Learning Objectives
- Describe the basic features of antisocial personality disorder and its etiology
Cluster B disorders include antisocial personality disorder, histrionic personality disorder, narcissistic personality disorder, and borderline personality disorder. People with these disorders usually are impulsive, overly dramatic, highly emotional, and erratic.
| Antisocial | continuously violates the rights of others; history of antisocial tendencies prior to age 15; often lies, fights, and has problems with the law; impulsive and fails to think ahead; can be deceitful and manipulative in order to gain profit or pleasure; irresponsible and often fails to hold down a job or pay financial debts; lacks feelings for others and remorse over misdeeds | B |
| Histrionic | excessively overdramatic, emotional, and theatrical; feels uncomfortable when not the center of others’ attention; behavior is often inappropriately seductive or provocative; speech is highly emotional but often vague and diffuse; emotions are shallow and often shift rapidly; may alienate friends with demands for constant attention | B |
| Narcissistic | overinflated and unjustified sense of self-importance and preoccupied with fantasies of success; feels entitled to special treatment from others; shows arrogant attitudes and behaviors; takes advantage of others; lacks empathy | B |
| Borderline | unstable in self-image, mood, and behavior; cannot tolerate being alone and experiences chronic feelings of emptiness; unstable and intense relationships with others; behavior is impulsive, unpredictable, and sometimes self-damaging; shows inappropriate and intense anger; makes suicidal gestures | B |
Most human beings live in accordance with a moral compass, a sense of right and wrong. Most individuals learn at a very young age that there are certain things that should not be done. We learn we should not lie or cheat. We are taught it is wrong to take things that do not belong to us, and it is wrong to exploit others for personal gain. We also learn the importance of living up to our responsibilities, of doing what we say we will do. People with antisocial personality disorder, however, do not seem to have a moral compass. These individuals act as though they neither have a sense of nor care about right or wrong. Not surprisingly, these people represent a serious problem for others and for society in general.
Figure 1. Individuals with ASPD may say things without thinking about how their words may affect others.
According to the DSM-5, the individual with antisocial personality disorder (ASPD) (sometimes referred to as psychopathy) shows no regard at all for other people’s rights or feelings. This lack of regard is exhibited a number of ways and can include repeatedly performing illegal acts, lying to or conning others, impulsivity and recklessness, irritability and aggressiveness toward others, and failure to act in a responsible way (e.g., leaving debts unpaid) (APA, 2013). The worst part about antisocial personality disorder, however, is that people with this disorder have no remorse over one’s misdeeds; these people will hurt, manipulate, exploit, and abuse others and not feel any guilt. Signs of this disorder can emerge early in life; however, a person must be at least 18 years old to be diagnosed with antisocial personality disorder.
People with antisocial personality disorder (ASPD) seem to view the world as self-serving and unkind. Those with ASPD seem to think they should use whatever means necessary to get by in life. They tend to view others not as living, thinking, feeling beings, but rather as pawns to be used or abused for a specific purpose. They often have an over-inflated sense of themselves and can appear extremely arrogant. They frequently display superficial charm; for example, without really meaning it, they might say exactly what they think another person wants to hear. They lack empathy: they are incapable of understanding the emotional point-of-view of others. People with this disorder may become involved in illegal enterprises, show cruelty toward others, leave their jobs with no plans to obtain another job, have multiple sexual partners, repeatedly get into fights with others, and show reckless disregard for themselves and others (e.g., repeated arrests for driving while intoxicated) (APA, 2013).
DSM-5 Criteria
Here is the DSM-5 diagnostic criteria for antisocial personality disorder (ASPD):
A. A pervasive pattern of disregard for and violation of the rights of others, since age 15 years, as indicated by three (or more) of the following:
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failure to conform to social norms concerning lawful behaviors, such as performing acts that are grounds for arrest
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deceitfulness, repeated lying, use of aliases, or conning others for pleasure or personal profit
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impulsivity or failure to plan
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irritability and aggressiveness, often with physical fights or assaults
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reckless disregard for the safety of self or others
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consistent irresponsibility, failure to sustain consistent work behavior, or honor monetary obligat
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lack of remorse, being indifferent to or rationalizing having hurt, mistreated, or stolen from another person
B. The individual is at least age 18 years.
C. Evidence of conduct disorder typically with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during schizophrenia or bipolar disorder.
