Definition

Also known as psychopathy, sociopathy or dyssocial personality disorder, antisocial personality disorder (APD) is a diagnosis applied to persons who routinely behave with little or no regard for the rights, safety or feelings of others. This pattern of behavior is seen in children or young adolescents and persists into adulthood.

The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, (the fourth edition, text revision or DSM-IV-TR ) classifies APD as one of four "Cluster B Personality Disorders" along with borderline, histrionic, and narcissistic personality disorders .

Description

People diagnosed with APD in prison populations act as if they have no conscience. They move through society as predators, paying little attention to the consequences of their actions. They cannot understand feelings of guilt or remorse. Deceit and manipulation characterize their interpersonal relationships.

Men or women diagnosed with this personality disorder demonstrate few emotions beyond contempt for others. Their lack of empathy is often combined with an inflated sense of self-worth and a superficial charm that tends to mask an inner indifference to the needs or feelings of others. Some studies indicate people with APD can only mimic the emotions associated with committed love relationships and friendships that most people feel naturally.

People reared by parents with antisocial personality disorder or substance abuse disorders are more likely to develop APD than members of the general population. People with the disorder may be homeless, living in poverty, suffering from a concurrent substance abuse disorder, or piling up extensive criminal records, as antisocial personality disorder is associated with low socioeconomic status and urban backgrounds. Highly intelligent individuals with APD, however, may not come to the attention of the criminal justice or mental health care systems and may be underrepresented in diagnostic statistics.

Some legal experts and mental health professionals do not think that APD should be classified as a mental disorder, on the grounds that the classification appears to excuse unethical, illegal, or immoral behavior. Despite these concerns, juries in the United States have consistently demonstrated that they do not regard a diagnosis of APD as exempting a person from prosecution or punishment for crimes committed.

Furthermore, some experts disagree with the American Psychiatric Association's (APA's) categorization of antisocial personality disorder. The APA considers the term psychopathy as another, synonymous name for APD. However, some experts make a distinction between psychopathy and APD. Dr. Robert Hare, an authority on psychopathy and the originator of the Hare Psychopathy Checklist , claims that all psychopaths have APD but not all individuals diagnosed with APD are psychopaths.

Causes and symptoms

Causes

Studies of adopted children indicate that both genetic and environmental factors influence the development of APD. Both biological and adopted children of people diagnosed with the disorder have an increased risk of developing it. Children born to parents diagnosed with APD but adopted into other families resemble their biological more than their adoptive parents. The environment of the adoptive home, however, may lower the child's risk of developing APD.

Researchers have linked antisocial personality disorder to childhood physical or sexual abuse; neurological disorders (which are often undiagnosed); and low IQ. But, as with other personality disorders, no one has identified any specific cause or causes of antisocial personality disorder. Persons diagnosed with APD also have an increased incidence of somatization and substance-related disorders.

DSM-IV-TR adds that persons who show signs of conduct disorder with accompanying attention-deficit/hyperactivity disorder before the age of ten have a greater chance of being diagnosed with APD as adults than do other children. The manual notes that abuse or neglect combined with erratic parenting or inconsistent discipline appears to increase the risk that a child diagnosed with conduct disorder will develop APD as an adult.

Symptoms

The central characteristic of antisocial personality disorder is an extreme disregard for the rights of other people. Individuals with APD lie and cheat to gain money or power. Their disregard for authority often leads to arrest and imprisonment. Because they have little regard for others and may act impulsively, they are frequently involved in fights. They show loyalty to few if any other people and are likely to seek power over others in order to satisfy sexual desires or economic needs.

People with APD often become effective "con artists." Those with well-developed verbal abilities can often charm and fool their victims, including unsuspecting or inexperienced therapists. People with APD have no respect for what others regard as societal norms or legal constraints. They may quit jobs on short notice, move to another city, or end relationships without warning and without what others would consider good reason. Criminal activities typically include theft, selling illegal drugs and check fraud. Because persons with antisocial personality disorder make "looking out for number one" their highest priority, they are quick to exploit others. They commonly rationalize these actions by dismissing their victims as weak, stupid or unwary.

Demographics

APD is estimated to affect 3% of males and 1% of females in the general United States population. Mental health professionals may diagnose 3%–30% of the population in clinical settings as having the disorder. The percentages may be even higher among prison inmates or persons in treatment for substance abuse. By some estimates, three-quarters of the prison population may meet the diagnostic criteria for APD.

