Which of the following characteristics relates to antisocial personality disorder?

Etiology and risk factors

Antisocial personality disorder develops from genetic factors and environmental factors such as childhood abuse. Impulsive aggression may be a factor, related to abnormal serotonin transporter functioning. In early childhood, disregard for others’ pain has been linked to antisocial behavior in late adolescence. This disorder is more common in first-degree relatives of patients who have the disorder than in the general population. Risks for antisocial personality disorder are increased in adopted as well as biologic children of parents with the disorder. If conduct disorder develops with ADHD before age 10, the risk of developing antisocial personality disorder in adulthood is increased. Risks of conduct disorder developing into antisocial personality disorder may be higher when parents abuse or neglect a child, or if they are inconsistent in discipline or parenting methods, such as changing from supportive and warm to critical and cold. Other risk factors for antisocial personality disorder include family history, poverty, and alcoholic parents.

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.

List of Abbreviations

ASPD

antisocial personality disorder

Diagnostic and Statistical Manual of Mental Disorders

serotonin or 5-hydroxytryptophan

central nervous system

5-hydroxyindoleacetic acid

cerebrospinal fluid

dopamine

dopamine transporter

single-photon emission computed tomography

monoamine oxidase-A

orbitofrontal cortex

ventral striatum

functional magnetic resonance imaging

high in vitro activity MAO-A genotype

low in vitro activity MAO-A genotype

Psychopathy Checklist-Revised

intimate partner violence

substance use disorders

Antisocial personality disorder and homicide

Individuals with antisocial personality disorder are at a high risk of committing criminal acts during adolescence and adulthood. Early onset of this disorder may promote chronic violence in 35%–75% of cases. The development of antisocial personality disorder is influenced by neurobiological, environmental, and social factors. Neurobiological factors include imbalances of neurotransmitters, while environmental factors include severe discipline by parents. Social factors include the lack of personal relationships. The onset of antisocial personality disorder in toddlers and children often results from disturbed temperaments and environments that are of poor quality. A child who is introverted or behaviorally difficult who is raised with excessive strictness is at risk for developing this disorder. As adults, males with antisocial personality disorder have significant disregard for the emotions of other people, are unable to experience guilt, are consistently irritable, and have a very low tolerance for frustration. Adult females with antisocial personality disorder are usually irresponsible, impulsive, aggressive, and often have histories of childhood abuse.

Many experts describe those with antisocial personality disorder as sociopaths. They have impairments in interpersonal and self-functioning, along with pathological personality traits. Impairments in interpersonal functioning include a lack of concern for the feelings, needs, or suffering of others; and incapacity for mutually intimate relationships, since “exploitation” is the primary way that they relate to other people. Self-functioning impairments include an ego-centered identity and goal setting that is based on personal gratification. Pathological personality traits include being manipulative, insensitive, deceitful, hostile, impulsive, irresponsible, and also likely to take extreme risks. Those with antisocial personality disorder can easily switch between being charming at first, to extremely cruel.

Individuals who have either antisocial personality disorder or are psychopaths commit a large amount of violent crimes, especially involving repeated acts of violence. One murderer with antisocial personality disorder was Archibald McCafferty. His childhood had been one long continuous history of theft, vandalism, and fighting. His family moved from Scotland to Australia in an attempt to somehow drastically improve his behavior problems. Instead, his activities grew worse, including burglary, car theft, larceny, and receiving stolen goods. By age 24, McCafferty had 34 different convictions and had been in jail many times. He began abusing alcohol, sedatives, and LSD. After getting married, he beat his wife. When their baby son died, McCafferty started to have auditory hallucinations. He believed that his son was “talking” to him, and telling him to kill seven people in order to “avenge” his death. After three murders, McCafferty was caught and sentenced to life in prison, where he killed several other inmates.

Adults with antisocial personality disorder are often treated with cognitive-behavioral therapy and encouraged to recognize suicidal or homicidal urges. They are taught to replace dysfunctional ideas with healthier ideas. This therapy has resulted in lower levels of physical aggression and antisocial behaviors after 6 months. Schema-based therapy may also be successful, and utilizes questionnaires to identify schemas (also known as “life traps”), and then patients are taught to recognize schemas in their daily lives. They are then encouraged to replace negative schemas with positive thought processes. Patients showed improvements in social functioning after 18–36 months of training.

Significant point

Between 3% and 30% of psychiatric outpatients have antisocial personality disorder. According to the National Comorbidity Survey and the DSM, approximately 5.8% of men and 1.2% of women have antisocial personality disorder for life. In prison, statistics are much higher—up to 80% of male prison inmates show signs and symptoms of this disorder, and up to 65% of female prison inmates have these signs and symptoms.

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.