Thursday, 16 August 2012

Antisocial Personality Disorder

Antisocial Personality Disorder

Antisocial personality disorder (ASPD) is described by the American Psychiatric Association's Diagnostic and Statistical Manual, fourth edition (DSM-IV-TR), as an Axis II personality disorder characterized by "...a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood.
The World Health Organization's International Statistical Classification of Diseases and Related Health Problems', tenth edition (ICD-10), defines a conceptually similar disorder to antisocial personality disorder called (F60.2) Dissocial personality disorder.
Though the diagnostic criteria for ASPD were based in part on Hervey Cleckley's pioneering work on psychopathy, ASPD is not synonymous with psychopathy and the diagnostic criteria are different.


The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM IV-TR), defines antisocial personality disorder (in Axis II Cluster B)
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:
failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;
deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
impulsiveness 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;
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.
The individual must be at least 18 years of age to be diagnosed with this disorder (Criterion B), but those diagnosed with ASPD as adults were commonly diagnosed with conduct disorder as children. The prevalence of this disorder is 3% in males and 1% from females, as stated in the DSM IV-TR.
Further diagnostic considerations

Psychopathy and sociopathy

Although there are behavioral similarities, ASPD and psychopathy are not synonymous. A diagnosis of ASPD using the DSM criteria is based on behavioral patterns, whereas psychopathy measurements also include more indirect personality characteristics. The diagnosis of antisocial personality disorder covers two to three times as many prisoners as are rated as psychopaths. Most offenders scoring high on the PCL-R also pass the ASPD criteria but most of those with ASPD do not score high on the PCL-R

Theodore Millon's subtypes

Theodore Millon identified five subtypes of Anti-Social Personality Disorder. exhibiting all of the following:
covetous antisocial – variant of the pure pattern where individuals feel that life has not given them their due.
reputation-defending antisocial – including narcissistic features
risk-taking antisocial – including histrionic features
nomadic antisocial – including schizoid, avoidant features
malevolent antisocial – including sadistic, paranoid features.
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"

Causes and pathophysiology

Hormones and neurotransmitters

Antisocial personality disorder is said to be genetically based but typically has environmental factors, such as family relations, that trigger its onset. 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. One of the neurotransmitters that have been discussed in individuals with ASPD is serotonin.
A recent meta-analysis of 20 studies showed a correlation between ASPD and serotonin metabolic 5-hydroxyindoleacetic acid (5-HIAA). The study found a reasonable effect size (5-HIAA levels in antisocial groups were 0.45 standard deviation lower than in non-antisocial groups)
J.F.W. Deakin of University of Manchester's Neuroscience and Psychiatry Unit has discussed additional evidence of 5HT's connection with antisocial personality disorder. 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.
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.  In a study looking at the relationship between the combined effects of central serotonin activity and acute testosterone levels on human aggression, researchers found that aggression was significantly higher in subjects with a combination of high testosterone and high cortisol responses, which correlated to decreased serotonin levels.  Correspondingly, The Diagnostic and Statistical Manual of Mental Disorders classifies "impulsiveness or failure to plan ahead" and "irritability and aggressiveness" as two of the seven criteria in diagnosing someone with 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.

Cultural influences

Robert Hare has suggested that the rise in antisocial personality disorder that has been reported in the United States may be linked to changes in cultural mores, the latter serving to validate many of the individual with ASPD's behavioural tendencies. While the rise reported may be in part merely a byproduct of the widening use (and abuse) of diagnostic techniques,[citation needed] 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, 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 behaviour.

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