Antisocial personality disorder

Antisocial personality disorder
Antisocial personality disorder
Specialty	Psychiatry, psychology

Antisocial personality disorder (APD), or dissocial personality disorder, is a personality disorder which is often characterised by antisocial and impulsive behaviour. APD is generally (if controversially) considered to be the same as, or similar to, the disorders known as psychopathic or sociopathic personality disorder. Approximately 3% of men and 1% of women have some form of antisocial personality disorder (source: DSM-IV). The word antisocial is often misused to refer to someone with social anxiety.

Although criminal activity is not a necessary requirement for the diagnosis, these individuals often encounter legal difficulties due to their disregard for societal standards and the rights of others. Therefore, many of these individuals can be found in prisons. However, it should be noted that criminal activity does not automatically warrant a diagnosis of APD, nor does a diagnosis of APD imply that a person is a criminal. It is hypothesized that many high achievers exhibit APD characteristics. This, however, brings much criticism upon the diagnostic criteria specified for those exhibiting Antisocial Personality Disorder and the PCL-R. Both of these tests depend upon the person in question being a criminal or having participated in criminal activities.

Research has shown that individuals with APD are indifferent to the possibility of physical pain or many punishments, and show no indications that they experience fear when so threatened; this may explain their apparent disregard for the consequences of their actions, and their lack of empathy when others are suffering.

Central to understanding psychopaths is that they do not appear to experience true human emotions, or at least, they do not appear to experience a full range of human emotions. This can explain the lack of empathy for the suffering of others, since they cannot experience emotion associated with either empathy or suffering. Risk-seeking behavior and substance abuse may be attempts to fill the emotional void. The rage exhibited by psychopaths and the anxiety associated with certain types of ASPD may represent the limit of emotion experienced, or they may be physiological responses without analogy to emotion experienced by others.

Emotions which the true psychopath exhibits are the fruits of watching and mimicking other people's emotions. This is to mask their sociopathic tendencies from others.

One approach to explaining APD behaviors is put forth by sociobiology, a science that attempts to understand and explain a wide variety of human behavior. One route to doing so is by exploring evolutionarily stable strategies; that is, strategies that being successful will tend to be passed on to the next generation, thus becoming more common in the gene pool. For example, in one well-known 1995 paper by Linda Mealey, chronic antisocial/criminal behavior is explained as a combination of two such strategies.

According to the older theory of Freudian psychoanalysis, a sociopath has a strong id and ego that overpowers the superego. The theory proposes that internalized morals of our unconscious mind are restricted from surfacing to the ego and consciousness.

Establishing the diagnosis

Antisocial personality disorder and the closely related construct of psychopathy can be assessed and diagnosed through clinical interview, self-rating personality surveys, and ratings from coworkers and family. For diagnosing psychopathy in forensic male populations, the Psychopathy Checklist-Revised (PCL-R) is definitive.

Diagnostic criteria (DSM-IV-TR)

The Diagnostic and Statistical Manual of Mental Disorders, a widely used manual for diagnosing mental and behavioral disorders (see also: DSM cautionary statement), defines antisocial personality disorder as 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 steady work or honor financial obligations
lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

The manual lists the following additional necessary criteria:

The individual is at least age 18 years.
There is evidence of Conduct Disorder with onset before age 15 years.
The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.

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". [1]

Diagnostic criteria (ICD-10)

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 attention because of a gross disparity between behaviour and the prevailing social norms, and characterized by:

callous unconcern for the feelings of others;
gross and 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 behaviour 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.

Diagnostic criteria (PCL-R test)

In contemporary research and clinical practice, psychopathy is most commonly assessed with the Hare Psychopathy Checklist- Revised (PCL-R), which is a clinical rating scale with 20 items. Each of the items in the PCL-R is scored on a three-point scale according to specific criteria through file information and a semi-structured interview. The items are as follows:

Factor 1: Aggressive narcissism

Glibness/superficial charm
Grandiose sense of self-worth
Pathological lying
Cunning/manipulative
Lack of remorse or guilt
Shallow affect
Callous/lack of empathy
Failure to accept responsibility for own actions

Factor 2: Socially deviant lifestyle

Need for stimulation/proneness to boredom
Parasitic lifestyle
Poor behavioral controls
Early behavioral problems
Lack of realistic, long-term goals
Impulsivity
Irresponsibility
Juvenile delinquency
Revocation of conditional release

Traits not correlated with either factor

Promiscuous sexual behavior
Many short-term marital relationships
Criminal versatility

Score 0 if the trait is absent, 1 if it is possibly or partially present and 2 if it is present. The item scores are summed to yield a total score ranging from 0 to 40 which is then considered to reflect the degree to which they resemble the prototypical psychopath. A score higher than 30 supports a diagnosis of psychopathy. Forensic studies of prison populations have reported average scores of around 22 on PCL-R; control "normal" populations show an average score of around 5.

