Who is most likely to develop antisocial personality disorder

Abstract

Antisocial and narcissistic personality disorders are forms of persistent maladaptive personality styles that interfere with a person's functioning. Antisocial personality disorder is characterized by a disregard for the rights of others often exemplified by criminal behavior and a lack of remorse. Narcissistic personality disorder is characterized by a grandiose sense of self and pathological self-centeredness. Antisocial and narcissistic personality disorders often co-occur with one another and with other personality disorders and substance use disorders. The causes of antisocial and NPDs include both genetic and environmental influences. Success in treating these disorders often proves difficult.

Epidemiology

Antisocial personality disorder affects approximately 7.4 million Americans, accounting for over 3.5% of the population. This disorder is more common in men than in women. Although the patient must be 18 years old for a diagnosis to be made, signs of this disorder must be present before the age of 15 years. Patients with a family history of antisocial personality disorder are at a higher risk for this disorder. Native Americans, persons living in the western United States, and those with a lower income, less education, and single marital status are at higher risk. Asians are at a lower risk for this disorder.

Antisocial Personality Disorder

Antisocial personality disorder (ASPD) is a pervasive pattern of disregard for, and in violation of, the rights of others. Its primary diagnostic criteria include criminal activity, deceitfulness, impulsivity, recklessness, aggressiveness, callouosness, irresponsibility, and indifference to the mistreatment of others (APA, 2013). DSM-5 ASPD overlaps substantially with the diagnosis of psychopathy, the latter typically assessed by the psychopathy checklist revised (PCL-R; Hare et al., 2012). Psychopathy includes such additional traits as glib charm, arrogance, and lack of empathy. Much of the research literature is now predomninated by studies of psychopathy rather than ASPD. Recent formulations of psychopathy have also included further additional traits such as fearlessness, feelings of invincibility, and boldness (Lilienfeld et al., 2012; Lynam et al., 2011). There is also interest in the identification of the ‘successful psychopath;’ that is, psychopathic persons who have successfully avoided legal or ethical scrutiny. Whereas unsuccessful psychopaths are characterized by such traits as low conscientiousness (e.g., irresponsibility, rashness, and negligence), successful psychopaths are characterized by traits of high conscientiousness, such as self-discipline, achievement-striving, and competence (Mullins-Sweatt et al., 2010).

ASPD is much more common in men than in women. A sociobiological explanation is a potential genetic advantage for social irresponsibility, infidelity, superficial charm, and deceit in males (i.e., males with these traits are more likely to produce offspring than males without these traits). Approximately 20–30% of male prisoners meet the PCL-R criteria for psychopathy.

ASPD is one PD for which much is known about childhood antecedents. Approximately 40% of persons diagnosed with childhood-onset conduct disorder meet DSM-5 ASPD criteria as an adult (APA, 2013). ASPD is a relatively chronic disorder, although as the person reaches middle to older age, research suggests that the frequency of criminal acts tends to decrease. Nevertheless, the core personality traits (e.g., lack of empathy, callousness, and glib charm) may remain largely stable (Hare et al., 2012).

Twin, family, and adoption studies indicate a genetic contribution for ASPD. Exactly what is inherited in ASPD, however, is not known. It could be traits such as impulsivity, antagonistic callousness, abnormally low anxiousness, or all of these dispositions combined. Numerous environmental factors have also been implicated. Low family income, inner city residence, poor parental supervision, single-parent households, rearing by antisocial parents, delinquent siblings, parental conflict, harsh discipline, neglect, large family size, and having a young mother have all been implicated as risk factors for antisocial behavior. Nonshared environmental influences (i.e., influences not shared by siblings) include: delinquent peers; individual, social and academic experiences; and sexual or physical abuse.

The interactive effects of genetic and environmental influences are difficult to tease apart and likely create confusion about what these estimates mean in terms of causation (Hare et al., 2012). For example, an individual who is genetically disposed to psychopathic behavior will elicit environmental factors associated with antisocial outcomes, such as peer problems, academic difficulties, and harsh discipline from parents. In addition, psychopathic individuals may receive their genes from psychopathic parents who also exhibit delinquent and irresponsible behavior, thus creating an immediate home environment that models instability and criminality.

Considerable research effort has been focused on trying to isolate the primary pathology of psychopathy and antisocial behavior. A variety of potential deficits have been implicated, including a deficiency or inability to (1) have feelings of sympathy or empathy, (2) anticipate negative consequences, (3) suppress reward seeking behavior in the presence of negative consequences, (4) feel anxious or fearful, and/or (e) anticipate or respond to punishment (Hare et al., 2012).