Persistent antisocial behavior as well as a lack of regard for others in childhood and adolescence is known as conduct disorder and considered a precursor of ASPD. About 25–40% of youths with conduct disorder will be diagnosed with ASPD in adulthood.[1]
Differential Diagnosis
Some similar disorders to antisocial personality disorder include
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narcissistic personality disorder (cluster B personality disorder with overlap; exploitive and uncompassionate, but not aggressive or deceitful).
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borderline personality disorder (cluster B personality disorder with overlap; manipulative, but for reassurance and nurture).
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substance use disorder (Impulsivity and irresponsibility due to substance influence must be ruled out before diagnosing ASPD. ASPD can be diagnosed if substance use is co-occurring).
Etiology and Epidemiology
Although the precise etiology is unknown, both genetic and environmental factors have been found to play a role in the development of ASPD.
ASPD is observed in about 3.6% of the population; the disorder is much more common among males, with a 3:1 ratio of men to women, and it is more likely to occur in men who are younger, widowed, separated, divorced, of lower SES, live in urban areas, and live in the western United States (Compton, Conway, Stinson, Colliver, & Grant, 2005). Compared to men with ASPD, women with the disorder are more likely to have experienced emotional neglect and sexual abuse during childhood, and they are more likely to have had parents who abused substances and who engaged in antisocial behaviors themselves (Alegria et al., 2013).
The table below shows some of the differences in the specific types of antisocial behaviors that men and women with APSD exhibit (Alegria et al., 2013).
| Men with antisocial personality disorder are more likely than women with ASPD to | Women with ASPD are more likely than men with antisocial personality to |
|---|---|
|
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Family, twin, and adoption studies suggest that both genetic and environmental factors influence the development of ASPD, as well as general antisocial behavior (criminality, violence, aggressiveness) (Baker, Bezdjian, & Raine, 2006). Personality and temperament dimensions that are related to this disorder, including fearlessness, impulsive antisociality, and callousness, have a substantial genetic influence (Livesley & Jang, 2008). Adoption studies clearly demonstrate that the development of antisocial behavior is determined by the interaction of genetic factors and adverse environmental circumstances (Rhee & Waldman, 2002). For example, one investigation found that adoptees of biological parents with ASPD were more likely to exhibit adolescent and adult antisocial behaviors if they were raised in adverse adoptive family environments (e.g., adoptive parents had marital problems, were divorced, used drugs, and had legal problems) than if they were raised in a more normal adoptive environment (Cadoret, Yates, Ed, Woodworth, & Stewart, 1995).
Researchers who are interested in the importance of the environment in the development of ASPD have directed their attention to such factors as the community, the structure and functioning of the family, and peer groups. Each of these factors influences the likelihood of antisocial behavior. One longitudinal investigation of more than 800 Seattle-area youth measured risk factors for violence at 10, 14, 16, and 18 years of age (Herrenkohl et al., 2000). The risk factors examined included those involving the family, peers, and community. A portion of the findings from this study are provided in Figure 1.
Figure 2. Longitudinal studies have helped to identify risk factors for predicting violent behavior.
Individuals with antisocial tendencies do not seem to experience emotions the way most other people do. These individuals fail to show fear in response to environmental cues that signal punishment, pain, or noxious stimulation. For instance, they show less skin conductance (sweatiness on hands) in anticipation of electric shock than do people without antisocial tendencies (Hare, 1965). Skin conductance is controlled by the sympathetic nervous system and is used to assess autonomic nervous system functioning. When the sympathetic nervous system is active, people become aroused and anxious, and sweat gland activity increases. Thus, increased sweat gland activity, as assessed through skin conductance, is taken as a sign of arousal or anxiety. For those with ASPD, a lack of skin conductance may indicate the presence of characteristics such as emotional deficits and impulsivity that underlie the propensity for antisocial behavior and negative social relationships (Fung et al., 2005).