A note of caution: the test must be administered by a trained mental health practitioner under controlled conditions for it to have any validity.

A Three-Factor Model of Psychopathy

Cooke and Michie eliminated criteria related to criminal incarceration and juvenile delinquency and statistically analyzed three factors of psychopathy. This allows for a conception of the psychopathic personality that is better applicable outside forensic populations.

Arrogant/Deceitful Interpersonal Style

Glibness/superficial charm
Egocentricity/Grandiose sense of self-worth
Pathological lying
Cunning/Manipulative

Deficient Affective Experience

Lack of remorse or guilt
Callous/Lack of empathy
Shallow affect
Failure to accept responsibility for own actions

Impulsive/Irresponsible Behavioral Style

Need for stimulation/Proneness to boredom
Parasitic lifestyle
Lack of realistic, long-term goals
Impulsivity
Irresponsibility

Cooke D.J., Michie C. "Refining the construct of psychopathy: Towards a hierarchical model." Psychological Assessment (2001), 13 (2): 171-188.

Portrayal of psychopaths in the media

Psychopaths in popular fiction and movies generally possess a number of standard characteristics which are not necessarily as common amongst real-life psychopaths. The traditional "Hollywood psychopath" is likely to exhibit some or all of the following traits which make them ideal villains.

High intelligence, and a preference for intellectual stimulation (music, fine art etc.)
A somewhat vain, stylish, almost "cat-like" demeanor
Prestige, or a successful career or position
A calm, calculating and always-in-control attitude

It is this last feature which is probably most at odds with the typical real-life psychopath: an individual with APD is much more likely to be impulsive, disorganised and short-tempered rather than the smooth-talking, self-disciplined character portrayed by Anthony Hopkins or Kiefer Sutherland. Perhaps more accurate portrayals of psychopaths are Don Logan (Ben Kingsley in Sexy Beast), Doyle Hargrave (Dwight Yoakam in "Sling Blade"), and Frank Booth (Dennis Hopper in Blue Velvet), all of whom are crude, impulsive characters who relentlessly torment other people. Failing to plan ahead and disregarding the consequences of his actions, Logan is eventually killed by his victims.

In popular culture, "psychopath" is often used interchangeably with "serial killer" (such as the characters in slasher films) though the terms are not synonymous. It is, however, true that most serial killers are also sociopaths.

See List of fictional psychopaths

Psychopathy's Relationship with Other Mental Disorders

Psychopathy, as measured on the PCL-R, is negatively correlated with all DSM-IV Axis I disorders except substance-abuse disorders. Psychopathy is most strongly correlated with DSM-IV antisocial personality disorder. PCL-R Factor 1 is correlated with narcissistic personality disorder and histrionic personality disorder. PCL-R Factor 2 is particularly strongly correlated to antisocial personality disorder and criminality.

PCL-R Factor 2 is associated with reactive anger, anxiety, increased risk of suicide, criminality, and impulsive violence. PCL-R Factor 1, in contrast, is associated with extroversion and positive affect. Factor 1, the so-called core personality traits of psychopathy, may even be beneficial for the psychopath (in terms of nondeviant social functioning).

Corporate Psychopathy

The Corporation, a documentary exploring the "psyche" of modern corporations, alleges that if they were to be psychologically regarded as persons (as they are legally regarded in most developed nations), their "personalities" would meet the DSM-IV requirements for psychopathy. This claim has been called sensationalist and disingenuous, as the application of a psychological test to entities lacking self-awareness and a set of behavioural norms is very misleading, but it's this very lacking of self-awareness and behavioural norms of corporations that the film wants to criticize. It has been observed that the DSM-IV could be applied to most animals to produce the same result, though compared to corporations many animals do have individual behavioural norms and some have forms of individual self-awareness.

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