 2013}} Because of their very low or absent capacity for remorse, individuals with ASPD often lack sufficient motivation and fail to see the costs associated with antisocial acts.<ref name="Gabbard" /> They may only simulate remorse rather than truly commit to change: they can be seductively charming and dishonest, and may manipulate staff and fellow patients during treatment.<ref name="Oldhamskodol">Oldham, John M., Skodol, Andrew E., Bender, Donna S. (2005) ''The American Psychiatric Publishing Textbook of Personality Disorders.'' American Psychiatric Publishing. ISBN 978-1-58562-159-0.</ref>{{Verify source|date=June 2013}} Studies have shown that outpatient therapy is not likely to be successful, however the extent to which persons with ASPD are entirely unresponsive to treatment may have been exaggerated.<ref>{{cite journal|author=Salekin, R. |title=Psychopathy and therapeutic pessimism: Clinical lore or clinical reality?|journal=Clinical Psychology Review|year=2002|volume= 22|issue=|pages =169–183}}</ref>
ASPD is considered to be among the most difficult personality disorders to treat.<ref name="Gabbard">Gabbard, Glen O., Gunderson John G. (2000) ''Psychotherapy for Personality Disorders. First Edition.'' American Psychiatric Publishing. ISBN 978-0-88048-273-8.</ref><ref>Stone, Michael H. (1993) ''Abnormalities of Personality. Within and Beyond the Realm of Treatment.'' Norton. ISBN 978-0-393-70127-2</ref>{{Verify source|date=July 2013}} Because of their very low or absent capacity for remorse, individuals with ASPD often lack sufficient motivation and fail to see the costs associated with antisocial acts.<ref name="Gabbard" /> They may only simulate remorse rather than truly commit to change: they can be seductively charming and dishonest, and may manipulate staff and fellow patients during treatment.<ref name="Oldhamskodol">Oldham, John M., Skodol, Andrew E., Bender, Donna S. (2005) ''The American Psychiatric Publishing Textbook of Personality Disorders.'' American Psychiatric Publishing. ISBN 978-1-58562-159-0.</ref>{{Verify source|date=June 2013}} Studies have shown that outpatient therapy is not likely to be successful, however the extent to which persons with ASPD are entirely unresponsive to treatment may have been exaggerated.<ref>{{cite journal|author=Salekin, R. |title=Psychopathy and therapeutic pessimism: Clinical lore or clinical reality?|journal=Clinical Psychology Review|year=2002|volume= 22|issue=|pages =169–183|doi=10.1016/S0272-7358(01)00083-6}}</ref>


