Antisocial Personality Disorder
Antisocial personality disorder
Definition
Antisocial behavior is that which is verbally or physically harmful to other people, animals, or property, including behavior that severely violates social expectations for a given environment. Antisocial personality disorder in adults is also referred to as sociopathy or psychopathy.
Description
Antisocial behavior can be broken down into two components: the presence of antisocial (i.e., angry, aggressive, or disobedient) behavior and the absence of prosocial (i.e., communicative, affirming, or cooperative) behavior. Most children exhibit some antisocial behavior during their development, and different children demonstrate varying levels of prosocial and antisocial behavior. Some children—for example, the popular but rebellious child—may exhibit high levels of both antisocial and prosocial behaviors. Others—for example, the withdrawn, thoughtful child—may exhibit low levels of both types of behaviors.
High levels of antisocial behavior are considered a clinical disorder. Young children may exhibit hostility towards authority, and be diagnosed with oppositional-defiant disorder. Older children may lie, steal, or engage in violent behaviors, and be diagnosed with conduct disorder . A minority of children with conduct disorder whose behavior does not improve as they mature will go on to develop adult antisocial personality disorder.
A salient characteristic of antisocial children and adolescents is that they appear to have no feelings. They demonstrate no care for others' feelings or remorse for hurting others, and tend not to show their own feelings except for anger and hostility, and even these are communicated through aggressive acts and are not necessarily expressed through affect. One analysis of antisocial behavior is that it is a defense mechanism that helps children avoid painful feelings, or avoid the anxiety caused by lack of control over the environment.
Antisocial behavior may also be a direct attempt to alter the environment. Social learning theory suggests that negative behaviors are reinforced during childhood by parents, caregivers, or peers. In one formulation, a child's negative behavior (e.g., whining, hitting) initially serves to stop the parent from behaving in ways that are aversive to the child (the parent may be fighting with a partner, yelling at a sibling, or even crying). The child will apply the learned behavior at school, and a vicious cycle sets in: he or she is rejected, becomes angry and attempts to force his will or assert his pride, and is then further rejected by the very peers from whom he might learn more positive behaviors. As the child matures, "mutual avoidance" sets in with the parent(s), as each party avoids the negative behaviors of the other. Consequently, the child receives little care or supervision and, especially during adolescence , is free to join peers who have similarly learned antisocial means of expression.
Demographics
Mental health professionals agree, and rising rates of serious school disciplinary problems, delinquency, and violent crime indicate, that antisocial behavior in general is increasing. Thirty to 70% of childhood psychiatric admissions are for disruptive behavior disorders, and diagnoses of behavior disorders are increasing overall. A small percentage of antisocial children (about 3% of males and 1% of females) grow up to become adults with antisocial personality disorder, and a greater proportion suffer from the social, academic, and occupational failures resulting from their antisocial behavior.
Causes and symptoms
Factors that contribute to a particular child's antisocial behavior vary, but they usually include some form of family problems (e.g., marital discord, harsh or inconsistent disciplinary practices or actual child abuse , frequent changes in primary caregiver or in housing, learning or cognitive disabilities, or health problems). Attention deficit/hyperactivity disorder is highly correlated with antisocial behavior.
A child may exhibit antisocial behavior in response to a specific stressor (such as the death of a parent or a divorce ) for a limited period of time, but this is not considered a psychiatric condition. Children and adolescents with antisocial behavior problems have an increased risk of accidents, school failure, early alcohol and substance use, suicide , and criminal behavior. The elements of a moderate to severely antisocial personality are established as early as kindergarten. Antisocial children score high on traits of impulsiveness, but low on anxiety and reward-dependence—the degree to which they value, and are motivated by, approval from others. Yet underneath their tough exterior, antisocial children have low self-esteem .
Although antisocial personality disorder is only diagnosed in people over age 18, the symptoms are similar to those of conduct disorder, and the criteria for diagnosis include the onset of conduct disorder before the age of 15. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision (DSM-IV-TR), people with antisocial personality disorder demonstrate a pattern of antisocial behavior since age 15.
