Antisocial personality disorder

Antisocial personality disorder (adyp or Atu) is defined by the American Psychiatric Association's Diagnostic and Statistical Manual as "...a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood."

Antisocial personality disorder is sometimes referred to as psychopathy or sociopathy. However, these three are not the same. Rather, psychopathy and sociopathy are generally considered subsets of ASPD. Some researchers, however, believe that ASPD and psychopathy may be separate conditions altogether.

Signs and symptoms
Characteristics of people with antisocial personality disorder may include: Other common characteristics of those with Antisocial Personality Disorder include superficial charm, shallowed emotions, a distorted sense of self, a constant search for new sensations (which can have bizarre consequences), a tendency to physically or verbally abuse peers or relatives, and manipulation of others without remorse or empathy for the victim. Egocentrism, megalomania, lack of responsibility, extroversion, excessive hedonism, high impulsivity, and the desire to experience sensations of control and power can also be present. This type of disorder does not relate to assaults of panic or to schizophrenia.
 * Persistent lying or stealing
 * Apparent lack of remorse or empathy for others
 * Cruelty to animals
 * Poor behavioral controls &mdash; expressions of irritability, annoyance, impatience, threats, aggression, and verbal abuse; inadequate control of anger and temper
 * A history of childhood conduct disorder
 * Recurring difficulties with the law
 * Promiscuity
 * Tendency to violate the boundaries and rights of others
 * Aggressive, often violent behavior; prone to getting involved in fights
 * Inability to tolerate boredom
 * Poor or abusive relationships
 * Irresponsible work behavior
 * Disregard for safety

DSM
The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR = 301.7, a widely used manual for diagnosing mental disorders, defines antisocial personality disorder (in Axis II Cluster B) as:


 * A) There is a pervasive pattern of disregard for and violation of the rights of others occurring for as long as either childhood, or in the case of many who are influenced by environmental factors, around age 15, as indicated by three (or more) of the following:
 * failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;
 * deceitfulness, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
 * impulsivity or failure to plan ahead;
 * irritability and aggressiveness, as indicated by repeated physical fights or assaults;
 * reckless disregard for safety of self or others;
 * consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
 * lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another;
 * promiscuity;
 * having shallow or seemingly nonexistent feelings.

New evidence points to the fact that children often develop Antisocial Personality Disorder as a cause of their environment, as well as their genetic line. The individual must be at least 18 years of age to be diagnosed with this disorder (Criterion B) But those commonly diagnosed with ASPD as adults, were diagnosed with Conduct Disorder as children. The prevalence of this disorder is 3% in males and 1% from females, as stated from the DSM IV-TR.

Criticism
Researchers have heavily criticized the ASPD DSM-IV criteria because not enough emphasis was placed on traditional psychopathic traits such as a lack of empathy, superficial charm, and inflated self appraisal.

These latter traits are harder to assess than behavioral problems (like impulsivity and acting out). Thus, the DSM-IV framers sacrificed validity for reliability. That is, the ASPD diagnosis focuses on behavioral traits, but only limited emphasis is placed on affective and unemotional interpersonal traits.

Researchers debate about whether psychopathy/sociopathy are incorrectly put together under ASPD. These clinicians and researchers who believe that it was incorrect to label the two in the same category are upset that an important distinction has been lost between these two disorders. In other words, the DSM-IV-TR considers ASPD and psychopathy to be the same, or similar. However, they are not the same since antisocial personality disorder is diagnosed via behavior and social deviance, whereas psychopathy also includes affective and interpersonal personality factors.

Also, ASPD, unlike psychopathy, does not have biological markers confirmed to underpin the disorder. Other criticisms of ASPD are that it is essentially synonymous with criminality. Nearly 80%–95% of felons will meet criteria for ASPD &mdash; thus ASPD predicts nothing in criminal justice populations, whereas psychopathy (using the Hare Psychopathy Checklist-Revised (PCL-R)) is found in only roughly 20% of inmates and PCL-R is considered one of the best predictors of violent recidivism. Also, the DSM-IV field trials never included incarcerated populations.

The official stance of the American Psychiatric Association as presented in the DSM-IV-TR is that "psychopathy" and "sociopathy" are obsolete synonyms. The World Health Organization takes a similar stance in its ICD-10 by referring to psychopathy, antisocial personality, asocial personality, and amoral personality as synonyms for dissocial personality disorder.