While emotional deficits may contribute to antisocial personality disorder, so too might an inability to relate to others’ pain. In a recent study, 80 prisoners were shown photos of people being intentionally hurt by others (e.g., someone crushing a person’s hand in an automobile door) while undergoing brain imaging (Decety, Skelly, & Kiehl, 2013). Prisoners who scored high on a test of antisocial tendencies showed significantly less activation in brain regions involved in the experience of empathy and feeling concerned for others than did prisoners with low scores on the antisocial test. Notably, the prisoners who scored high on the antisocial test showed greater activation in a brain area involved self-awareness, cognitive function, and interpersonal experience. The investigators suggested that the heightened activation in this region when watching social interactions involving one person harming another may reflect a propensity or desire for this kind of behavior.
Case Study
Consider the case study of a 27-year-old male, Joseph, who committed murder at age 17. He stayed in a high-security hospital for 10 years and started individual treatment after being released. He was an intelligent boy who did well in school until his peers began to tease him. This teasing made Joseph feel helpless and unable to defend himself. At home, however, he felt strong and supportive of his mother. His father lived with another woman. He experienced himself as a loser among his peers but as a winner with his mother.
At the end of elementary school, his father, who then had accumulated substantial wealth, returned home, and the parents resumed their marriage and intimacy. Joseph’s situation at school changed as he became popular and the teasing stopped, but he still felt insecure and uneasy. With his newfound popularity, Joseph found it easy to get others to do things for him and enjoyed organizing mischief in his neighborhood. At this same time, he decided to attend karate school to gain a sense of power.
In high school, a peer introduced Joseph to a gang where he felt accepted and appreciated. During a robbery, he became incredibly angry and physically violent without really understanding why. The victim died as a consequence of his attack, and Joseph was sent to prison for two years, followed by a high-security hospital for treatment. While he accepted his prison sentence, he protested treatment in the psychiatric hospital. He was suspicious, remained non-relative, and was often restrained due to anger outbursts. Joseph was diagnosed with ASPD. A therapist confronted him with the fact that his behavior could lead to a prolonged hospital stay and pointed to his choice of future inside or outside the hospital. This was a turning point that made him focus on goals and training for a future with a life outside of an institution. After discharge, he continued to work on self-esteem and trustworthiness; shame and guilt; and how to understand, control, and come to terms with his anger. Two years later, he was married with a son and pursuing a career as a teacher.
Treatment
No current diagnostic modalities, including serology tests, are currently accepted standards in diagnosing ASPD. However, genetic testing and neuroimaging have been used to evaluate potential causes and patterns with ASPD. Patients with ASPD are at a higher risk of contracting certain viral infections and sexually transmitted diseases associated with high-risk behavior, including hepatitis C and human immunodeficiency virus, as well as increased mortality rates due to accidents, traumatic injuries, suicides, and homicides.
Literature suggests early treatment intervention with conduct disorder in children as the least costly and most effective in treating ASPD. Most of the needs of ASPD are addressable in the outpatient setting. No pharmacological intervention has been shown to treat ASPD, but medications are highly recommended to treat co-occurring conditions.
Key Takeaways: Antisocial Personality Disorder
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Glossary
antisocial personality disorder (ASPD): characterized by a lack of regard for others’ rights, impulsivity, deceitfulness, irresponsibility, and lack of remorse over misdeeds
- Zoccolillo M, Pickles A, Quinton D, Rutter M (November 1992). "The outcome of childhood conduct disorder: implications for defining adult personality disorder and conduct disorder". Psychological Medicine. Cambridge, England: Cambridge University Press. 22 (4): 971–86. doi:10.1017/s003329170003854x. PMID 1488492 ↵