The adult with antisocial personality disorder displays at least three of the following behaviors:
- fails to conform to social norms, as indicated by frequently performing illegal acts, and pursuing illegal occupations
- is deceitful and manipulative of others, often in order to obtain money, sex, or drugs
- is impulsive, holding a succession of jobs or residences
- is irritable or aggressive, engaging in physical fights
- exhibits reckless disregard for the safety of self or others, misusing motor vehicles, or playing with fire
- is consistently irresponsible, failing to find or sustain work or to pay bills and debts
- demonstrates lack of remorse for the harm his or her behavior causes others
An adult diagnosed with antisocial personality disorder will demonstrate few of his or her own feelings beyond contempt for others. Authorities have linked antisocial personality disorder with abuse, either physical or sexual, during childhood, neurological disorders (which are often undiagnosed), and low IQ. Those with a parent with an antisocial personality disorder or substance abuse problem are more likely to develop the disorder. The antisocially disordered person may be poverty-stricken, homeless, a substance abuser, or have an extensive criminal record. Antisocial personality disorder is associated with low socioeconomic status and urban settings.
When to call the doctor
When symptoms of antisocial behavior appear, a child should be taken to his or her health care provider as soon as possible for evaluation and possible referral to a mental health care professional. If a child or teen reveals at any time that he/she has had recent thoughts of self-injury or suicide, or if he/she demonstrates behavior that compromises personal safety or the safety of others, professional assistance from a mental health care provider or care facility should be sought immediately.
Diagnosis
Antisocial behavior and childhood antisocial disorders such as conduct disorder may be diagnosed by a family physician or pediatrician, social worker, school counselor, psychiatrist, or psychologist. A comprehensive evaluation of the child should ideally include interviews with the child and parents, a full social and medical history, review of educational records, a cognitive evaluation, and a psychiatric exam.
One or more clinical inventories or scales may be used to assess the child, including the Youth Self-Report, the School Social Behavior Scales (SSBS), the Overt Aggression Scale (OAS), Behavioral Assessment System for Children (BASC), Child Behavior Checklist (CBCL), the Nisonger Child Behavior Rating Form (NCBRF), Clinical Global Impressions scale (CGI), and Diagnostic Interview Schedule for Children (DISC). The tests are verbal and/or written and are administered in both hospital and outpatient settings.
Treatment
The most important goals of treating antisocial behavior are to measure and describe the individual child's or adolescent's actual problem behaviors and to effectively teach him or her the positive behaviors that should be adopted instead. In severe cases, medication will be administered to control behavior, but it should not be used as a substitute for therapy. A child who experiences explosive rage may respond well to medication. Ideally, an interdisciplinary team of teachers, social workers, and guidance counselors will work with parents or caregivers to provide services to help the child in all aspects of his or her life: home, school, work, and social contexts. In many cases, parents themselves need intensive training on modeling and reinforcing appropriate behaviors in their child, as well as in providing appropriate discipline to prevent inappropriate behavior.
A variety of methods may be employed to deliver social skills training, but especially with diagnosed anti-social disorders, the most effective methods are systemic therapies which address communication skills among the whole family or within a peer group of other antisocial children or adolescents. These probably work best because they entail actually developing (or redeveloping) positive relationships between the child or adolescent and other people. Methods used in social skills training include modeling, role-playing, corrective feedback, and token reinforcement systems. Regardless of the method used, the child's level of cognitive and emotional development often determines the success of treatment. Adolescents capable of learning communication and problem-solving skills are more likely to improve their relations with others.
Unfortunately, conduct disorders, which are the primary form of diagnosed antisocial behavior, are highly resistant to treatment. Few institutions can afford the comprehensiveness and intensity of services required to support and change a child's whole system of behavior. In most cases, for various reasons, treatment is terminated (usually by the client) long before it is completed. Often, the child may be fortunate to be diagnosed at all. Schools are frequently the first to address behavior problems, and regular classroom teachers only spend a limited amount of time with individual students. Special education teachers and counselors have a better chance at instituting long-term treatment programs—if the student stays in the same school for a period of years. One study showed teenage boys with conduct disorder had had an average of nine years of treatment by 15 different institutions. Treatments averaged seven months each.
