Antisocial personality disorder

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Overview
Antisocial personality disorder (APD) is a psychiatric condition characterized by an individual's common disregard for social rules, norms, and cultural codes, as well as impulsive behavior, and indifference to the rights and feelings of others. Antisocial personality disorder is terminology used by the American Psychiatric Association's Diagnostic and Statistical Manual, while the World Health Organization's ICD-10 refers to Dissocial personality disorder. People diagnosed with this disorder are typically called Sociopaths.

Diagnosis
Diagnosis of Antisocial personality disorder is documented to be significantly more common among men than among women.

Central to identifying individuals exhibiting characteristics of the disorder is that they appear to experience a limited range of human emotions. This can explain their lack of empathy for the suffering of others, since they cannot experience the emotion associated with either empathy or suffering. Risk-seeking behavior and substance abuse may be attempts to escape feeling empty or emotionally void. The rage exhibited by sociopaths, as well as the anxiety associated with certain presentations of antisocial personality disorder, may represent the limit of emotion(s) experienced, or might also suggest physiological responses, without analogy to emotion, experienced by others.

According to the older theory of Freudian psychoanalysis, a person with antisocial personality disorder 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. However, this explanation provides no insight into the cause or treatment of the problem.

Research has shown that individuals with antisocial personality disorder are indifferent to the possibility of physical pain or many punishments and show no indications that they experience fear when so threatened.

One approach to explaining antisocial personality disorder behaviors is put forth by sociobiology, a science that attempts to understand and explain a wide variety of human behavior based on evolutionary biology. Sociobiological explanations for antisocial behavior types explore evolutionarily stable strategies, attempting to discern whether the antisocial phenotype has evolved because it gains fitness specifically within, or alongside, the survival strategies of other humans exhibiting different, perhaps complementary behaviors (e.g., in a symbiotic or parasitic manner).

Establishing the diagnosis
Antisocial personality disorder and the closely related condition of psychopathy can be assessed and diagnosed through clinical interview, self-rating personality surveys, and ratings from coworkers and family. The Psychopathy Checklist-Revised (PCL-R) is one source for diagnosing psychopathy in forensic male populations.

Diagnostic criteria (DSM-IV-TR)
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, currently DSM-IV-TR), a widely used manual for diagnosing mental and behavioral disorders, defines antisocial personality disorder as a pervasive pattern of disregard for and violation of the rights of others occurring since age 15vc, 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) deceitfulness, as indicated by repeated 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 steady work or honor financial obligations
 * 7) 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:
 * 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."

Sex differences: APD is diagnosed much more frequently in men than in women. The DSM-IV diagnostic criteria does not take into account relational aggression, in which women are more likely to engage than physical aggression.

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 attf a gross disparity between behavior 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 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.

Causes
The cause of this disorder is unknown, but biological or genetic factors may play a role.

A family history of the disorder — such as having an antisocial parent — increases the chances of developing the condition. A number of environmental factors within the childhood home, school and community, such as an overly punitive home or school environment may also contribute.

Robins (1966) found an increased incidence of sociopathic characteristics and alcoholism in the fathers of individuals with antisocial personality disorder. He found that, within such a family, males had an increased incidence of APD, whereas females tended to show an increased incidence of somatization disorder instead.

Bowlby (1944) saw a connection between antisocial personality disorder and maternal deprivation in the first five years of life. Glueck and Glueck (1968) saw indications that the mothers of children who developed this personality disorder tended to display a lack of consistent discipline and affection, and an abnormal tendency to alcoholism and impulsiveness. These factors all contributing to failure to create a stable and functional home with consistent structure and behavioral boundaries.

Adoption studies support the role of both genetic and environmental contributions to the development of the disorder. Twin studies also indicate an element of hereditability of antisocial behaviour in adults and have shown that genetic factors are more important in adults than in antisocial children or adolescents where shared environmental factors are more important. (Lyons et al., 1995)

Symptoms
Common characteristics of people with antisocial personality disorder 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
 * Impulsiveness
 * A sense of extreme entitlement
 * Inability to make or keep friends
 * Lack of guilt
 * Recklessness, impulsivity

People who have antisocial personality disorder often experience difficulties with authority figures.

Prevalence
The National Comorbidity Survey, which used DSM-III-R criteria, found that 5.8% of males and 1.2% of females showed evidence of a lifetime risk for the disorder. In penitentiaries, the percentage is estimated to be as high as 75%. Prevalence estimates within clinical settings have varied from 3% to 30%, depending on the predominant characteristics of the populations being sampled. {Diagnostic and Statistical Manual of Mental Disorders} Perhaps not surprisingly, the prevalence of the disorder is even higher in selected populations, such as people in prisons (who include many violent offenders) (Hare 1983). 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.

Relationship with other mental disorders
Antisocial personality disorder is negatively correlated with all DSM-IV Axis I disorders except substance-abuse disorders. Antisocial personality disorder is most strongly correlated with Psychopathy as measured on the Psychopathy Checklist-Revised (PCL-R).

Potential markers
Although antisocial personality disorder cannot be formally diagnosed before age 18, three markers for the disorder, known as the MacDonald Triad, can be found in some children. These are, a longer-than-usual period of bedwetting, cruelty to animals, and pyromania.

It is not known how many children who exhibit these signs grow up to develop antisocial personality disorder, but these signs are often found in the histories of diagnosed adults. Because it is unknown how many children have these symptoms and who do not develop antisocial personality disorder, the predictive value (ie, the usefulness of these symptoms for predicting future antisocial personality disorder) is unclear.

These three traits are now included in the Diagnostic and Statistical Manual of Mental Disorders IV-TR under conduct disorder.

A child who shows signs of antisocial personality disorder may be diagnosed as having either conduct disorder or oppositional defiant disorder. Not all of these children, however, will grow up to develop antisocial personality disorder.