Those with ASPD may stay in treatment only as required by an external source, such as a parole. Residential programs that provide a carefully controlled environment of structure and supervision along with peer confrontation have been recommended.<ref name="Gabbard" /> There has been some research on the treatment of ASPD that indicated positive results for therapeutic interventions.<ref>{{cite journal|last=Derefinko|first=Karen J.|coauthors=Thomas A. Widiger|title=Antisocial Personality Disorder|journal=The Medical Basis of Psychiatry|year=2008|pages=213–226}}</ref>
Those with ASPD may stay in treatment only as required by an external source, such as a parole. Residential programs that provide a carefully controlled environment of structure and supervision along with peer confrontation have been recommended.<ref name="Gabbard" /> There has been some research on the treatment of ASPD that indicated positive results for therapeutic interventions.<ref>{{cite journal|last=Derefinko|first=Karen J.|coauthors=Thomas A. Widiger|title=Antisocial Personality Disorder|journal=The Medical Basis of Psychiatry|year=2008|pages=213–226|doi=10.1007/978-1-59745-252-6_13|isbn=978-1-58829-917-8}}</ref>
[[Schema Therapy]] is also being investigated as a treatment for ASPD.<ref>{{cite journal|url=http://web.archive.org/web/20110726163913/http://www.iafmhs.org/files/Bernstein.pdf|title=Schema Focused Therapy in Forensic Settings: Theoretical Model and Recommendations for Best Clinical Practice|journal=International Journal of Forensic Mental Health |year=2007|volume= 6|issue=2|pages =169–183}}</ref> A review by Charles M. Borduin features the strong influence of [[Multisystemic therapy]] (MST) that could potentially improve this imperative issue. However this treatment requires complete cooperation and participation of all family members.<ref>Gatzke L.M, Raine A. (2000). Treatment and Prevention Implications of Antisocial Personality Disorder [http://download.springer.com/static/pdf/872/art%253A10.1007%252Fs11920-000-0042-2.pdf?auth66=1354411604_345b229494743fa8e72c0aa670400e8c&ext=.pdf] Current Science Inc. Department of Psychology, University of Southern California. 2:51–55</ref> Some studies have found that the presence of ASPD does not significantly interfere with treatment for other disorders, such as substance abuse,<ref>{{cite journal|title=Anti-social personality disorder and response to methadone maintenance treatment|pmid=16203382|year=1996|last1=Darke|first1=S|last2=Finlay-Jones|first2=R|last3=Kaye|first3=S|last4=Blatt|first4=T|volume=15|issue=3|pages=271–6|doi=10.1080/09595239600186011|journal=Drug and alcohol review}}</ref> although others have reported contradictory findings.<ref>{{cite journal|title=Prediction of 7 months methadone maintenance treatment response by four measures of antisociality|pmid=9571386|year=1998|last1=Alterman|first1=AI|last2=Rutherford|first2=MJ|last3=Cacciola|first3=JS|last4=McKay|first4=JR|last5=Boardman|first5=CR|volume=49|issue=3|pages=217–23|journal=Drug and alcohol dependence|doi=10.1016/S0376-8716(98)00015-5}}</ref>
[[Schema Therapy]] is also being investigated as a treatment for ASPD.<ref>{{cite journal|url=http://web.archive.org/web/20110726163913/http://www.iafmhs.org/files/Bernstein.pdf|title=Schema Focused Therapy in Forensic Settings: Theoretical Model and Recommendations for Best Clinical Practice|journal=International Journal of Forensic Mental Health |year=2007|volume= 6|issue=2|pages =169–183|doi=10.1080/14999013.2007.10471261|last1=Bernstein|first1=David P.|last2=Arntz|first2=Arnoud|last3=Vos|first3=Marije de}}</ref> A review by Charles M. Borduin features the strong influence of [[Multisystemic therapy]] (MST) that could potentially improve this imperative issue. However this treatment requires complete cooperation and participation of all family members.<ref>Gatzke L.M, Raine A. (2000). Treatment and Prevention Implications of Antisocial Personality Disorder [http://download.springer.com/static/pdf/872/art%253A10.1007%252Fs11920-000-0042-2.pdf?auth66=1354411604_345b229494743fa8e72c0aa670400e8c&ext=.pdf] Current Science Inc. Department of Psychology, University of Southern California. 2:51–55</ref> Some studies have found that the presence of ASPD does not significantly interfere with treatment for other disorders, such as substance abuse,<ref>{{cite journal|title=Anti-social personality disorder and response to methadone maintenance treatment|pmid=16203382|year=1996|last1=Darke|first1=S|last2=Finlay-Jones|first2=R|last3=Kaye|first3=S|last4=Blatt|first4=T|volume=15|issue=3|pages=271–6|doi=10.1080/09595239600186011|journal=Drug and alcohol review}}</ref> although others have reported contradictory findings.<ref>{{cite journal|title=Prediction of 7 months methadone maintenance treatment response by four measures of antisociality|pmid=9571386|year=1998|last1=Alterman|first1=AI|last2=Rutherford|first2=MJ|last3=Cacciola|first3=JS|last4=McKay|first4=JR|last5=Boardman|first5=CR|volume=49|issue=3|pages=217–23|journal=Drug and alcohol dependence|doi=10.1016/S0376-8716(98)00015-5}}</ref>