Studies show that children who are given social skills instruction decrease their antisocial behavior, especially when the instruction is combined with some form of supportive peer group or family therapy . But the long-term effectiveness of any form of therapy for anti-social behavior has not been demonstrated. The fact that peer groups have such a strong influence on behavior suggests that schools that employ collaborative learning and the mainstreaming of antisocial students with regular students may prove most beneficial to the antisocial child. Because the classroom is a natural environment, learned skills do not need to be transferred. By dividing the classroom into groups and explicitly stating procedures for group interactions, teachers can create opportunities for positive interaction between antisocial and other students.
Prognosis
Early and intensive intervention is the best hope for children exhibiting antisocial behaviors or diagnosed conduct disorder. For those who grow into adults with antisocial personality disorder, the prognosis is not promising; the condition is difficult to treat and tends to be chronic. Although there are medications available that could quell some of the symptoms of antisocial personality disorder, noncompliance or abuse of the drugs prevents their widespread use. The most successful treatment programs are long-term, structured residential settings in which the patient systematically earns privileges as he or she modifies behavior.
Prevention
A supportive, nurturing, and structured home environment is believed to be the best defense against anti-social behavioral problems. Children with learning disabilities and/or difficulties in school should get appropriate academic assistance. Addressing these problems when they first appear helps to prevent the frustration and low self-esteem that may lead to antisocial issues later.
Parental concerns
A child with antisocial behavioral problems can have a tremendous impact on the home environment and on the physical and emotional welfare of siblings and others sharing the household, as well as their peers at school. While seeking help for their child, parents must remain sensitive to the needs of their other children. This may mean avoiding leaving siblings alone together, getting assistance with childcare, or even seeking residential or hospital treatment for the child if the safety and well-being of other family members is in jeopardy. Parents should also maintain an open dialog with their child's teachers to ensure that their child receives appropriate educational assistance and that classmates are not put at risk.
KEY TERMS
Attention deficit hyperactivity disorder (ADHD) —A condition in which a person (usually a child) has an unusually high activity level and a short attention span. People with the disorder may act impulsively and may have learning and behavioral problems.
Major depressive disorder —A mood disorder characterized by profound feelings of sadness or despair.
Modeling —A type of teaching method used in social skills training. Therapists who use this method may offer positive and negative examples of the behaviors that make up a social skill.
Prosocial behavior —Actions that promote communication, cooperation, and other positive interactions with peers and family members.
See also Aggression; Conduct disorder; Oppositional defiant disorder.
Resources
BOOKS
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision (DSMIV-TR). Washington, DC: American Psychiatric Press, Inc., 2000.
Connor, Daniel. Aggression and Antisocial Behavior in Children and Adolescents: Research and Treatment. New York: Guilford Press, 2002.
Eddy, J. Mark. Conduct Disorders: The Latest Assessment and Treatment Strategies. Kansas City, MO: Compact Clinicals, 2003.
PERIODICALS
Cellini, Henry R. "Biopsychological Treatment of Antisocial and Conduct-Disordered Offenders." Federal Probation 66, no. 2 (September 2002): 78+.
Connor, Daniel F. "Aggression and Antisocial Behavior in Youth." Brown University Child & Adolescent Behavior Letter 18, no. 9 (September 2002): 1+.
ORGANIZATIONS
The American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Ave., N.W., Washington, D.C. 20016-3007. (202) 966-7300. Web site: <www.aacap.org>
WEB SITES
The National Mental Health Association. <www.nmha.org>.
NYU Child Study Center. Changing the Face of Child Mental Health. <www.aboutourkids.org>.
