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Epidemiology of psychiatric disorders in Edmonton. Antisocial personality disorders
Abstract
3258 randomly selected adult household residents of Edmonton, Canada, were interviewed by trained lay interviewers using the Diagnostic Interview Schedule (DIS). 104 subjects fulfilled DSM-III antisocial personality disorder (ASP) criteria. Lifetime prevalence rates were found to be significantly higher in males and in the younger adult age groups. The age of onset (i.e. age at which conduct disorder symptoms first appeared) was found to be under 10 years in the majority of cases, with females lagging just slightly behind males. Symptom patterns and frequencies were examined and the relative risks for these symptoms were calculated. Comorbidity, calculated using full DSM-III severity criteria, but without exclusion criteria, revealed an increased prevalence of nearly every other psychiatric disorder in those with antisocial personality disorder, with 90.4% having at least one other lifetime psychiatric diagnosis.
... Their children generally live in bad conditions such as lack of hygiene, malnutrition, or accommodation. All these disadvantages result in high rates of unemployment, bad housing, and being imprisoned and dying prematurely due to reckless behavior [4,5]. ...
... The prevalence of ASPD varies from depending on the instruments, methodology, and the country. It is between 1.3 and 6.8% for men and 0 and 0.8% for women [5,12]. The prevalence is higher in populations that are affected by low socioeconomic factors. ...
... The ratio of men/women is 3. Approximately 50-80% of the criminals meet the diagnostic criteria of ASPD [13,14]. Patients with ASPD may also have comorbid substance use disorders, anxiety disorders, depressive disorders, somatic symptoms and impulse control problems such as gambling disorder [5,15,16]. ...
... Although social and moral concerns of societies shift over time, the scope of modern comorbidity studies of psychopathy manages to capture a bulk of the purported manifestations of degeneracy with surprising accuracy. Among the disorders and social problems whose comorbidity with psychopathy (or antisocial personality disorder) have recently been studied are schizophrenia (Robins, Tipp, & Pryzbeck, 1991), somatization disorder (Smith, Golding, Kashner, & Rost, 1991), mood disorders (Swanson, Bland, & Newman, 1994), suicide attempts and suicide (Robins, quoted in Dahl, 1998), alcoholism (Knop, Jensen, & Mortensen, 1998), narcotic addiction (Vaglum, 1998), pedophilia (Dorr, 1998), as well as job troubles, negligence towards children, illegal activities, marital relationships and promiscuity, physical violence, vagrancy, lying, the use of aliases, and traffic offences (Swanson et al., 1994). ...
... Although social and moral concerns of societies shift over time, the scope of modern comorbidity studies of psychopathy manages to capture a bulk of the purported manifestations of degeneracy with surprising accuracy. Among the disorders and social problems whose comorbidity with psychopathy (or antisocial personality disorder) have recently been studied are schizophrenia (Robins, Tipp, & Pryzbeck, 1991), somatization disorder (Smith, Golding, Kashner, & Rost, 1991), mood disorders (Swanson, Bland, & Newman, 1994), suicide attempts and suicide (Robins, quoted in Dahl, 1998), alcoholism (Knop, Jensen, & Mortensen, 1998), narcotic addiction (Vaglum, 1998), pedophilia (Dorr, 1998), as well as job troubles, negligence towards children, illegal activities, marital relationships and promiscuity, physical violence, vagrancy, lying, the use of aliases, and traffic offences (Swanson et al., 1994). ...
... All studies were conducted after 1977. Of the 14 studies included, 10 studies investigated violent outcomes (reported in eight publications), including violent crime (Elonheimo et al., 2007; Hodgins, Mednick, Brennan, Schulsinger, & Engberg, 1996; Ortmann, 1981) and other outcome measures (including self-and informant report) (Coid et al., 2006a; Johnson et al., 2000; Monahan & Appelbaum, 2000; Stueve & Link, 1997; Swanson, Bland, & Newman, 1994 ). Three investigations reported in two publications provided data for both violent and any antisocial behavior (Elonheimo et al., 2007; Hodgins et al., 1996). ...
... p < 0.01, I 2 = 88.7%). When one outlier (Swanson et al., 1994) was excluded from the analysis, the OR was 10.4 (95% CI = 7.3 to 14.0) with high heterogeneity between studies (χ 2 4 = 10.4, p = 0.02, I 2 = 71.2%). ...
Background: The risk of antisocial outcomes in individuals with personality disorder (PD) remains uncertain.
Aims: To synthesize the current evidence on the risks of antisocial behavior, violence, and repeat offending in PD, and explore sources of heterogeneity in risk estimates.
Method: Systematic review and meta-regression analysis of observational studies comparing antisocial outcomes in personality disordered individuals with controls groups.
Results: Fourteen studies examined risk of antisocial and violent behavior in 10,007 individuals with PD, compared with over 12 million general population controls. There was a substantially increased risk of violent outcomes in studies with all PDs (random-effects pooled odds ratio [OR] = 3.0, 95% CI = 2.6 to 3.5). Meta-regression revealed that antisocial PD and gender were associated with increased risk (p = .01 and .07, respectively). Twenty-five studies reported the risk of repeat offending in PD compared with other offenders. The risk of a repeat offence was also increased (fixed-effects pooled OR = 2.4, 95% CI = 2.2 to 2.7) in offenders with PD.
Conclusion: Although PD is associated with antisocial outcomes and repeat offending, the risk appears to differ by PD category, gender, and whether individuals are offenders or not.
... Evidence supports the existence of two sub-types, Childhood-Onset indicating presence prior to age 10 and Adolescent-Onset when criteria are met only between the ages of 10 and 15 years. Approximately 3 one-half of adults diagnosed with ASPD meet criteria for CD before age 10 and 95% by the age of 12 (Swanson, Bland, & Newman, 1994). ...
... The life-time prevalence of ASPD among men (4.5%) was found to be almost six times higher than among women (0.8%) (Robins et al., 1991). Similarly, in a study of a community sample of 7 3,258 individuals in Canada using the same diagnostic interview protocol, the life-time prevalence among men (6.5%) was eight times higher than among women (0.8%) (Swanson, Bland, & Newman, 1994). More recently, in a US study of 43,093 individuals, the life-time prevalence of ASPD was 5.5% among men and 1.9% among women (Compton et al., 2005). ...
... Es gibt zwei Untertypen, einerseits einen Beginn in der Kindheit mit Auffälligkeiten bereits vor dem zehnten Lebensjahr, andererseits eine Manifestation in der Adoleszenz, wenn die Kriterien der CD erst zwischen dem zehnten und fünfzehnten Lebensjahr erfüllt werden. Ungefähr die Hälfte aller Erwachsenen , bei denen die Diagnose ASPD gestellt wird, erfüllen die Kriterien der CD vor dem Alter von zehn Jahren, und 95% bis zum zwölften Lebensjahr [106]. Bei Erwachsenen, bei denen eine Störung des Sozialverhaltens (CD) vor dem fünfzehnten Lebensjahr festgestellt wurde, wird die Diagnose der ASPD gestellt, wenn ein " tiefgreifendes Muster von Missachtung und Verletzung von Rechten anderer seit dem fünfzehnten Lebensjahr " [2, S. 706] vorliegt. ...
... Eine kanadische Bevölkerungsstichprobe von 3.258 Personen kam mit dem gleichen Interviewprotokoll zu ähnlichen Ergebnissen. Die Lebenszeitprävalenz bei Männern (6,5%) war achtmal größer als die bei Frauen (0,8%) [106] . In jüngerer Zeit kam eine amerikanische Studie von 43.093 Personen zur Lebenszeitprävalenz der ASPD auf 5,5% bei Männern und 1,9% bei Frauen [13] . ...