ASPD is considered to be the most difficult PD to treat. Persons who meet criteria for ASPD are at times excluded from substance use treatment programs because they are unlikely to be responsive and may interfere with or complicate the treatment of fellow patients. Some ASPD treatment programs put less emphasis on personality change and focus instead on ‘harm reduction,’ or a reduction in risk for recidivism and violent behavior. Residential programs that provide a carefully controlled environment of structure and supervision, combined with peer confrontation, have also been used. These treatment programs will demonstrate short-term success, but it is unknown what benefits are sustained after the ASPD individual leaves this environment.

Antisocial personality disorder

Antisocial personality disorder (ASPD) is primarily characterized by a pervasive disregard and lack of concern for other people, specifically including a diminished empathy for others' distress. As is the case with NPD, relatively little research directly examining this assumption has been carried out, but the existing evidence again suggests that any empathy deficit is limited to the emotional domain; those with an ASPD diagnosis show no inability to entertain other's perspectives (e.g., Dolan and Fullam, 2004), although they may perform more poorly on emotion recognition tasks (Bertone et al., 2017). Consistent with this interpretation, trait measures of psychopathy typically are negatively correlated with emotional responses to other's distress, but are largely unrelated to the cognitive ability to adopt the perspective of others.

Diagnoses on Axis II

Antisocial personality disorder is frequently associated with violent and impulsive behavior and criminality. Further complicating this is that sociopaths frequently have co-morbid substance abuse. Patients with borderline personality disorder may display aggression toward themselves or others as part of their impulsive behaviors. Those with a paranoid personality disorder often react to perceived threats with violent reactions toward that perceived threat. Those with mental retardation and other developmental disorders tend to have poor impulse control; depending on the underlying cause (e.g., head trauma), these states may lead to violence.56–58

Effects of chronic community crowding on social pathology

Social pathology can be defined as those phenomena that contribute to the demise of a society, typically by reducing its population, but also by disrupting its institutions and social relations. Thus, high rates of crime, mortality, accidents, disease, and divorce are indicators of social pathology. In the minds of many, social pathologies are linked to large cities, where they seem to proliferate and concentrate. Because large cities are both highly populated and full of social pathology, scientists have attempted to determine whether community crowding is at the root of the pathology evident in cities.

Interest in the relation between community density and pathology has been apparent since at least the end of the nineteenth century. Along with the industrial revolution came a rapid growth in cities throughout the western world. Some social theorists thought that the diversity of people, the personal anonymity, and high levels of individual autonomy existing between people in large cities would lead to psychological distress and anomie. In contrast, people from small towns and agrarian societies were expected to have richer social lives and greater morale because of familiarity and close interaction with similar others. Other social theorists argued that the high density of cities would expose people to overwhelming amounts of stimulation. In response to the stimulus overload, city-people would socially withdraw. Social withdrawal could be a strategy for reducing stimulus overload. By reducing concern for others and by interacting at a superficial level, there would be fewer stimulus inputs to cope with in day-to-day life. However, there would naturally be social costs if everyone acted this way, including apathy, frustration, conflict, and competition.

Contemporary social scientists pursue many of the same questions regarding community crowding and pathology as did their counterparts from a hundred years ago. Typically, researchers researching on crowding investigate whether areas with high levels of community density also have high concentrations of social, psychological, and biological pathologies or problems. Community population density has been studied in relation to rates of death, infant mortality, perinatal mortality, accidental death, suicide, tuberculosis, venereal disease, mental hospitalization, birth, illegitimate birth, juvenile delinquency, imprisonment, crimes, public welfare, admissions to general hospitals, and divorce. The current evidence suggests that there is little or no relation between population density and major indicators of social pathology, such as mortality, crime, and juvenile delinquency. One research group observed that a higher ratio of persons per acre was associated with slightly elevated rates of mortality, fertility, juvenile delinquency, admissions to mental hospitals, and public assistance. However, the researchers also noted that certain ethnic and economic groups were over represented in the high-density areas. Thus, factors such as poverty, rather than density, could have caused the higher rates of pathology observed among individuals living in high-density areas. Indeed, when the researchers controlled for the effects of social class and ethnic background on the pathological outcomes, the relations between density and the outcomes disappeared.