Therapists of individuals with ASPD may have considerable negative feelings toward clients with extensive histories of aggressive, exploitative, and abusive behaviors.<ref name="Gabbard" /> Rather than attempt to develop a sense of conscience in these individuals, therapeutic techniques should be focused on rational and utilitarian arguments against repeating past mistakes. These approaches would focus on the tangible, material value of prosocial behavior.<ref>Beck, Aaron T., Freeman, Arthur, Davis, Denise D. (2006) ''Cognitive Therapy of Personality Disorders. Second Edition.'' The Guilford Press. ISBN 978-1-59385-476-8.</ref>
Therapists of individuals with ASPD may have considerable negative feelings toward clients with extensive histories of aggressive, exploitative, and abusive behaviors.<ref name="Gabbard" /> Rather than attempt to develop a sense of conscience in these individuals, therapeutic techniques should be focused on rational and utilitarian arguments against repeating past mistakes. These approaches would focus on the tangible, material value of prosocial behavior.<ref>Beck, Aaron T., Freeman, Arthur, Davis, Denise D. (2006) ''Cognitive Therapy of Personality Disorders. Second Edition.'' The Guilford Press. ISBN 978-1-59385-476-8.</ref>
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==Prognosis==
==Prognosis==
According to Professor Emily Simonoff, Institute of Psychiatry, "childhood hyperactivity and conduct disorder showed equally strong prediction of antisocial personality disorder (ASPD) and criminality in early and mid-adult life. Lower IQ and reading problems were most prominent in their relationships with childhood and adolescent antisocial behaviour."<ref>{{cite journal|last=Simonoff|first=Emily|coauthors=James Elander, Janet Holmshaw,Andrew Pickles, Robin Murray, Michael Rutter.|title=Predictors of antisocial personality Continuities from childhood to adult life|journal=[[The British Journal of Psychiatry]] |year=2004|volume=200|pages=118–127|pmid=14754823}}</ref>
According to Professor Emily Simonoff, Institute of Psychiatry, "childhood hyperactivity and conduct disorder showed equally strong prediction of antisocial personality disorder (ASPD) and criminality in early and mid-adult life. Lower IQ and reading problems were most prominent in their relationships with childhood and adolescent antisocial behaviour."<ref>{{cite journal|last=Simonoff|first=Emily|coauthors=James Elander, Janet Holmshaw,Andrew Pickles, Robin Murray, Michael Rutter.|title=Predictors of antisocial personality Continuities from childhood to adult life|journal=[[The British Journal of Psychiatry]] |year=2004|volume=200|pages=118–127|pmid=14754823|doi=10.1192/bjp.184.2.118|issue=2}}</ref>


==Epidemiology==
==Epidemiology==

Revision as of 20:30, 7 January 2014

Antisocial personality disorder
SpecialtyPsychiatry, psychology Edit this on Wikidata

Antisocial (or dissocial) personality disorder is a personality disorder characterized by a pervasive pattern of disregard for, or violation of, the rights of others. There may be an impoverished moral sense or conscience and a history of crime, legal problems, impulsive and aggressive behavior.

Antisocial personality disorder (ASPD) is the name of the disorder as defined in the Diagnostic and Statistical Manual (DSM). Dissocial personality disorder is the name of a similar or equivalent concept defined in the International Statistical Classification of Diseases and Related Health Problems (ICD), where it states that the diagnosis includes antisocial personality disorder. Both manuals have similar but not identical criteria.[1] Both have stated that their diagnoses have been referred to, or include what is referred to, as psychopathy or sociopathy, though the criteria are different to some other commonly used assessments; for example, certain personality assumptions may be excluded.[2][3][4][5][6] ASPD falls under the dramatic/erratic cluster of personality disorders.[7]

Diagnosis

DSM-IV-TR

The APA's Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV-TR), defines antisocial personality disorder (in Axis II Cluster B):[8]

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. deception, 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 age 18 years.
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.

In the DSM-5, the diagnosis antisocial personality disorder is kept, but it is no longer on another axis as the other mental disorders.[9]

ICD-10

The WHO's International Statistical Classification of Diseases and Related Health Problems, tenth edition (ICD-10), has a diagnosis called dissocial personality disorder (F60.2):[10][11]

It is characterized by at least 3 of the following:
  1. Callous unconcern for the feelings of others;
  2. Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations;
  3. Incapacity to maintain enduring relationships, though having no difficulty in establishing them;
  4. Very low tolerance to frustration and a low threshold for discharge of aggression, including violence;
  5. Incapacity to experience guilt or to profit from experience, particularly punishment;
  6. Marked readiness to blame others or to offer plausible rationalizations for the behavior that has brought the person into conflict with society.

The ICD states that this diagnosis includes "amoral, antisocial, asocial, psychopathic, and sociopathic personality (disorder)". Although the disorder is not synonymous with conduct disorder, presence of conduct disorder during childhood or adolescence may further support the diagnosis of dissocial personality disorder. There may also be persistent irritability as an associated feature.[11][12]

It is a requirement of the ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.[11]

Further considerations

Psychopathy

Psychopathy is commonly defined as a personality disorder characterized partly by antisocial behavior, a diminished capacity for remorse, and poor behavioral controls.[6][13][14][15] Psychopathic traits are assessed using various measurement tools, including Canadian researcher Robert D. Hare's Psychopathy Checklist, Revised (PCL-R).[16] However, "psychopathy" is not the title of any diagnosis in the DSM or ICD; both manuals instead refer to antisocial/dissocial personality disorder.[17][18]