The diagnosis of Antisocial Personality Disorder (ASPD) is based on robust scientific evidence identifying a group of individuals who display antisocial behaviour from a very young age that remains stable across the life-span. This population of persons with ASPD is heterogeneous, composed of distinct sub-types defined by comorbid disorders. Evidence indicates that ASPD is distinct from both psychopathy, as defined by the PCL-R, and from Dissocial Personality Disorder, as defined by ICD-10. Studies of the prevalence of ASPD are reviewed, highlighting the difficulties inherent in designing and conducting investigations of community samples that derive accurate estimates. The few studies of the socio-demographic correlates of ASPD are presented followed by a review of the evidence on disorders that are comorbid with ASPD. Finally, a hypothesis is presented for orienting future research on the aetiology of ASPD and the development of effective programmes for reducing violence among persons with ASPD.
... (a) Epidemiology Estimates of the lifetime prevalence of ASPD in the general population vary with rates in North America of 4.5% in men and 0.8% in women (Robins et al. 1991), 6.8% in men and 0.8% in women (Swanson et al. 1994) both of these being significantly higher than in Europe that has corresponding figures of 1.3% in men and 0% in women (Torgensen et al. 2001) and 1% in men and 0.2% in women (Coid et al. 2006). Whether these differences are real differences in rates or a consequence of different methodologies is unclear; nonetheless, we can draw two conclusions. ...
... They found that young men with ASPD in particular had a high rate of premature death with those under the age of 40 having an SMR of 33 with the risk diminishing with increasing age. As regards an increase in morbidity, ASPD is often comorbid with several other Axis I disorders, with the Swanson et al. (1994) community study showing that those with ASPD had an increased prevalence of '.nearly every other psychiatric disorder . with 90.4% having at least one other psychiatric disorder.' ...
This paper examines the evidence to justify intervening in those with personality disorder, specifically antisocial personality disorder (ASPD) as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, American Psychiatric Association 1994). The evidence from randomized controlled trials in the mental health literature is reviewed and found to be deficient with only five trials satisfying Cochrane criteria, all of which had a reduction in substance misuse as their primary outcome, rather than a change in the personality disorder per se .
Next, I consider the contribution of Thomas Kuhn to explain why it is difficult to develop a scientific basis in forensic mental health. I argue that, because forensic mental health is inclusive in its purpose (interacting with the law, social services and the penal system, all of which have different rules and agendas), it is difficult to develop a consensus on fundamentals, this consensus being a hallmark of a science.
Finally, I argue that despite the absence of evidence from mental health, providers for ASPD are in a fortunate position in being able to draw upon the correctional literature. This is relevant, provided that we agree that a reduction in offending is the primary outcome. While mental health can learn much from correctional practice, it can also enhance the efficacy of the latter by, for instance, drawing attention to the specific vulnerabilities of the personality structure that might impede programme delivery in correctional settings. Means of achieving a conjunction of mental health and correctional practice are urgently required as this would be beneficial to both.
... For example, in their study of the sociodemographic characteristics, network profiles, and antecedent behaviors of 119 lone actors, Gill et al. [7] reported that 31.9% of the sample had a history of mental ill- [30,31], it is notable, and expected, that the prevalence of antisocial personality disorder in the sample (21%) was higher than that reported among men in the general population in both European [32,33] and North American samples [34,35], 1%-1.3% and 2%-4%, respectively. ...
The increasing recognition of the risks posed by lone-actor terrorists provides the impetus for understanding the psychosocial and ideological characteristics that distinguish lone from group actors. This study examines differences between lone and group actor terrorists in two domains: (i) attitudes toward terrorism, ideology, and motivation for terrorist acts; and (ii) empirically derived risk factors for terrorism. Using a cross-sectional research design and primary source data from 160 men convicted of terrorism in Iraq, this study applied bivariate and logistic regression analyses to assess group differences. It tested the hypothesis that there are no statistically significant differences between the groups. Bivariate analyses revealed that lone actors were less likely than group actors, to be unemployed, to cite personal or group benefit as the main motives for terrorist activity, and to believe that acts of terrorism achieved their goals. Regression analysis indicated that having an authoritarian father was the only factor that significantly predicted group membership, with group actors three times more likely to report this trait. Lone actors and group actors are almost indistinguishable except for certain differences in attitudes, motives, employment, and having an authoritarian father.
... Longitudinal studies show that ASPD-afflicted males experience severe lifelong interpersonal problems (Paris, 2003). Furthermore, some estimates suggest that 7% of the general population (Swanson et al, 1994) and nearly 50% of incarcerated individuals (Fazel and Danesh, 2002) meet criteria for ASPD. This evidence provides a compelling rationale to intensify research efforts. ...
Background:
The influence of genetic variation on resting-state neural networks represents a burgeoning line of inquiry in psychiatric research. Monoamine oxidase A, an X-linked gene, is one example of a molecular target linked to brain activity in psychiatric illness. Monoamine oxidase A genetic variants, including the high and low variable nucleotide tandem repeat polymorphisms, have been shown to differentially affect brain functional connectivity in healthy humans. However, it is currently unknown whether these same polymorphisms influence resting-state brain activity in clinical conditions. Given its high burden on society and strong connection to violent behavior, antisocial personality disorder is a logical condition to study, since in vivo markers of monoamine oxidase A brain enzyme are reduced in key affect-modulating regions, and striatal levels of monoamine oxidase A show a relation with the functional connectivity of this same region.
Methods:
We utilized monoamine oxidase A genotyping and seed-to-voxel-based functional connectivity to investigate the relationship between genotype and corticostriatal connectivity in 21 male participants with severe antisocial personality disorder and 19 male healthy controls.
Results:
Dorsal striatal connectivity to the frontal pole and anterior cingulate gyrus differentiated antisocial personality disorder subjects and healthy controls by monoamine oxidase A genotype. Furthermore, the linear relationship of proactive aggression to superior ventral striatal-angular gyrus functional connectivity differed by monoamine oxidase A genotype in the antisocial personality disorder groups.
Conclusions:
These results suggest that monoamine oxidase A genotype may affect corticostriatal connectivity in antisocial personality disorder and that these functional connections may also underlie use of proactive aggression in a genotype-specific manner.
... Additionally, latent trajectory analyses have revealed a childhood-limited CD group which do not meet ASPD criteria as adults , on which there has been very little research. Population prevalence of ASPD in the US is estimated to 6.8% among men and 0.8% in women (Swanson et al., 1994), while in Norway prevalence is estimated to 1.3% among men and 0.2% in women (Torgersen et al., 2001). In prison samples, 47% of men and 21% of women met ASPD criteria (Fazel and Danesh, 2002). ...
... Trots att det inte finns specifika behandlingsformer som lindrar uttrycken för det antisociala personlighetssyndromet, som är det personlighetssyndrom som är mest förknippat med våld och kriminalitet, så finns epidemiologiska data som talar för att uttryck för psykopati och antisocialt personlighetssyndrom, framför allt fenomenen impulsivitet och kriminalitet, avtar med stigande ålder [22][23][24][25]. Omfattningen av våldsutövande hos personer med antisocialt personlighetssyndrom över tid är dessutom relaterat till samsjuklighet med missbruk, uppmärksamhetsstörning, psykossjukdom och samtidigt förekommande annat personlighetssyndrom, det vill säga samsjuklighet som i sig är behandlingsbar [26]. ...
Personality disorders, violence and criminal behaviour The importance of personality disorders for violent and criminal behaviour is illustrated by their high prevalence in prison populations. Especially antisocial personality disorder and antisocial personality traits are linked to violence. During diagnostic assessment of personality disorders, violence risk screening is recommended. Cognitive behaviour treatment focused on violent behaviour has some effect in criminal populations, but the antisocial personality traits are resistant to treatment. Evidence for pharmacological treatment of repetitive aggressive behaviour is weak. But, bensodiazepines seem to increase the risk of violent behaviour among patients with personality disorders. Antisocial personality traits diminish over time. This spontaneous decrease can be delayed by comorbidity such as other personality disorder, substance use disorder, psychosis and attention deficit disorders. Therefore it is recommended to actively treat these comorbid conditions.