Paula Ford-Martin
Antisocial Personality Disorder
Antisocial Personality Disorder
Definition
Also known as psychopathy, sociopathy, or dissocial 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 can persist 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
Men or women diagnosed with this personality disorder demonstrate few emotions beyond contempt for other people. 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 that 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 categorization by the American Psychiatric Association (APA) 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. Recent reports have made this distinction even clearer, suggesting that there is emotional deficit component of psychopathy that is not necessarily present in people with APD. One expert review comments that only 25% of people diagnosed with APD or the putatively related “conduct disorder” will show psychopathic tendencies.
Causes and symptoms
Causes
Studies of adopted children indicate that both genetic and environmental factors influence the development of APD, with heritability estimates ranging from 44% to 72%. 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 in this regard. 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. Some experts have recently questioned the link between psychopathy, which these experts distinguish from APD, and early environmental trauma. As with other personality disorders, no one has identified any specific cause or causes of antisocial personality disorder. Indeed, one group with the U.S. National Institute of Mental Health has stated that “there are many developmental routes to an elevated risk for antisocial behavior.” Persons diagnosed with APD also have an increased incidence of somatization disorder and substance-related disorders.
The DSM-IV-TR adds that persons who show signs of conduct disorder with accompanying attention-deficit/hyperactivity disorder before the age of 10 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.
Brain imaging studies have identified some specific characteristics in the brains of people diagnosed with APD that suggest dysfunction of structures in the frontal and temporal lobes of the brain.
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.
Some work has been done on the relationship between what are called “minor physical anomalies” and the presence of various disorders, including aggression disorders and psychopathy. The presence of these features—which include low-seated ears and adherent ear lobes—is associated with developmental derailments in the fetus at the end of the third trimester of pregnancy, and they have been linked with the development of conduct disorder and violence in adulthood. Studies directly examining their association, if any, with psychopathy or APD are lacking. Birth complications are known risk factors for violent, antisocial behaviors.
Demographics
APD is estimated to affect 3% of males and 1% of females in the general population of the United States. 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-Revised or the self-reporting Psychopathic Personality Inventory, 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.
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.
KEY TERMS
Attention-deficit/hyperactivity disorder —A learning and behavioral disorder characterized by difficulty in sustaining attention, impulsive behavior, and excessive activity.
Conduct disorder —A behavioral and emotional disorder of childhood and adolescence in which children display physical aggression and infringe on or violate the rights of others. Youths diagnosed with conduct disorder may set fires, exhibit cruelty toward animals or other children, sexually assault others, or lie and steal for personal gain.
Psychopathy —A psychological syndrome that includes lack of a conscience or sense of guilt, lack of empathy, egocentricity, pathological lying, repeated violations of social norms, disregard of the law, shallow emotions, and a history of victimizing others.
Somatization disorder —A type of mental disorder in which the patient has physical complaints that serve as coping strategies for emotional distress.
Substance abuse disorder —Disorder that is characterized by: an individual’s need for more of a drug or alcohol than intended, an inability to stop using by choice, and an ongoing difficulty in recovering from the effects of the substance.
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 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 can follow 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 ed., Text rev. Washington D.C.: American Psychiatric Association, 2000.
Black, Donald, W., with C. Lindon Larson. Bad Boys, Bad Men: Confronting Antisocial Personality Disorder. New York: 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: The Guilford Press, 1993.
Lykken, David T. The Antisocial Personalities. Hillsdale, NJ: Lawrence Erlbaum Associates, 1995.
Simon, Robert I. Bad Men Do What Good Men Dream: A Forensic Psychiatrist Illuminates the Darker Side of Human Behavior. Washington D.C.: American Psychiatric Press, 1996.
PERIODICALS
Abbott, Alison. “Into the Mind of a Killer.” Nature 410 (2001): 296–98.
OTHER
Hare, Robert D. “Dr. Robert Hare’s Page for the Study of Psychopaths.” <http://www.hare.org> (January 29, 2002).
National Library of Medicine. National Institutes of Health. “Antisocial Personality Disorder.” <http://www.nlm.nih.gov/medlineplus/ency/article/000921.htm>.
Dean A. Haycock, PhD
Emily Jane Willingham, PhD
Antisocial personality disorder
Antisocial personality disorder
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.