On the other hand, it is possible that some community-crowding studies have underestimated the effects of high density on human pathology. Aggregate measures of density, such as persons per square mile, and aggregate measures of pathology, such as number of hospital admissions, do not precisely reveal the exposure to high density or its effects on individuals. For example, a person living in a high-density community might spend most of his or her waking hours at a job in a community that has a low level of density. Or, a person from a low-density suburb might work all day in a high-density city. The actual exposure of these respective individuals to high density is different than what one would expect based on the density of their communities. In one instance, the negative effects of living in a high-density community could be underestimated. In the other instance, the benefits of living in a low-density community could be overestimated. If there are many of these peculiar cases in a study population, then an aggregate measure of community density will not be a good estimate of exposure to crowding. Nor would such a measure be useful for examining the effects of crowding on human health and behavior. There are also problems with aggregate measures of pathology. The principle problem is that data on social pathology originate from official public records, which can be incomplete and inaccurate.

To make matters more complicated, researchers can never know whether the relations between density and pathology are overestimated or underestimated when analyzing aggregate data. That is, the data errors caused by using aggregate measures could make the effects of density on pathology look stronger or weaker than they are in reality. One way around the problems associated with aggregate data is to study the effects of high density on individuals rather than on whole communities. That is, one could carefully measure individuals’ exposure to density and their health and behaviors. This is usually done by surveying individuals about the levels of density in their households and about their health, behavior, and psychological well-being. Findings from this type of research are discussed in the next section.

Risk management

Individuals with antisocial personality disorder are at a high risk of criminal offending, although only a minority will be violent to others. However, because ASPD in combination with other risk factors for violence can increase risk, it is sensible to have risk assessment and management strategies as a core component of any management plan. This may include close working with criminal justice agencies. Risk assessment tools (such as the HCR-20: Webster et al 1995) which provide historical (static) and dynamic measures of risk may be helpful. Previous offending histories, early age of first offence, drug and alcohol use, co-morbid psychiatric illness, presence of psychopathy and social isolation are recognized risk factors for violence. Other key issues are the degree of physical harm done, and whether the harmful violence is escalating.

Antisocial Personality Disorder

Another possible common factor is antisocial personality disorder. Extensive research has shown that antisocial personality disorder and its childhood precursor conduct disorder, are strongly related to increased vulnerability to SUD, and a more severe course of addiction. In addition, similar associations have been reported between antisocial personality disorder and serious mental illness. Specifically, symptoms of conduct disorder in childhood, such as repeated fighting, truancy, and lying, have been found to be predictive of the later development of schizophrenia, and to a lesser extent, bipolar disorder. Furthermore, increased rates of antisocial personality disorder have been reported in both schizophrenia and bipolar disorder.

The strong associations between conduct disorder, antisocial personality disorder, and SUDs, and the increased prevalence of antisocial personality disorder in persons with serious mental illness, suggest a role for antisocial personality disorder as a common factor underlying increased comorbidity. More direct support is provided by evidence of people with serious mental illness and past conduct disorder or antisocial personality disorder are more likely to have comorbid SUD than similar people without antisocial personality disorder. Finally, among persons with co-occurring disorders, the additional diagnosis of conduct disorder or antisocial personality disorder is associated with a more severe course of SUD and a stronger family history of SUD, consistent with research on antisocial personality disorder in persons with primary SUD.

Thus, moderately strong evidence suggests that antisocial personality disorder is a common factor that may contribute to the increased rate of SUDs in a subset of people with serious mental illness. Further work is needed to evaluate the role of temperament and to rule out other common factors related to antisocial personality disorder that could account for its relationships with SUD and serious mental illness.

Antisocial and Narcissistic Personality Disorders

Patients with antisocial personality disorder display the defining trait of disregard for the rights of others. The disorder satisfies the general criteria for the other personality disorders and consistently manifests at least three of the following traits4: rule-breaking, lying, impulsivity or poor planning, belligerence, recklessness, irresponsibility or faithlessness, and a lack of conscience or empathy.

Narcissistic personality disorder4 defines itself in the grandiosity and lack of empathy shown by at least five of the following traits: arrogance; a lust for power through beauty, love, brilliance, or money; convictions of “specialness”; a hunger for admiration; entitlement; exploitation and manipulativeness; stunted empathy (an inability to “feel into” the other person); envy; and displays of contemptuousness.