American psychiatrist Hervey Cleckley's work[citation needed] on psychopathy formed the basis of the diagnostic criteria for ASPD, and the DSM has stated that ASPD has also been referred to as psychopathy.[2][6] However, critics have argued that ASPD is not synonymous with psychopathy as the diagnostic criteria are not exactly the same, since criteria relating to personality traits were excluded from the diagnostic criteria for ASPD in the DSM, in part because it was believed that such traits were difficult to measure reliably and it was "easier to agree on the behaviors that typify a disorder than on the reasons why they occur".[2][3][4][5][6]

Although the diagnosis of ASPD covers two to three times as many prisoners as are rated as psychopaths, Hare believes that the PCL-R is better able to predict future criminality, violence, and recidivism than a diagnosis of ASPD.[2][3] Hare suggests that there are differences between PCL-R-diagnosed psychopaths and non-psychopaths on "processing and use of linguistic and emotional information", while such differences are potentially smaller between those diagnosed with ASPD and without.[3][4] Hare argued that confusion regarding how to diagnose ASPD, confusion regarding the difference between ASPD and psychopathy, as well as the differing future prognoses regarding recidivism and treatability, may have serious consequences in settings such as court cases where psychopathy is often seen as aggravating the crime.[3][4]

The Pocket Guide to the DSM-5 Diagnostic Exam, authored by Abraham M. Nussbaum and published by American Psychiatric Publishing, a division of the APA, suggests that someone with ASPD may present "with psychopathic features" if he or she exhibits "a lack of anxiety or fear and a bold, efficacious interpersonal style"; under this specifier, affective and interpersonal characteristics are comparatively emphasized over behavioral components.[19]

Theodore Millon's subtypes

Theodore Millon suggested five subtypes of ASPD:[20][21]

Subtype Features
Nomadic (including schizoid and avoidant features) Feels jinxed, ill-fated, doomed, and cast aside; peripheral, drifters; gypsy-like roamers, vagrants; dropouts and misfits; itinerant vagabonds, tramps, wanderers; impulsively not benign.
Malevolent (including sadistic and paranoid features) Belligerent, mordant, rancorous, vicious, malignant, brutal, resentful; anticipates betrayal and punishment; desires revenge; truculent, callous, fearless; guiltless.
Covetous (variant of "pure" pattern) Feels intentionally denied and deprived; rapacious, begrudging, discontentedly yearning; envious, seeks retribution, and avariciously greedy; pleasure more in taking than in having.
Risk-taking (including histrionic features) Dauntless, venturesome, intrepid, bold, audacious, daring; reckless, foolhardy, impulsive, heedless; unbalanced by hazard; pursues perilous ventures.
Reputation-defending (including narcissistic features) Needs to be thought of as infallible, unbreakable, invincible, indomitable, formidable, inviolable; intransigent when status is questioned; over-reactive to slights.

Elsewhere, Millon differentiates ten subtypes (partially overlapping with the above) – covetous, risk-taking, malevolent, tyrannical, malignant, unprincipled, disingenuous, spineless, explosive, and abrasive – but specifically stresses that "the number 10 is by no means special ... Taxonomies may be put forward at levels that are more coarse or more fine-grained."[22]

Comorbidity

The following conditions commonly coexist with ASPD:[23]

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When combined with alcoholism, people may show frontal function deficits on neuropsychological tests greater than those associated with each condition.[24]

Causes and pathophysiology

Personality disorders seem to be caused by a combination of these genetic and environmental influences. Genetically, it is the temperament and the kind of personality a person is born with, and environmentally, it is the way in which a person grows up and the experiences they have had.[25]

Hormones and neurotransmitters

Traumatic events can lead to a disruption of the standard development of the central nervous system, which can generate a release of hormones that can change normal patterns of development.[26] Aggressiveness and impulsivity are among the possible symptoms of ASPD. Testosterone is a hormone that plays an important role in aggressiveness in the brain.[27] For instance, criminals who have committed violent crimes have higher levels of testosterone.[27] The effect of testosterone is counteracted by cortisol which facilitates the cognitive control on impulsive tendencies.[27]

One of the neurotransmitters that have been discussed in individuals with ASPD is serotonin.[26] A meta-analysis of 20 studies found significantly lower 5-HIAA levels (indicating lower serotonin levels), especially in those who are younger than 30 years of age.[28]