PERIODICALS
Abbott, Alison. "Into the mind of a killer." Nature. 410 (15 March 2001): 296–298.
OTHER
Hare, Robert D. Dr. Robert Hare's Page for the Study of Psychopaths. January 29, 2002 (cited March 25, 2002.) <http://www.hare.org>.
Dean A. Haycock, Ph.D.
Antisocial Personality Disorder
Antisocial Personality Disorder
What Is Antisocial Personality Disorder?
What Causes Antisocial Personality Disorder?
How Is Antisocial Personality Disorder Treated?
Antisocial personality disorder (APD) is an ongoing pattern of behavior in an adult that involves disregard for social rules and serious violation of the rights of others through aggressive, dishonest, reckless, and irresponsible acts.
KEYWORDS
for searching the Internet and other reference sources
Antisocial behaviors
Disruptive behaviors
What Is Antisocial Personality Disorder?
Antisocial personality disorder (APD) is one of the ten different types of personality disorders* that are currently classified by mental health experts. Like other personality disorders, APD refers to a personality style that consists of troubled ways of thinking, feeling, and behaving, and it is diagnosed only in adults (but the personality style and the problematic behavior it causes must have been present since adolescence). Of all the personality disorders, APD has been the focus of the most research and attention, perhaps because people with APD often cause harm to others and have a negative effect on society.
- * personality disorders
- are a group of mental disorders characterized by long-term patterns of behavior that differ from those expected by society. People with personality disorders have patterns of emotional response, impulse control, and perception that differ from those of most people.
Adults with APD engage in aggressiveness or physical assaults, cheating, lying, or other behaviors for which they can get arrested. They are often impulsive* and reckless and disregard their own safety or the safety of others. People with APD tend to be poor planners, and they may ignore financial responsibilities like paying rent or other bills. They often have poor work records and many engage in impulsive criminal behavior or spousal abuse. To be diagnosed with APD, a person must have had symptoms of conduct disorder* since the age of 15, thus demonstrating a longstanding pattern of antisocial behaviors*.
- * impulsive
- means acting quickly before thinking about the effect of a certain action or behavior.
- * conduct disorder
- is diagnosed in children and adolescents who have had serious problems with lying, stealing, and aggressive behavior for at least 6 months.
- * antisocial behaviors
- are behaviors that differ significantly from the norms of society and are considered harmful to society.
APD was first described in the 1800s as a “defect of moral character” and as “moral insanity.” The terms psychopath and sociopath have also been used to describe what is now called antisocial personality disorder. Those with APD seem to lack a conscience and fail to learn from consequences or punishment alone. They may fail to show remorse and may lack sympathy for those they have hurt. People with APD may experience most emotions at a shallow level.
What Causes Antisocial Personality Disorder?
Antisocial behavior tends to run in families. Researchers have tried to determine how much of this tendency is due to genetics and biology and how much is learned behavior. Some studies have identified certain brain problems and learning defects in people with APD. For example, researchers have found that areas of the brain that are involved in thinking ahead and in considering the consequences of one’s actions may be different in people with APD. This finding lends evidence to the theory that an inherited brain problem may contribute to the poor planning and impulsivity that are characteristic of people with APD.
Other studies have found differences in the brains of people with APD that may contribute to disordered learning and attention. One series of experiments demonstrated that people with antisocial personalities did not experience normal anxiety before being given a shock and that they did not learn to avoid the shock like other subjects in the experiment did. This may explain why people with APD do not seem to learn from negative consequences or punishment.
Research that separates genetic from environmental factors (for example, studies of identical twins raised in different homes) has shown that genetic factors explain about half of antisocial behavior. Family environment or upbringing plays an important role as well. Experts currently believe that a combination of genetic inheritance and environmental factors lead to most cases of APD. In other words, some people seem to have a biological tendency to develop APD and the family environment will determine whether or not that tendency is fulfilled. People without the biological tendency for APD, regardless of the family environment in which they are raised, are not likely to develop APD as an adult (although they may have conduct disorder as a youth).