WHO
The World Health Organization's ICD-10 defines a conceptually similar disorder to antisocial personality disorder called  Dissocial personality disorder.


 * It is characterized by at least 3 of the following:


 * Callous unconcern for the feelings of others and lack of the capacity for empathy.
 * Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations.
 * Incapacity to maintain enduring relationships.
 * Very low tolerance to frustration and a low threshold for discharge of aggression, including violence.
 * Incapacity to experience guilt and to profit from experience, particularly punishment.
 * Markedly prone to blame others or to offer plausible rationalizations for the behavior bringing the subject into conflict.
 * Persistent irritability.


 * The criteria specifically rule out conduct disorders.  Dissocial personality disorder criteria differ from those for antisocial and sociopathic personality disorders.

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Millon's subtypes
Theodore Millon identified five subtypes of antisocial behavior. Any antisocial individual may exhibit none, one or more than one of the following:


 * covetous antisocial - variant of the pure pattern where individuals feel that life has not given them their due.
 * reputation-defending antisocial - including narcissistic features
 * risk-taking antisocial - including histrionic features
 * nomadic antisocial - including schizoid, avoidant features
 * malevolent antisocial - including sadistic, paranoid features.

Differential diagnosis
The following conditions commonly coexist with antisocial personality disorder: When combined with alcoholism, people may show frontal function deficits on neuropsychological tests greater than those associated with each condition.
 * Anxiety disorders
 * Depressive disorder
 * Substance-related disorders
 * Somatization disorder
 * Pathological risk-seeking
 * Borderline personality disorder
 * Histrionic personality disorder
 * Narcissistic personality disorder

Treatment
To date there have been no controlled studies reported which found an effective treatment for ASPD, although contingency management programs, or a reward system, has been shown moderately effective for behavioral change. Some studies have found that the presence of ASPD does not significantly interfere with treatment for other disorders, such as substance abuse, although others have reported contradictory findings. Schema therapy is being investigated as a treatment for antisocial personality disorder, as well as medicinal marijuana treatments.

Epidemiology
Antisocial personality disorder in the general population is about 3% in males and 1% in females.

It is seen in 3% to 30% of psychiatric outpatients. The prevalence of the disorder is even higher in selected populations, such as people in prisons (who include many violent offenders). Similarly, the prevalence of ASPD is higher among patients in alcohol or other drug (AOD) abuse treatment programs than in the general population (Hare 1983), suggesting a link between ASPD and AOD abuse and dependence.

Related Terms
Psychopathy and sociopathy are terms related to ASPD. Psychopathy once referred to ASPD in general, but is now (like sociopathy) generally considered a subset of ASPD.

Psychopathy
Psychopathy was, until 1980, the term used for a personality disorder characterized by an abnormal lack of empathy combined with strongly amoral conduct but masked by an ability to appear outwardly normal. The publication of DSM-III changed the name of this mental disorder to Antisocial Personality Disorder and also broadened the diagnostic criteria considerably by shifting from clinical inferences to behavioral diagnostic criteria. However, the DSM-V working party is recommending a revision of Antisocial Personality Disorder to include "Antisocial/Psychopathic Type", with the diagnostic criteria having a greater emphasis on character than on behavior. The ICD-10 diagnostic criteria of the World Health Organization also lacks psychopathy as a personality disorder, its 1992 manual including Dissocial (Antisocial) Personality Disorder, which encompasses amoral, antisocial, asocial, psychopathic, and sociopathic personalities.

Sociopathy
Hare writes that the difference between sociopathy and psychopathy may "reflect the user's views on the origins and determinates of the disorder."

In the preface to the fifth edition of The Mask of Sanity, Cleckly stated, "... revisions of the nomenclature have been made by the American Psychiatric Association. The classification of psychopathic personality was changed to that of sociopathic personality in 1958", suggesting that he did not recognise any difference between the conditions.

David T. Lykken proposes psychopathy and sociopathy are two distinct kinds of antisocial personality disorder. He believes psychopaths are born with temperamental differences such as impulsivity, cortical underarousal, and fearlessness that lead them to risk-seeking behavior and an inability to internalize social norms. On the other hand, he claims sociopaths have relatively normal temperaments; their personality disorder being more an effect of negative sociological factors like parental neglect, delinquent peers, poverty, and extremely low or extremely high intelligence. Both personality disorders are the result of an interaction between genetic predispositions and environmental factors, but psychopathy leans towards the hereditary whereas sociopathy tends towards the environmental.