Diagnosis

The diagnosis of antisocial personality disorder is usually based on a combination of a careful medical as well as psychiatric history and an interview with the patient. The doctor will look for recurrent or repetitive patterns of antisocial behavior. He or she may use a diagnostic questionnaire for APD, such as the Hare Psychopathy Checklist, if the patient's history suggests the diagnosis. A person aged 18 years or older with a childhood history of disregard for the rights of others can be diagnosed as having APD if he or she gives evidence of three of the following seven behaviors associated with disregard for others:

• Fails to conform to social norms, as indicated by frequently performing illegal acts or pursuing illegal occupations.
• Deceives and manipulates others for selfish reasons, often in order to obtain money, sex, drugs or power. This behavior may involve repeated lying, conning or the use of false names.
• Fails to plan ahead or displays impulsive behavior, as indicated by a long succession of short-term jobs or frequent changes of address.
• Engages in repeated fights or assaults as a consequence of irritability and aggressiveness.
• Exhibits reckless disregard for safety of self or others.
• Shows a consistent pattern of irresponsible behavior, including failure to find and keep a job for a sustained length of time and refusal to pay bills or honor debts.
• Shows no evidence of sadness, regret or remorse for actions that have hurt others.

In order to meet DSM-IV-TR criteria for APD, a person must also have had some symptoms of conduct disorder before age 15. An adult 18 years or older who does not meet all the criteria for APD may be given a diagnosis of conduct disorder.

Antisocial behavior may appear in other mental disorders as well as in APD. These conditions must be distinguished from true APD. For instance, it is not uncommon for a person with a substance abuse disorder to lie to others in order to obtain money for drugs or alcohol. But unless indications of antisocial behavior were present during the person's childhood, he or she would not be diagnosed with antisocial personality disorder. People who meet the criteria for a substance abuse disorder as well as APD would be given a dual diagnosis .

Treatments

Antisocial personality disorder is highly unresponsive to any form of treatment, in part because persons with APD rarely seek treatment voluntarily. If they do seek help, it is usually in an attempt to find relief from depression or other forms of emotional distress. Although there are medications that are effective in treating some of the symptoms of the disorder, noncompliance with medication regimens or abuse of the drugs prevents the widespread use of these medications. The most successful treatment programs for APD are long-term structured residential settings in which the patient systematically earns privileges as he or she modifies behavior. In other words, if a person diagnosed with APD is placed in an environment in which they cannot victimize others, their behavior may improve. It is unlikely, however, that they would maintain good behavior if they left the disciplined environment.

If some form of individual psychotherapy is provided along with behavior modification techniques, the therapist's primary task is to establish a relationship with the patient, who has usually had very few healthy relationships in his or her life and is unable to trust others. The patient should be given the opportunity to establish positive relationships with as many people as possible and be encouraged to join self-help groups or prosocial reform organizations.

Unfortunately, these approaches are rarely if ever effective. Many persons with APD use therapy sessions to learn how to turn "the system" to their advantage. Their pervasive pattern of manipulation and deceit extends to all aspects of their life, including therapy. Generally, their behavior must be controlled in a setting where they know they have no chance of getting around the rules.

Prognosis

APD usually follows a chronic and unremitting course from childhood or early adolescence into adult life. The impulsiveness that characterizes the disorder often leads to a jail sentence or an early death through accident, homicide or suicide . There is some evidence that the worst behaviors that define APD diminish by midlife; the more overtly aggressive symptoms of the disorder occur less frequently in older patients. This improvement is especially true of criminal behavior but may apply to other antisocial acts as well.

Prevention

Measures intended to prevent antisocial personality disorder must begin with interventions in early childhood, before youths are at risk for developing conduct disorder. Preventive strategies include education for parenthood and other programs intended to lower the incidence of child abuse; Big Brother/Big Sister and similar mentoring programs to provide children at risk with adult role models of responsible and prosocial behavior; and further research into the genetic factors involved in APD.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Black, Donald, W., with C. Lindon Larson. Bad Boys, Bad Men: Confronting Antisocial Personality Disorder. New York, NY: Oxford University Press, 1999.

Cleckley, Hervey. The Mask of Sanity. 5th ed. Augusta, GA: Emily S. Cleckley, 1988.

Hare, Robert D. Without Conscience: The Disturbing World of the Psychopaths Among Us. New York, NY: The Guilford Press, 1993.

Lykken, David T. The Antisocial Personalities. Hillsdale, NJ: Lawrence Erlbaum Associates, Publishers, 1995.

Simon, Robert I. Bad Men Do What Good Men Dream: A Forensic Psychiatrist Illuminates the Darker Side of Human Behavior. 1st ed. Washington, DC: American Psychiatric Press, Inc., 1996