... Most estimates of life-time prevalence of ASPD vary among men from 4.5% to 6.5% and among women from 0.8% to 2.5% (Compton, Conway, Stinson, Colliver, & Grant, 2005;Robins et al., 1991;Samuels, personal communication, June 4, 2007;Samuels et al., 2002;Swanson, Bland, & Newman, 1994). A study of a representative sample of Norwegians aged between 18 and 65 years identified no case of ASPD among 1,142 women and a life-time prevalence of 1.3% among 911 men (Torgersen, Kringlen, & Cramer, 2001), while the prevalence of ASPD was estimated at 1% among men and 0.2% among women in a general population sample in Britain (Coid, Yang, Tyrer, Roberts, & Ullrich, 2006a). ...
This chapter reviews evidence about individuals who display antisocial behavior throughout their lives. This syndrome is diagnosed as antisocial personality disorder (ASPD) in adulthood and conduct disorder (CD) prior to age 15. The chapter focuses on the majority of these individuals who present low or no traits of psychopathy. It presents a description of children with CD who develop schizophrenia. The proportions of children with CD who present elevated levels of callous-unemotional traits and adults with ASPD who present high levels of psychopathic traits or the syndrome of psychopathy are unknown. The prevalence of depression is much higher among children with CD than without, and the combination is associated with more severe symptoms and higher levels of social impairment. Children with CD present elevated rates of childhood maltreatment and adults with antisocial behavior experience repeated victimisation.
... ASPD is chronic psychiatric illness that first onsets during youth as conduct disorder. It is a common condition with a prevalence of 7% in the community [12] and 50% among incarcerated individuals [13]. Individuals with ASPD frequently act impulsively and engage in repeated bouts of aggressive behavior [14]. ...
Purpose of Review
Variation in the monoamine oxidase A (MAO-A) gene and MAO-A enzyme levels have been linked to antisocial behavior and aggression in clinical and non-clinical populations. Here, we provide an overview of the genetic, epigenetic, and neuroimaging research that has examined MAO-A structure and function in antisocial personality disorder (ASPD) and borderline personality disorder (BPD).
Recent Findings
The low-activity MAO-A variable nucleotide tandem repeat genetic polymorphism has shown a robust association with large samples of violent and seriously violent offenders, many of whom had ASPD. A recent positron emission tomography (PET) study of ASPD similarly revealed low MAO-A density in brain regions thought to contribute to the psychopathology of the condition. By contrast, PET has also demonstrated that brain MAO-A levels are increased in BPD and that they relate to symptoms of low mood and suicidality.
Summary
Candidate gene studies have produced the most compelling evidence connecting MAO-A genetic variants to both ASPD and BPD. Still, conflicting results abound in the literature, making it highly unlikely that ASPD or BPD is related to a specific MAO-A genetic variant. Future research should strive to examine how MAO-A genotypes interact with broad-spectrum environmental influences to produce brain endophenotypes that may ultimately become tractable targets for novel treatment strategies.
... Trots att det inte finns specifika behandlingsformer som lindrar uttrycken för det antisociala personlighetssyndromet, som är det personlighetssyndrom som är mest förknippat med våld och kriminalitet, så finns epidemiologiska data som talar för att uttryck för psykopati och antisocialt personlighetssyndrom, framför allt fenomenen impulsivitet och kriminalitet, avtar med stigande ålder [22][23][24][25]. Omfattningen av våldsutövande hos personer med antisocialt personlighetssyndrom över tid är dessutom relaterat till samsjuklighet med missbruk, uppmärksamhetsstörning, psykossjukdom och samtidigt förekommande annat personlighetssyndrom, det vill säga samsjuklighet som i sig är behandlingsbar [26]. ...
The importance of personality disorders for violent and criminal behaviour is illustrated by their high prevalence in prison populations. Especially antisocial personality disorder and antisocial personality traits are linked to violence. During diagnostic assessment of personality disorders, violence risk screening is recommended. Cognitive behaviour treatment focused on violent behaviour has some effect in criminal populations, but the antisocial personality traits are resistant to treatment. Evidence for pharmacological treatment of repetitive aggressive behaviour is weak. But, bensodiazepines seem to increase the risk of violent behaviour among patients with personality disorders. Antisocial personality traits diminish over time. This spontaneous decrease can be delayed by comorbidity such as other personality disorder, substance use disorder, psychosis and attention deficit disorders. Therefore it is recommended to actively treat these comorbid conditions.
... Co-existence of other psychiatric disorders in BPD has been reported as 41-83 % for major depression, 12-39 % for dysthymia [5], and 39 % for narcissistic personality disorder [6,7]. Regarding antisocial personality disorder (ASPD), over 90 % of those with the condition have at least one other psychiatric disorder [8], at least 50 % have co-occurring anxiety disorders [9] and 25 % have a depressive disorder [10]. Notwithstanding the varying current views in relation to the classification of categories of personality disorder [11,12], individuals who meet criteria for both ASPD and BPD can be considered as showing a particularly complex and severe form of personality disorder in so far as they are likely to present with particularly high levels of both DSM Axis I and Axis II comorbidity [13]. ...
Background
Antisocial personality disorder (ASPD) is an under-researched mental disorder. Systematic reviews and policy documents identify ASPD as a priority area for further treatment research because of the scarcity of available evidence to guide clinicians and policymakers; no intervention has been established as the treatment of choice for this disorder. Mentalization-based treatment (MBT) is a psychotherapeutic treatment which specifically targets the ability to recognise and understand the mental states of oneself and others, an ability shown to be compromised in people with ASPD. The aim of the study discussed in this paper is to investigate whether MBT can be an effective treatment for alleviating symptoms of ASPD. Methods
This paper reports on a sub-sample of patients from a randomised controlled trial of individuals recruited for treatment of suicidality, self-harm, and borderline personality disorder. The study investigates whether outpatients with comorbid borderline personality disorder and ASPD receiving MBT were more likely to show improvements in symptoms related to aggression than those offered a structured protocol of similar intensity but excluding MBT components. ResultsThe study found benefits from MBT for ASPD-associated behaviours in patients with comorbid BPD and ASPD, including the reduction of anger, hostility, paranoia, and frequency of self-harm and suicide attempts, as well as the improvement of negative mood, general psychiatric symptoms, interpersonal problems, and social adjustment. ConclusionsMBT appears to be a potential treatment of consideration for ASPD in terms of relatively high level of acceptability and promising treatment effects. Trial registrationISRCTN ISRCTN27660668, Retrospectively registered 21 October 2008
... It is possible that age is to some extent a proxy for mentalizing, in that it has been shown that mentalizing capability increases with age into early adulthood (Dumontheil et al., 2010). The GSI was also a significant predictor; given the high levels of ASPD in the offender group and the known comorbidity of ASPD with other Axis I mental disorders (Swanson, Bland, & Newman, 1994;Ullrich & Coid, 2009), this relationship was expected. ...
This study was designed to test the hypothesis that individuals with antisocial, particularly violent, histories of offending behavior have specific problems in social cognition, notably in relation to accurately envisioning mental states. Eighty-three male offenders on community license, 65% of whom met the threshold for antisocial personality disorder (ASPD), completed a battery of computerized mentalizing tests requiring perspective taking (Perspectives Taking Test), mental state recognition from facial expression (Reading the Mind in the Eyes Test), and identification of mental states in the context of social interaction (Movie for the Assessment of Social Cognition). The results were compared with a partially matched sample of 42 nonoffending controls. The offender group showed impaired mentalizing on all of the tasks when compared with the control group for this study when controlling for demographic and clinical variables, and the offending group performed poorly in comparisons with participants in published studies, suggesting that limited capacity to mentalize may be part of the picture presented by individuals with histories of offending behavior. Offenders with ASPD demonstrated greater difficulty with mentalizing than non-ASPD offenders. Mentalization subscales were able to predict offender status and those with ASPD, indicating that specific impairments in perspective taking, social cognition, and social sensitivity, as well as tendencies toward hypomentalizing and nonmentalizing, are more marked in individuals who meet criteria for a diagnosis of ASPD. Awareness of these deficits may be helpful to professionals working with offenders, and specifically addressing these deficits may be a productive aspect of therapy for this "hard to reach" clinical group.