Antisocial personality disorder and narcissistic personality disorder are similar in terms of selfishness but different in terms of social destructiveness. One could think of the difference as that between criminality and shabby ethics. Whether these two entities differ more in degree or in kind is a question perhaps better left to religion or philosophy, yet in psychiatry one view has been that the personality disorders have similar ego defects (except in degree) and similar underlying psychic organizations5–7 or even a common one called borderline personality organization.8 If it is true that a change in social context (e.g., incarceration) brings out borderline personality in persons who otherwise look antisocial, as some have claimed,9 there may be some utility to the notion of a core personality disorder called borderline with several variant presentations. At any rate, the management strategies discussed subsequently work for borderline and for other personality disorders alike, given a rigorous application and a sufficiently strong social structure.

The concept of an underlying or core borderline personality organization is a metaphor that has considerable utility in the discussion of the difficult patient. In the medical setting, antisocial and narcissistic patients are difficult only when they are acting like borderlines. The idea is that the underlying good–bad split or fragmented borderline personality organization is held together by the self-promoting program of the antisocial person and the grandiosity of the narcissist. Antisocial and narcissistic patients who believe their physicians’ interests parallel their own are unctuous and undifficult (“prison sincerity”). When the psychopathy and grandiosity are punctured by illness or injury and thwarted by medical treatment, the underlying fragmented, rageful, splitting, attacking borderline comes out. In the discussion that follows, therefore, borderline personality is the referent paradigm of difficulty, to be discussed more at length and used interchangeably with difficult patient.

Diagnoses

The diagnosis of ASPD indexes a life-long pattern of antisocial behavior (American Psychiatric Association, 2013) and is applied to individuals age 18 years or older who presented CD prior to age 15. Among boys, but not girls, ODD may lead to CD. While CD indexes patterns of behaviors that break laws or norms, ODD indexes recurrent negativistic, defiant, disobedient, and hostile behavior toward authority figures. CD/ASPD is highly comorbid with anxiety. Studies report that anxiety disorders were presented by 78% of a clinical sample of children with CD, 35% of a community sample with conduct problems (CP) (Polier et al., 2012), and one-half of adults with ASPD (Hodgins et al., 2018). Individuals with CD/ASPD additionally present elevated levels of psychopathic traits that vary dimensionally in the population, as do other personality traits. The two behavioral traits of psychopathy index antisocial, impulsive, and irresponsible behavior, as does the diagnosis of ASPD, and the two personality traits of psychopathy index callousness, a lack of empathy, grandiosity, and manipulativeness. Even at low levels, these traits are associated with negative outcomes in adolescence and adulthood (McMahon et al., 2010; Hemphälä and Hodgins, 2014; Waller et al., 2016) and with abnormalities of brain structure and function (Carré et al., 2013; Lindner et al., 2017). Further complicating these disorders, between 8.7% and 45.4% of boys and 1.2% and 61.4% of girls with CD also present attention deficit hyperactivity disorder (ADHD) (Disney et al., 1999; McCabe et al., 2004). ADHD is associated with impairments in cool executive functions and abnormalities in associated neural structures and functions, while CD/ASPD is associated with hot executive functions, and thus with different neural abnormalities (Rubia, 2011; Bayard et al., 2018). This chapter focuses on individuals who present ESAAB and who would thereby meet the diagnostic criteria for CD/ASPD, and in some cases in early childhood ODD, with high levels of comorbid anxiety, psychopathic traits, and ADHD.

The life-time prevalence of ASPD varies among men from 4.5% to 6.5% and among women from 0.8% to 2.5% (Compton et al., 2005; Odgers et al., 2008). Similarly, studies show that CD is twice as common among boys than girls. For example, in a British sample of 7977 children aged 5–16 years of age, 7.5% of boys and 3.9% of girls met ICD-10 criteria for CD (Green et al., 2005), and in a US sample of 3199 children, 12.0% of boys and 7.1% of girls met DSM-IV criteria for CD (Nock et al., 2006). Childhood ODD is similarly prevalent in boys and girls (Keenan, 2012). However, prospective, longitudinal, studies of birth cohorts identify greater proportions of individuals displaying ESAAB than cross-sectional studies (for a discussion see Hodgins et al., 2018). For example, in a birth cohort of approximately 1000 individuals followed to age 32, 7.5% of females and 10.5% of males presented ESAAB (Odgers et al., 2008). Anxiety disorders are more common among females than males (Bekker and van Mens-Verhulst, 2007), and psychopathic traits are higher in males than females (Hemphälä et al., 2015).