J.F.W. Deakin of University of Manchester's Neuroscience and Psychiatry Unit has discussed additional evidence of 5HT's connection with ASPD. Deakin suggests that low cerebrospinal fluid concentrations of 5-HIAA, and hormone responses to 5HT, have displayed that the two main ascending 5HT pathways mediate adaptive responses to post and current conditions. He states that impairments in the posterior 5HT cells can lead to low mood functioning, as seen in patients with ASPD. It is important to note that the dysregulated serotonergic function may not be the sole feature that leads to ASPD but it is an aspect of a multifaceted relationship between biological and psychosocial factors.[citation needed]

While it has been shown that lower levels of serotonin may be associated with ASPD, there has also been evidence that decreased serotonin function is highly correlated with impulsiveness and aggression across a number of different experimental paradigms. Impulsivity is not only linked with irregularities in 5HT metabolism but may be the most essential psychopathological aspect linked with such dysfunction.[29] Correspondingly, the DSM classifies "impulsivity or failure to plan ahead" and "irritability and aggressiveness" as two of seven sub-criteria in category A of the diagnostic criteria of ASPD.[8]

Some studies have found a relationship between monoamine oxidase A and antisocial behavior, including conduct disorder and symptoms of adult ASPD, in maltreated children.[citation needed]

Limbic neural maldevelopment

Cavum septum pellucidum (CSP) is a marker for limbic neural maldevelopment.[30] One study found that those with CSP had significantly higher levels of antisocial personality, psychopathy, arrests and convictions compared with controls.[30]

Cultural influences

The Socio-cultural perspective of clinical psychology view disorders as being influenced by cultural aspects, since cultural norms differ significantly, mental disorders such as ASPD are viewed differently.[31] Robert D. Hare has suggested that the rise in ASPD that has been reported in the United States may be linked to changes in cultural mores, the latter serving to validate the behavioral tendencies of many individuals with ASPD.[32] While the rise reported may be in part merely a byproduct of the widening use (and abuse) of diagnostic techniques,[33] given Eric Berne's division between individuals with active and latent ASPD – the latter keeping themselves in check by attachment to an external source of control like the law, traditional standards, or religion[34] – it has been plausibly suggested that the erosion of collective standards may indeed serve to release the individual with latent ASPD from their previously prosocial behavior.[35]

There is also a continuous debate as to the extent to which the legal system should be involved in the identification and admittance of patients with preliminary symptoms of ASPD.[36]

Environment

Some studies suggest that the social and home environment has contributed to the development of antisocial behavior.[37] The parents of these children have been shown to display antisocial behavior, which could be adopted by their children.[37]

Head injuries

Researchers have linked physical head injuries with antisocial behavior.[38][39][40] Since the 1980s, scientists have correlated traumatic brain injury, including damage to the prefrontal cortex, with an inability to make morally and socially acceptable decisions.[38][40] Children with early damage in the prefrontal cortex may never fully develop social or moral reasoning and become "psychopathic individuals ... characterized by high levels of aggression and antisocial behavior performed without guilt or empathy for their victims."[38][39] Additionally, damage to the amygdala may impair the ability of the prefrontal cortex to interpret feedback from the limbic system, which could result in uninhibited signals that manifest in violent and aggressive behavior.[38]

Treatment

ASPD is considered to be among the most difficult personality disorders to treat.[41][42][verification needed] Because of their very low or absent capacity for remorse, individuals with ASPD often lack sufficient motivation and fail to see the costs associated with antisocial acts.[41] They may only simulate remorse rather than truly commit to change: they can be seductively charming and dishonest, and may manipulate staff and fellow patients during treatment.[43][verification needed] Studies have shown that outpatient therapy is not likely to be successful, however the extent to which persons with ASPD are entirely unresponsive to treatment may have been exaggerated.[44]

Those with ASPD may stay in treatment only as required by an external source, such as a parole. Residential programs that provide a carefully controlled environment of structure and supervision along with peer confrontation have been recommended.[41] There has been some research on the treatment of ASPD that indicated positive results for therapeutic interventions.[45] Schema Therapy is also being investigated as a treatment for ASPD.[46] A review by Charles M. Borduin features the strong influence of Multisystemic therapy (MST) that could potentially improve this imperative issue. However this treatment requires complete cooperation and participation of all family members.[47] Some studies have found that the presence of ASPD does not significantly interfere with treatment for other disorders, such as substance abuse,[48] although others have reported contradictory findings.[49]