... Antisocial personality disorder is associated with considerable and complex comorbidity with other mental disorders (Swanson 1994), particularly substance misuse (Robins 1991;Compton 2005). At least half of individuals with antisocial personality disorder have a co-occurring anxiety disorder (Goodwin 2003) and a quarter have a depressive disorder (Lenzenweger 2007). ...
... ASPD is associated with considerable and complex comorbidity with other psychiatric conditions (Swanson et al. 1994), particularly substance misuse (Robins et al. 1991), and increased mortality through reckless behavior (Black et al. 1996). At least half of those with ASPD have co-occurring anxiety disorders (Goodwin and Hamilton 2003), and a quarter have a depressive disorder (Lenzenweger et al. 2007). ...
... Antisocial personality disorder is associated with considerable and complex comorbidity with other mental disorders (Swanson 1994), particularly substance misuse (Robins 1991;Compton 2005). At least half of individuals with antisocial personality disorder have a co-occurring anxiety disorder (Goodwin 2003) and a quarter have a depressive disorder (Lenzenweger 2007). ...
Antisocial personality disorder is a complex condition carrying high rates of comorbidity and mortality for individuals as well as harmful consequences for their families and society. Despite the publication of National Institute for Health and Care Excellence (NICE) guidelines for the disorder, the evidence base and provision of effective treatments remain inadequate, and the belief that the condition is untreatable remains widespread among psychiatrists and other professionals. This article highlights current diagnostic controversies and summarises the evidence for conceptualising antisocial personality disorder as a disorder of attachment. Informed by this developmental perspective, we provide a framework for the management and treatment of adults with antisocial personality disorder, highlighting the importance of creating a safe setting and recommending adaptations of therapeutic technique to facilitate the engagement of this ‘treatment-rejecting’ patient population. We conclude with an outline of the current government policy on the treatment of high-risk offenders with personality disorder.
LEARNING OBJECTIVES
Know the current diagnostic criteria and epidemiology of antisocial personality disorder.
Evaluate the evidence that antisocial personality disorder can be conceptualised as a disorder of attachment, and use a developmental framework to inform treatment interventions.
Gain an understanding of psychological approaches to antisocial personality disorder.
... Most subjects (69.5%) in the ASPD group had committed violent crimes, and many (24%) had committed at least one homicide. However, the occurrence of violence is not well documented among ASPD males in community (Robins, Tipp and Przybeck, 1991;Swanson, Bland and Newman, 1994). The material of the present study is comparable with that reported by Paanila, Hakola and Tiihonen (1999), although homicidal offences were not as common in that study. ...
The aim of this study was to investigate the mortality and causes of death of criminal offenders having antisocial personality disorder (ASPD) over a wide range of age groups, relative to the general population. The death rates of 250 Finnish men with ASPD were compared with those of the general Finnish male population. Among those having ASPD in younger age groups, up to 50, the overall mortality rate showed from a fivefold to a ninefold increase. The mortality rate for other than natural causes (suicide, accident, homicide) showed from a sixfold increase to a seventeenfold increase. The high death rate at a young age for those having ASPD is likely to have an effect on the rate of criminal offences among the older age groups of the whole population.
... The evidence suggests that a substantial proportion of individuals with PG have a history of antisocial behavior that most likely predated their gambling involvement. The mean age of onset of ASPD in two large epidemiologic surveys was 8.5 years for both men and women (Robins, Tipp, & Przybeck, 1991), 7.6 years for men, and 9.2 years for women (Swanson, Bland, Newman, 1994). In contrast, general-population surveys have reported mean ages of onset of 18 years for any betting and 21 years for weekly gambling (Wallisch, 1996), an average age of first gambling or betting heavily of 22 years (Cunningham-Williams, Cottier, Compton, & Spitznagel, 1998), and age of onset of heavy betting of 25 years (Bland et al., 1993) among adults with a history of PG (recent surveys of adolescent samples suggest that the average ages of onset of gambling behavior and symptoms of PG have been declining markedly over the past two decades; National Research Council, 1999). ...
Many individuals with a history of pathological gambling (PG) also have a history of engaging in antisocial behaviors, and this has often been interpreted as a result of the former causing the latter. In a sample of 7,869 men in 4,497 twin pairs form the Vietnam Era Twin Registry, the authors examined (a) the association between PG and antisocial personality disorder (ASPD), (b) the extent to which PG might be differentially associated with childhood conduct disorder (CD) and adult antisocial behavior (AAB), and (c) the contribution of genetic and environmental factors to the association of PG with ASPD, CD, and AAB. PG was significantly associated with all 3 antisocial behavior disorders, and the association of PG with ASPD, CD, and AAB was predominantly explained by genetic factors. The results of this study suggest that the greater-than-chance co-occurrence of PG and antisocial behavior disorders is partially due to their sharing a common genetic vulnerability. The antisocial behavior observed among many individuals with PG probably cannot be interpreted as being simply a consequence of the PG. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
... The diagnosis of ASPD requires the presence of Conduct Disorder (CD) prior to age 15, and thereby, ASPD indexes a pattern of antisocial behaviour that onsets in childhood or early adolescence and remains stable across the lifespan. Evidence indicates that approximately half of the adults with ASPD display symptoms prior to age 10 and 95% before age 12 (Swanson et al ., 1994 ). The diagnosis is fi rmly grounded in a large body of research from prospective, longitudinal investigations (Moffi tt & Caspi, 2001 ; Moffi tt et al ., 2002 ; Moffi tt et al ., 2008 ). ...
Introduction
A large body of research from diverse fields suggests that impaired neuropsychological functioning may play an important role in the aetiology of aggression and violent behaviour (Giancola, 1995; Bergvall et al., 2001; Brower & Price, 2001; Séguin et al., 2007). Most research has focused on the role of the prefrontal cortex (PFC) and the so-called executive functions (Morgan & Lilienfeld, 2000; Séguin & Zelazo, 2005). Executive functions are ‘a collection of varying abilities that involve regulatory control over thought and behaviour in the service of goal-directed or intentional action, problem solving, and flexible shifting of actions to meet task demands’ (Lesaca, 2001; p. 1). Understanding the contribution of executive functioning to violent behaviour may prove to have important implications for rehabilitation programmes.
... Traffic offences have been described as one of the most common symptoms of antisocial personality disorder in community samples. Swanson et al. [27] found that 81.7% of youngsters with ASPD had a history of traffic offenses; in the Epidemiological Catchment Area study [22] it was present in 56% of the ASPD sample. ...
Low and middle-income countries experience an expressive growth in the number of circulating motorcycles, paralleled by an increasing number of traffic accidents. Delivery motorcycles drivers ("motoboys") are generally perceived as accountable for this scenario. Although traffic accidents have a multivariate etiology, mental disorders, such as substance use disorders (SUD) and attention deficit/hyperactivity disorder (ADHD), are often involved. This paper aims at investigating the prevalence of ADHD, SUD and other mental disorders in a sample of Brazilian motoboys, and additionally, to evaluate the association between psychiatric diagnoses, motorcycle accidents and traffic violation tickets.
A convenient sample of subjects was invited to participate in a cross-sectional assessment including an inventory of traffic accidents and violations. Psychiatric diagnoses were based on semi-structured and clinical interviews.