How Is Antisocial Personality Disorder Treated?
Treatment of APD presents a challenge because those with APD are unlikely to consider themselves as having a problem and are therefore unlikely to seek help. Without motivation to change one’s own behavior, it is unlikely that any meaningful change will take place. Because people with APD tend to violate the rights of others, they often encounter the criminal justice system. Though they may be imprisoned, punishment alone usually fails to teach someone with APD to behave differently. Still, APD is a serious social problem. Some early interventions may help prevent APD from developing in those at risk, such as youth with severe conduct disorders and those who are juvenile offenders.
See also
Bullying
Lying and Stealing
Oppositional Defiant Disorder
Personality
and Personality Disorders
Resources
Organizations
The Personality Disorders Foundation has a website that provides information about personality disorders. http://pdf.uchc.edu/
The American Psychological Association has a website that provides information about personality disorders. http://www.apa.org
Antisocial Personality Disorder
Antisocial personality disorder
A behavior disorder developed by a small percentage of children with conduct disorder whose behavior does not improve as they mature. Also known as sociopathy or psychopathy.
About 3% of males and 1% of females develop antisocial personality disorder, which is essentially the adult version of childhood conduct disorder . Antisocial personality disorder is only diagnosed in people over age 18, the symptoms are similar to those of conduct disorder, and the criteria for diagnosis include the onset of conduct disorder before the age of 15. According to the Diagnostic and Statistical Manual of Mental Disorders (DSMIV), people with antisocial personality disorder demonstrate a pattern of antisocial behavior since age 15.
The adult with antisocial personality disorder displays at least three of the following behaviors:
- Fails to conform to social norms, as indicated by frequently performing illegal acts, and pursuing illegal occupations.
- Is deceitful and manipulative of others, often in order to obtain money, sex, or drugs.
- Is impulsive, holding a succession of jobs or residences.
- Is irritable or aggressive, engaging in physical fights.
- Exhibits reckless disregard for safety of self or others, misusing motor vehicles or playing with fire.
- Is consistently irresponsible, failing to find or sustain work or to pay bills and debts.
- Demonstrates lack of remorse for the harm his or her behavior causes others.
An individual diagnosed with antisocial personality disorder will demonstrate few of his or her own feelings beyond contempt for others. This lack of affect is strangely combined with an inflated sense of self-worth and often a superficial charm, which tends to mask their inner apathy. Authorities have linked antisocial personality disorder with abuse, either physical or sexual, during childhood, neurological disorders (which are often undiagnosed), and low IQ. Those with a parent with an antisocial personality disorder or substance abuse problem are more likely to develop the disorder. The antisocially disordered person may be poverty-stricken, homeless, a substance abuser, or have an extensive criminal record. Antisocial personality disorder is associated with low socioeconomic status and urban settings.
Treatment
Antisocial personality disorder is highly unresponsive to any form of treatment. Although there are medications available that could quell some of the symptoms of the disorder, noncompliance or abuse of the drugs prevents their widespread use. The most successful treatment programs are long-term, structured residential settings in which the patient systematically earns privileges as he or she modifies behavior. Some form of dynamic psychotherapy is usually given along with the behavior modification . The therapist's primary task is to establish a relationship with the patient, who has usually had very few relationships in his or her life and is unable to trust, fantasize, feel, or learn. 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.
See also Antisocial behavior; Conduct disorder; Oppositional-defiant disorder; Peer acceptance
Further Reading
Cleckley, Hervey M. The Mask of Sanity. Rev. ed. New York: New American Library; St. Louis: Mosby, 1982.
Magid, Ken, and Carole A. McKelvey. High Risk. New York: Bantam Books, 1988.
Winnicott, D. W. Deprivation and Delinquency. New York: Tavistock Publications, 1984.
Further Information
Antisocial and Violent Behavior Branch. Division of Biometry and Applied Sciences. National Institute of Mental Health. 18-105 Parklawn Bldg., 5600 Fishers Lane, Rockville, MD 20857, (301) 443–3728.