Therapists of individuals with ASPD may have considerable negative feelings toward clients with extensive histories of aggressive, exploitative, and abusive behaviors.[41] Rather than attempt to develop a sense of conscience in these individuals, therapeutic techniques should be focused on rational and utilitarian arguments against repeating past mistakes. These approaches would focus on the tangible, material value of prosocial behavior.[50]

No medications have been approved by the FDA to treat ASPD, although certain psychiatric medications may alleviate conditions sometimes associated with the disorder and with symptoms such as aggression, including antipsychotic, antidepressant or mood-stabilizing medications.[51]

Prognosis

According to Professor Emily Simonoff, Institute of Psychiatry, "childhood hyperactivity and conduct disorder showed equally strong prediction of antisocial personality disorder (ASPD) and criminality in early and mid-adult life. Lower IQ and reading problems were most prominent in their relationships with childhood and adolescent antisocial behaviour."[52]

Epidemiology

ASPD is seen in 3% to 30% of psychiatric outpatients.[23] The prevalence of the disorder is even higher in selected populations, like prisons, where there is a preponderance of violent offenders.[53] A 2002 literature review of studies on mental disorders in prisoners stated that 47% of male prisoners and 21% of female prisoners had ASPD.[54] 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.[55]

History

The first version of the DSM in 1952 listed sociopathic personality disturbance. Individuals to be placed in this category were said to be "...ill primarily in terms of society and of conformity with the prevailing milieu, and not only in terms of personal discomfort and relations with other individuals". There were four subtypes, referred to as "reactions"; antisocial, dyssocial, sexual and addiction. The antisocial reaction was said to include people who were "always in trouble" and not learning from it, maintaining "no loyalties", frequently callous and lacking responsibility, with an ability to "rationalize" their behavior. The category was described as more specific and limited than the existing concepts of "constitutional psychopathic state" or "psychopathic personality" which had had a very broad meaning; the narrower definition was in line with criteria advanced by Hervey M. Cleckley from 1941, while the term sociopathic had been advanced by George Partridge.

The DSM-II in 1968 rearranged the categories and "antisocial personality" was now listed as one of ten personality disorders but still described similarly, to be applied to individuals who are: "basically unsocialized", in repeated conflicts with society, incapable of significant loyalty, selfish, irresponsible, unable to feel guilt or learn from prior experiences, and who tend to blame others and rationalise. The DSM-II warned that a history of legal or social offenses was not by itself enough to justify the diagnosis, and that a "group delinquent reaction" of childhood or adolescence or "social maladjustment without manifest psychiatric disorder" should be ruled out first. The dyssocial personality type was relegated in the DSM-II to "dyssocial behavior" for individuals who are predatory and follow more or less criminal pursuits, such as racketeers, dishonest gamblers, prostitutes, and dope peddlers. (DSM-I classified this condition as sociopathic personality disorder, dyssocial type). It would later resurface as the name of a diagnosis in the ICD manual produced by the WHO, later spelled dissocial personality disorder and considered approximately equivalent to the ASPD diagnosis.[56]

The DSM-III in 1980 included the full term antisocial personality disorder and, as with other disorders, there was now a full checklist of symptoms focused on observable behaviors to enhance consistency in diagnosis between different psychiatrists ('inter-rater reliability'). The ASPD symptom list was based on the Research Diagnostic Criteria developed from the so-called Feighner Criteria from 1972, and in turn largely credited to influential research by sociologist Lee Robins published in 1966 as "Deviant Children Grown Up".[57] However, Robins has previously clarified that while the new criteria of prior childhood conduct problems came from her work, she and co-researcher psychiatrist Patricia O'Neal got the diagnostic criteria they used from Lee's husband the psychiatrist Eli Robins, one of the authors of the Feighner criteria who had been using them as part of diagnostic interviews.[58]

The DSM-IV maintained the trend for behavioral antisocial symptoms while noting "This pattern has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder" and re-including in the 'Associated Features' text summary some of the underlying personality traits from the older diagnoses. The DSM-5 has the same diagnosis of antisocial personality disorder. The Pocket Guide to the DSM-5 Diagnostic Exam suggests that a person with ASPD may present "with psychopathic features" if he or she exhibits "a lack of anxiety or fear and a bold, efficacious interpersonal style".[19]

See also

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References

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Further reading

  • Millon, T.; Davis, R. (1998). "Ten Subtypes of Psychopathy". In Millon, T.; et al. (eds.). Psychopathy: Antisocial, Criminal and Violent Behavior. New York. ISBN 1572303441. {{cite book}}: Explicit use of et al. in: |editor2-last= (help)CS1 maint: location missing publisher (link)

External links