A sample of 101 motoboys was assessed. Overall, 75% of subjects had a positive lifetime history of at least one psychiatric disorder. SUD was the most frequent diagnosis (43.6% for alcohol, 39.6% for cannabis). ADHD was associated with a higher number of traffic accidents (p=0.002), and antisocial personality disorder (APD) was associated with a greater number of traffic violations (p=0.007).
The prevalence of mental disorders was much higher in our sample than in the general population. ADHD and APD, but not SUD, were associated with negative traffic outcomes. These findings have implications for public mental health planning since mental disorders can be both prevented and treated, improving driving behavior and increasing road safety.
... Although the disorder itself appears more polysymptomatic, and characterized by more overt antisocial acts against people, among remorse- negative individuals, there are no clear qualitative differences in phenomenology between them and respondents who were remorse-positive. However, consistent with prior epi- demiologic studies [57,[60][61][62], the prevalence of mood, an- xiety, substance use, and other personality disorders among adults with ASPD in this survey was significantly greater, whether assessed over the past 12 months or over the entire lifespan, than among those without ASPD [36,41,63,64]. Individuals with ASPD rarely seek clinical care specif- ically for that disorder [57] and attempts to treat it have generally yielded disappointing results [10]. ...
The purpose of this study was to compare sociodemographic and family history correlates, symptomatic presentation, and comorbidity with Axis I and Axis II disorders, in an epidemiologic sample of adults with DSM-IV antisocial personality disorder (ASPD) who lacked, vs those who did not lack, remorse.
This study is based on a nationally representative sample of adults. Lifetime prevalences of each ASPD diagnostic criterion and each comorbid mood, anxiety, substance use, and personality disorder were estimated. Logistic regression was used to examine associations of lack of remorse with ASPD symptom patterns and comorbid disorders. Diagnoses were made using the National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version.
Among the 1422 respondents with ASPD, 728 (51%) lacked remorse. Respondents who lacked remorse were younger and more often reported a family history of drug problems than those who did not. More often than remorse-positive respondents, those who were remorse-negative met diagnostic criteria involving violence against persons and less often met criteria involving offenses against property. Remorse was not associated with cruelty to animals, nor with most nonviolent antisocial behaviors. Remorse-negative respondents endorsed more total lifetime violent behaviors than those who were remorse-positive. Lack of remorse was not associated with any lifetime comorbid Axis I or Axis II disorder. Patterns of findings were generally similar between men and women.
Lack of remorse appears to identify at best a modestly more symptomatically severe and violent form of ASPD in nonclinical populations.
The neuroscientific understanding of the brain of the psychopath is gathering apace. But to guide empirical research, a theory of the psychopath’s mind is also important. One such theory of mind is the psychoanalytic. Contemporary psychoanalytic theorists offer an explanatory model of the psychopath’s personality, which encompasses the dynamic nature of his mind and its developmental origins. Such a model needs to take into account attitudes and behaviours that may appear to be antithetical to human nature – the lack of empathy and emotional attachment, the inversion of moral values, the addiction to violence, cruelty and extreme states of excitement, the triumphant manipulation and deception of others, and the stance of arrogance, grandiosity and omnipotence. It also specifies the motivation and meaning of the psychopath’s behaviour, understand his subjective experience of the world, and informs our realistic perception of the risks he poses to himself and others (Meloy & Yakeley, 2021)KeywordsAffectAggressionAnxietyAttachmentCountertransferenceDefense mechanismsGene-environment interactionsGroup therapyMentalizationObject-relations theoryPersonality organizationPsychoanalyticPsychopathyPsychodynamic psychotherapyRisk-assessmentTherapeutic communityTrauma
Antisocial personality disorder (ASPD) is a debilitating condition that continues to be under-diagnosed and untreated.
Background
Antisocial personality disorder (ASPD), although associated with very significant health and social burden, is an under-researched mental disorder for which clinically effective and cost-effective treatment methods are urgently needed. No intervention has been established for prevention or as the treatment of choice for this disorder. Mentalization-based treatment (MBT) is a psychotherapeutic treatment that has shown some promising preliminary results for reducing personality disorder symptomatology by specifically targeting the ability to recognize and understand the mental states of oneself and others, an ability that is compromised in people with ASPD. This paper describes the protocol of a multi-site RCT designed to test the effectiveness and cost-effectiveness of MBT for reducing aggression and alleviating the wider symptoms of ASPD in male offenders subject to probation supervision who fulfil diagnostic criteria for ASPD.
Methods
Three hundred and two participants recruited from a pool of offenders subject to statutory supervision by the National Probation Service at 13 sites across the UK will be randomized on a 1:1 basis to 12 months of probation plus MBT or standard probation as usual, with follow-up to 24 months post-randomization. The primary outcome is frequency of aggressive antisocial behaviour as assessed by the Overt Aggression Scale – Modified. Secondary outcomes include violence, offending rates, alcohol use, drug use, mental health status, quality of life, and total service use costs. Data will be gathered from police and criminal justice databases, NHS record linkage, and interviews and self-report measures administered to participants. Primary analysis will be on an intent-to-treat basis; per-protocol analysis will be undertaken as secondary analysis. The primary outcome will be analysed using hierarchical mixed-effects linear regression. Secondary outcomes will be analysed using mixed-effects linear regression, mixed-effects logistic regression, and mixed-effects Poisson models for secondary outcomes depending on whether the outcome is continuous, binary, or count data. A cost-effectiveness and cost-utility analysis will be undertaken.
Discussion
This definitive, national, multi-site trial is of sufficient size to evaluate MBT to inform policymakers, service commissioners, clinicians, and service users about its potential to treat offenders with ASPD and the likely impact on the population at risk.
Trial registration
ISRCTN 32309003. Registered on 8 April 2016.
Over the past two decades, research has revealed that genetic factors shape the propensity for aggressive, antisocial, and violent behavior. The best-documented gene implicated in aggression is MAOA (Monoamine oxidase A), which encodes the key enzyme for the degradation of serotonin and catecholamines. Congenital MAOA deficiency, as well as low-activity MAOA variants, has been associated with a higher risk for antisocial behavior (ASB) and violence, particularly in males with a history of child maltreatment. Indeed, the interplay between low MAOA genetic variants and early-life adversity is the best-documented gene × environment (G × E) interaction in the pathophysiology of aggression and ASB. Additional evidence indicates that low MAOA activity in the brain is strongly associated with a higher propensity for aggression; furthermore, MAOA inhibition may be one of the primary mechanisms whereby prenatal smoke exposure increases the risk of ASB. Complementary to these lines of evidence, mouse models of Maoa deficiency and G × E interactions exhibit striking similarities with clinical phenotypes, proving to be valuable tools to investigate the neurobiological mechanisms underlying antisocial and aggressive behavior. Here, we provide a comprehensive overview of the current state of the knowledge on the involvement of MAOA in aggression, as defined by preclinical and clinical evidence. In particular, we show how the convergence of human and animal research is proving helpful to our understanding of how MAOA influences antisocial and violent behavior and how it may assist in the development of preventative and therapeutic strategies for aggressive manifestations.
This review focuses on the contribution of circadian rhythms to aggression with a multifaceted approach incorporating genetics, neural networks, and behavior. We explore the hypothesis that chronic circadian misalignment is contributing to increased aggression. Genes involved in both circadian rhythms and aggression are discussed as a possible mechanism for increased aggression that might be elicited by circadian misalignment. We then discuss the neural networks underlying aggression and how dysregulation in the interaction of these networks evoked by circadian rhythm misalignment could contribute to aggression. The last section of this review will present recent human correlational data demonstrating the association between chronotype and/or circadian misalignment with aggression. With circadian rhythms and aggression being a burgeoning area of study, we hope that this review initiates more interest in this promising and topical area.
Conduct disorder (CD) is a psychiatric disorder of childhood and adolescence which has been linked to deficient emotion processing and regulation. The behavioral and neuronal correlates targeting the interaction of emotion processing and response inhibition are still under investigation. Whole-brain event-related fMRI was applied during an affective Stroop task in 39 adolescents with CD and 39 typically developing adolescents (TD). Participants were presented with an emotional stimulus (negative/neutral) followed by a Stroop task with varying cognitive load (congruent/incongruent/blank trials). fMRI analysis included standard preprocessing, region of interest analyses (amygdala, insula, ventromedial prefrontal cortex) and whole-brain analyses based on a 2(group) × 2(emotion) × 3(task) full-factorial ANOVA. Adolescents with CD made significantly more errors, while reaction times did not significantly differ compared to TD. Additionally, we observed a lack of downregulation of left amygdala activity in response to incongruent trials and increased anterior insula activity for CD relative to TD during affective Stroop task processing [cluster-level family-wise error-corrected (p < 0.05)]. Even though no three-way interaction (group × emotion × task) interaction was detected, the findings presented still provide evidence for altered neuronal underpinnings of the interaction of emotion processing and response inhibition in CD. Moreover, our results may corroborate previous evidence of emotion dysregulation as a core dysfunction in CD. Future studies shall focus on investigating the interaction of emotion processing and response inhibition in CD subgroups (e.g., variations in callous-unemotional traits, impulsivity, or anxiety).
Objective
This review sought to systematically review evidence on the efficacy of mentalization‐based therapy (MBT) for the treatment of borderline personality disorder (BPD), in particular, in decreasing psychiatric symptoms associated with BPD and its comorbid disorders.
Method
Fourteen papers were included in the review which examined the effectiveness of MBT in the context of BPD; these included 11 original studies and three follow‐up papers.
Results
Mentalization‐based therapy was found to achieve either superior or equal reductions in psychiatric symptoms when compared with other treatments (supportive group therapy, treatment as usual/standard psychiatric care, structured clinical management, and specialized clinical management).
Discussion
Mentalization‐based therapy can achieve significant reductions in BPD symptom severity and the severity of comorbid disorders as well as increase quality of life. However, caution is required, as the need for better quality research such as randomized controlled trials is pressing. Research is also needed on the proposed mediators of MBT.
Practitioner points
• Mentalization‐based therapy (MBT) is increasingly being considered as a treatment for people with borderline personality disorder (BPD), and a systematic review was required to investigate its effectiveness.
• MBT was found to be equally as effective or superior to well‐established comparison treatments of BPD, however, the majority of studies was of unsatisfying quality.
• Little is known about the mechanisms of MBT.
• Further, better quality trials are needed to investigate its efficacy in treating BPD.
Contemporary mental health practice primarily centers around the neurobiological and psychological processes at the individual level. However, a more careful consideration of interpersonal and other group-level attributes (e.g., interpersonal relationship, mutual trust/hostility, interdependence, and cooperation) and a better grasp of their pathology can add a crucial dimension to our understanding of mental health problems. A few recent studies have delved into the interpersonal behavioral processes in the context of different psychiatric abnormalities. Neuroimaging can supplement these approaches by providing insight into the neurobiology of interpersonal functioning. Keeping this view in mind, we discuss a recently developed approach in functional neuroimaging that calls for a shift from a focus on neural information contained within brain space to a multi-brain framework exploring degree of similarity/dissimilarity of neural signals between multiple interacting brains. We hypothesize novel applications of quantitative neuroimaging markers like inter-subject correlation that might be able to evaluate the role of interpersonal attributes affecting an individual or a group. Empirical evidences of the usage of these markers in understanding the neurobiology of social interactions are provided to argue for their application in future mental health research.
Violent offending is elevated among individuals with antisocial personality disorder (ASPD) and high psychopathic traits (PP). Morphological abnormalities of the amygdala and orbitofrontal cortex (OFC) are present in violent offenders, which may relate to the violence enacted by ASPD + PP. Among healthy males, monoamine oxidase-A (MAO-A) genetic variants linked to low in vitro transcription (MAOA-L) are associated with structural abnormalities of the amygdala and OFC. However, it is currently unknown whether amygdala and OFC morphology in ASPD relate to MAO-A genetic polymorphisms. We studied 18 ASPD males with a history of violent offending and 20 healthy male controls. Genomic DNA was extracted from peripheral leukocytes to determine MAO-A genetic polymorphisms. Subjects underwent a T1-weighted MRI anatomical brain scan that provided vertex-wise measures of amygdala shape and surface area and OFC cortical thickness. We found that ASPD + PP subjects with MAOA-L exhibited decreased surface area in the right basolateral amygdala nucleus and increased surface area in the right anterior cortical amygdaloid nucleus versus healthy MAOA-L carriers. This study is the first to describe genotype-related morphological differences of the amygdala in a population marked by high aggression. Deficits in emotional regulation that contribute to the violence of ASPD + PP may relate to morphological changes of the amygdala under genetic control.
Background and objective:
Males and females who use methamphetamine (MA) differ in sociodemographics, MA diagnoses, comorbidities, and brain activity. The objective of this study was to investigate sex differences in the characteristics of MA use and dependence in patients at a Thai substance treatment center.
Methods:
Demographic, MA use, and diagnostic data for 782 MA users were obtained by using the Semi-Structured Assessment for Drug Dependence and Alcoholism-Thai version. Categorical comparisons of males (n = 413, 53%) and females (n = 369, 47%) were made by chi-square test. Factors significantly differentiating men and women with respect to MA-dependence were identified by logistic regression analysis controlling for demographic, diagnostic, and MA use variables.
Results:
Males admitted to residential drug treatment for MA use had an earlier age of onset for both MA use (17.7 ± 4.1 vs 19.7 ± 6.2 years; t = -5.3, P < 0.001) and dependence (20.4 ± 5.2 vs 22.2 ± 6.4 years; t = -3.6, P < 0.001). Females were more likely than males to be MA-dependent (79% vs 60%; χ1 = 33.7, P < 0.001), and to experience MA withdrawal (65.3% vs 48.9%; χ1 = 21.4, P < 0.001), withdrawal-related hypersomnia (77.2% vs 64.8%; χ1 = 14.5, P < 0.001), fatigue (77.5% vs 70.3%; χ1 = 5.2, P = 0.02), and psychomotor retardation (64.5% vs 57.0%; χ1 = 4.5, P = 0.03). Similarly, females had heavier (eg, largest daily amount [χ1 = 12.4, P < 0.001), more frequent (χ1 = 5.1, P = 0.02]) and greater lifetime episodes of MA use (χ1 = 24.1, P < 0.001) than males. After controlling for such variables by logistic regression, being female remained a significant factor influencing the occurrence of MA-dependence (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.8-4.1, P < 0.001). Shared associated factors (or comorbidities) for MA-dependence in both sexes included nicotine dependence (in males: OR 4.1, 95% CI 2.4-7.0, P < 0.001; and in females: OR 2.4, 95% CI 1.3-4.4, P = 0.007), greater lifetime episodes of MA use (in males: OR 3.5, 95% CI 1.9-6.4, P < 0.001; and in females: OR 5.9, 95% CI 3.1-11.4, P < 0.001), and more frequent use (in males: OR 5.1, 95% CI 2.8-9.1, P < 0.001; and in females: OR 3.6, 95% CI 1.9-6.9, P < 0.001). Comorbid antisocial personality disorder predicted MA-dependence in males only (OR 3.7, 95% CI 1.6-8.6, P = 0.002).
Conclusions:
The current study highlights both common (eg, nicotine dependence and severity of MA use) and sex-specific differences (eg, MA use/dependence characteristics and comorbidities), including sex itself, with respect to MA-dependence in a Thai treatment cohort.
Introduction Substantive findings Course, prognosis and developmental issues Treated prevalence Prevalence of specific personality disorders Antisocial personality disorder Conceptual issues Models of personality disorder Methodological issues Future directions References
about 50% of men with antisocial personality disorder (APD) present a comorbid anxiety disorder. Historically, it was thought that anxiety limited criminal activity and the development of APD, but recent evidence suggests that heightened responsiveness to threat may lead to persistent violent behaviour. Our study aimed to determine the prevalence of APD comorbid with anxiety disorders among offenders and the association of these comorbid disorders with violent offending.
a random sample of 495 male penitentiary inmates completed an interview using the Diagnostic Interview Schedule. After excluding men with psychotic disorders, 279 with APD were retained. All authorized access to their criminal records.
two-thirds of the prisoners with APD presented a lifetime anxiety disorder. Among them, one-half had the onset of their anxiety disorder before they were aged 16 years. Among the offenders with APD, those with, compared with those without, anxiety disorders presented significantly more symptoms of APD, were more likely to have begun their criminal careers before they were aged 15 years, to have diagnoses of alcohol and (or) drug abuse and (or) dependence, and to have experienced suicidal ideas and attempts. While there were no differences in the mean number of convictions for violent offences between APD prisoners with and without anxiety disorders, more of those with anxiety disorders had been convicted of serious crimes involving interpersonal violence.
among men with APD, a substantial subgroup present life-long anxiety disorders. This pattern of comorbidity may reflect a distinct mechanism underlying violent behaviour and signalling the need for specific treatments.
To examine 3-year quality-of-life (QOL) outcomes among United States adults with Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV) antisocial personality disorder (ASPD), syndromal adult antisocial behavior without conduct disorder (CD) before age 15 [adulthood antisocial behavioral syndrome (AABS), not a DSM-IV diagnosis], or no antisocial behavioral syndrome at baseline.
Face-to-face interviews (n = 34 653). Psychiatric disorders were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule - DSM-IV Version. Health-related QOL was assessed using the Short-Form 12-Item Health Survey, version 2 (SF-12v2). Other outcomes included past-year Perceived Stress Scale-4 (PSS-4) scores, employment, receipt of Supplemental Security Income (SSI), welfare, and food stamps, and participation in social relationships.
Antisocial personality disorder and AABS predicted poorer employment, financial dependency, social relationship, and physical health outcomes. Relationships of antisociality to SSI and food stamp receipt and physical health scales were modified by baseline age. Both antisocial syndromes predicted higher PSS-4, AABS predicted lower SF-12v2 Vitality, and ASPD predicted lower SF-12v2 Social Functioning scores in women.
Similar prediction of QOL by ASPD and AABS suggests limited utility of requiring CD before age 15 to diagnose ASPD. Findings underscore the need to improve prevention and treatment of antisocial syndromes.
In recent years, neurobiological markers of antisocial behavior have frequently been identified in children of the early-starter subtype of conduct disorder (CD, according DSM-IV). Some studies, however, produced inconsistent findings. The present review argues that, given the existing methodological opportunities, we need a more detailed phenotyping of children with CD. In particular, establishing comorbid anxiety in neuroendocrinological studies might constitute an important factor. There also seem to be associations between trait anxiety and alterations of brain function and brain structure. Finally, the impact of trait anxiety on different subtypes of aggressive behavior as well as on prognosis is emphasized. In sum, a more detailed characterization of children with CD might help to improve our understanding of antisocial development and enhance therapeutic options.
Antisocial personality disorder (AsPD) is associated with a wide range of disturbance including persistent rule-breaking, criminality, substance misuse, unemployment, homelessness and relationship difficulties.
To evaluate the potential beneficial and adverse effects of pharmacological interventions for people with AsPD.
We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 3), MEDLINE (1950 to September 2009), EMBASE (1980 to 2009, week 37), CINAHL (1982 to September 2009), PsycINFO (1872 to September 2009) , ASSIA (1987 to September 2009) , BIOSIS (1985 to September 2009), COPAC (September 2009), National Criminal Justice Reference Service Abstracts (1970 to July 2008), Sociological Abstracts (1963 to September 2009), ISI-Proceedings (1981 to September 2009), Science Citation Index (1981 to September 2009), Social Science Citation Index (1981 to September 2009), SIGLE (1980 to April 2006), Dissertation Abstracts (September 2009), ZETOC (September 2009) and the metaRegister of Controlled Trials (September 2009).
Controlled trials in which participants with AsPD were randomly allocated to a pharmacological intervention and a placebo control condition. Two trials comparing one drug against another without a placebo control are reported separately.
Three review authors independently selected studies. Two review authors independently extracted data. We calculated mean differences, with odds ratios for dichotomous data.
Eight studies met the inclusion criteria involving 394 participants with AsPD. Data were available from four studies involving 274 participants with AsPD. No study set out to recruit participants solely on the basis of having AsPD, and in only one study was the sample entirely of AsPD participants. Eight different drugs were examined in eight studies. Study quality was relatively poor. Inadequate reporting meant the data available were generally insufficient to allow any independent statistical analysis. The findings are limited to descriptive summaries based on analyses carried out and reported by the trial investigators. All the available data were derived from unreplicated single reports. Only three drugs (nortriptyline, bromocriptine, phenytoin) were effective compared to placebo in terms of improvement in at least one outcome. Nortriptyline was reported in one study as superior for men with alcohol dependency on mean number of drinking days and on alcohol dependence, but not for severity of alcohol misuse or on the patient's or clinician's rating of drinking. In the same study, both nortriptyline and bromocriptine were reported as superior to placebo on anxiety on one scale but not on another. In one study, phenytoin was reported as superior to placebo on the frequency and intensity of aggressive acts in male prisoners with impulsive (but not premeditated) aggression. In the remaining two studies, both amantadine and desipramine were not superior to placebo for adults with opioid and cocaine dependence, and desipramine was not superior to placebo for men with cocaine dependence.
The body of evidence summarised in this review is insufficient to allow any conclusion to be drawn about the use of pharmacological interventions in the treatment of antisocial personality disorder.
Background:
Antisocial personality disorder (AsPD) is associated with a wide range of disturbance including persistent rule-breaking, criminality, substance use, unemployment, homelessness and relationship difficulties.
Objectives:
To evaluate the potential beneficial and adverse effects of psychological interventions for people with AsPD.
Search strategy:
Our search included CENTRAL Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, PsycINFO, ASSIA, BIOSIS and COPAC.
Selection criteria:
Prospective, controlled trials in which participants with AsPD were randomly allocated to a psychological intervention and a control condition (either treatment as usual, waiting list or no treatment).
Data collection and analysis:
Three authors independently selected studies. Two authors independently extracted data. We calculated mean differences, with odds ratios for dichotomous data.
Main results:
Eleven studies involving 471 participants with AsPD met the inclusion criteria, although data were available from only five studies involving 276 participants with AsPD. Only two studies focused solely on an AsPD sample. Eleven different psychological interventions were examined. Only two studies reported on reconviction, and only one on aggression. Compared to the control condition, cognitive behaviour therapy (CBT) plus standard maintenance was superior for outpatients with cocaine dependence in one study, but CBT plus treatment as usual was not superior for male outpatients with recent verbal/physical violence in another. Contingency management plus standard maintenance was superior for drug misuse for outpatients with cocaine dependence in one study but not in another, possibly because of differences in the behavioural intervention. However, contingency management was superior in social functioning and counselling session attendance in the latter. A multi-component intervention utilising motivational interviewing principles, the 'Driving Whilst Intoxicated program', plus incarceration was superior to incarceration alone for imprisoned drink-driving offenders.
Authors' conclusions:
Results suggest that there is insufficient trial evidence to justify using any psychological intervention for adults with AsPD. Disappointingly few of the included studies addressed the primary outcomes defined in this review (aggression, reconviction, global functioning, social functioning, adverse effects). Three interventions (contingency management with standard maintenance; CBT with standard maintenance; 'Driving Whilst Intoxicated program' with incarceration) appeared effective, compared to the control condition, in terms of improvement in at least one outcome in at least one study. Each of these interventions had been originally developed for people with substance misuse problems. Significant improvements were mainly confined to outcomes related to substance misuse. No study reported significant change in any specific antisocial behaviour. Further research is urgently needed for this prevalent and costly condition.
To present nationally representative findings on total antisocial personality disorder (ASPD) symptoms, major violations of others' rights (MVOR), and violent symptoms over a 3-year follow-up in Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions among adults diagnosed at Wave 1 with ASPD versus syndromal adult antisocial behavior without conduct disorder before age 15 years (AABS, not a codable DSM-IV disorder).
Face-to-face interviews were conducted with 34,653 respondents aged 18 years and older. Antisocial syndromes and comorbid lifetime substance use, mood, and 6 additional personality disorders were diagnosed at Wave 1 using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version (AUDADIS-IV). The Wave 2 AUDADIS-IV assessed antisocial symptoms over follow-up, lifetime attention-deficit/hyperactivity disorder (ADHD) and posttraumatic stress disorder, and borderline, narcissistic, and schizotypal personality disorders. Wave 1 was conducted in 2001-2002 and Wave 2 in 2004-2005 by the National Institute on Alcohol Abuse and Alcoholism.
In unadjusted analyses, respondents with ASPD reported significantly more total, MVOR, and violent symptoms over follow-up than did respondents with AABS. Adjustment for baseline sociodemographics and psychiatric comorbidity attenuated these associations; after further adjustment for parallel antisocial symptom counts from age 15 years to Wave 1, associations with antisocial syndromes disappeared. Independent Wave 1 predictors of persistent antisociality over follow-up included male sex, not being married or cohabiting, low income, high school or less education, lifetime drug use disorders, additional personality disorders, and ADHD.
The distinction between ASPD and AABS holds limited value in predicting short-term course of antisocial symptomatology among adults. However, the prediction of persistent antisociality by psychiatric comorbidity argues for comprehensive diagnostic assessments, treatment of all identified disorders, and investigation of whether treatment of comorbidity might hasten remission of antisociality.
Building on findings about the prevalence and incidence of depression over a 40-year period, the authors provide data on trends in cigarette smoking and associations with depression.
Data come from interviews with adult population samples (1952, 1970, and 1992) and followed cohorts (1952-1970 and 1970-1992). Logistic regression models and survival regressions were used to analyze the data.
The associations between smoking and depression were small and nonsignificant in 1952 and 1970. In 1992, however, the odds that a smoker would be depressed were three times the odds that a nonsmoker would be depressed. The interaction between smoking and study year was significant, indicating that the association was limited to the most recent sample. In the cohort analysis, smoking at baseline did not predict the onset of depression, but subjects who became depressed were more likely to start or continue smoking and less likely to quit than those who never had a depression.
In terms of population trends, the association between depression and cigarette smoking became prominent as the use of tobacco declined because of awareness of the risks involved. The findings about individuals followed over time suggest that those who became depressed were more involved with nicotine than those who never had a depression. The authors discuss hypotheses involving "self-medication," risk-taking, and changes in the social climate but conclude that the relationships between smoking and depression are probably multiple and complex.
To review the literature on mental health and psychiatric morbidity in prison populations and relate findings to a Danish study on remand prisoners.
The literature is reviewed and subdivided in the following section: validity of psychometrics in prison populations, prevalence of psychiatric disorders prior to imprisonment, incidence of psychiatric disorders during imprisonment, psychopathy related to psychiatric comorbidity, dependence syndromes with special emphasis on different administrations of heroin use (smoke vs. injection). The results are compared with a longitudinal Danish study on remand prisoners in either solitary confinement (SC) or non-SC.
Many factors must be taken into consideration when dealing with prisoners and mental health, e.g. international differences, the prison setting, demographics and methodological issues. The prison populations in general are increasing worldwide. Psychometrics may perform differently in prison populations compared with general populations with the General Health Questionnaire-28 having a low validity in remand prisoners. Psychiatric morbidity including schizophrenia is higher and perhaps increasing in prison populations compared with general populations with dependence syndromes being the most frequent disorders. The early phase of imprisonment is a vulnerable period with a moderately high incidence of adjustment disorders and twice the incidence in SC compared with non-SC. Prevalence of psychopathy is lower in European than North American prisons. Medium to high scores of psychopathy is related to higher psychiatric comorbidity. Opioid dependence is the most frequent drug disorder with subjects using injection representing a more dysfunctional group than subjects using smoke administration. Many mentally ill prisoners remain undetected and undertreated.
There is a growing population of mentally ill prisoners being insufficiently detected and treated.
It is essential to identify childhood predictors of adult antisocial personality disorder (APD) to target early prevention. It has variously been hypothesized that APD is predicted by childhood conduct disorder (CD), attention-deficit/hyperactivity disorder (ADHD), or both disorders. To test these competing hypotheses, the authors used data from a single childhood diagnostic assessment of 163 clinic-referred boys to predict future APD during early adulthood. Childhood Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987) CD, but not ADHD, significantly predicted the boys' subsequent APD. An interaction between socioeconomic status (SES) and CD indicated that CD predicted APD only in lower SES families, however. Among children who met criteria for CD, their number of covert but not overt CD symptoms improved prediction of future APD, controlling for SES.
To evaluate systematically whether pathological gamblers with antisocial personality disorder (ASPD) experience increased severity of gambling, medical, psychiatric, substance use and psychosocial problems compared to pathological gamblers without ASPD. PARTICIPANTS, DESIGN AND MEASUREMENTS: Pathological gamblers (n = 237) entering an out-patient treatment study for pathological gambling completed the ASPD section of the Structured Clinical Interview for Diagnostic and Statistical Manual version IV (DSM-IV) Personality Disorders, California Psychological Inventory-Socialization Scale, Addiction Severity Index (ASI), Brief Symptom Inventory (BSI) and gambling questionnaires.
Pathological gambling research clinic.
Thirty-nine (16.5%) pathological gamblers met DSM-IV diagnostic criteria for ASPD. Compared to pathological gamblers without ASPD, pathological gamblers with ASPD were younger, more likely to be male and divorced/separated, and had fewer years of education. They also began gambling earlier in life, reported increased severity of gambling, medical and drug problems, and scored higher on the paranoid ideation, somatization and phobic anxiety subscales of the BSI. Further, logistic regression identified male gender, history of illicit drug use and severity of gambling and medical problems as independent predictors of ASPD.
These results underscore the importance of assessing a wide range of behaviors and personality indices, including ASPD, among treatment-seeking pathological gamblers.
Patterns of genetic, environmental, and phenotypic relationships among antisocial behavior and substance use disorders indicate the presence of a common externalizing liability. However, whether this liability is relatively continuous and graded, or categorical and class-like, has not been well established.
To compare the fit of categorical and continuous models of externalizing liability in a large, nationally representative sample.
Categorical and continuous models of externalizing liability were compared using interview data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).
Face-to-face interviews conducted in the United States.
Random sample of 43 093 noninstitutionalized adult civilians living in the United States.
Lifetime and current (past 12 months) diagnoses of antisocial personality disorder, nicotine dependence, alcohol dependence, marijuana dependence, cocaine dependence, and other substance dependence.
In the entire sample, as well as for males and females separately, using either lifetime or current diagnoses, the best-fitting model of externalizing liability was a continuous normal model. Moreover, there was a general trend toward latent trait models fitting better than latent class models, indicating that externalizing liability was continuous and graded, rather than categorical and class-like.
Liability to externalizing spectrum disorders is graded and continuous normal in distribution. Research regarding etiology, assessment, and treatment of externalizing disorders should target externalizing liability over a range of severity. Current diagnoses represent extremes of this continuous liability distribution, indicating that conditions currently classified as subthreshold are likely to provide important information regarding liability to externalizing phenomena.
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