Antisocial Personality
Disorder
Karin Neufeld, MD MPH
Addiction Treatment Services
Department of Psychiatry
Johns Hopkins University School of Medicine
Who was
Gary
Gilmore?
http://indice.elpais.es/2004/11/13/
Copyright Alcohol Medical
Scholars Program
2
History of Identification
 1835 Moral insanity
 1900 Psychopathic character
 1930 Sociopathic personality
 1980 Antisocial personality disorder
(ASPD)
Copyright Alcohol Medical
Scholars Program
3
Validity and Reliability
 Empirical data
 Childhood precursor
– Conduct disorder (CD)
 Good reliability
Copyright Alcohol Medical
Scholars Program
4
Societal Impacts of ASPD
 h Risk of death
– h 6x teens/young adults
 h Psychiatric comorbidity
–80% substance use disorder (SUD)
 High legal cost
–40% of prisoners
–$41 billion/yr for US prison system
Copyright Alcohol Medical
Scholars Program
5
Objectives
Review diagnosis
Describe epidemiology
Review risk factors
Describe the course
Review treatment
Copyright Alcohol Medical
Scholars Program
6
Key Points
 Very common in SUD patients
 Genes and environment involved
 Associated with great suffering
 Treatment is helpful
Copyright Alcohol Medical
Scholars Program
7
Objectives
Review diagnosis
Describe epidemiology
Review risk factors
Describe the course
Review treatment
Copyright Alcohol Medical
Scholars Program
8
DSM-IV Diagnosis 1
 Persistent violation of others’ rights with
3+ of:
-
Disobey the law
Lying or conning
Impulsivity
Irritability, aggressiveness, physical fights
Disregard for safety
No sustained work history
Lack of remorse
Copyright Alcohol Medical
Scholars Program
9
DSM-IV Diagnosis 2
 >18 y/o
 Early CD < 15yrs
– Aggression to people or animals
– Destruction of property
– Deceitfulness or theft
– Serious violation of rules
 R/O other major mental illness
Copyright Alcohol Medical
Scholars Program
10
Objectives
Review diagnosis
Describe epidemiology
Review risk factors
Describe the course
Review treatment
Copyright Alcohol Medical
Scholars Program
11
ASPD Prevalence
 General population ~ 3%
– M ~ 6%; F ~ 1%
 General medical clinics ~ 8%
 Mental health settings ~ 10%
 SUD treatment ~ at least 25%
 Prisoners ~ 40%
– M ~ 50%; F ~ 20%
Copyright Alcohol Medical
Scholars Program
12
Associated Demographics
 M:F = 6:1
 Young (25 – 44) > Older (45 +)
 Race: no difference
 School drop-out: 5x by 11 yrs
 Abuse/neglect in childhood
– 50% h risk of adult criminal behavior
Copyright Alcohol Medical
Scholars Program
13
Objectives
Review diagnosis
Describe epidemiology
Review risk factors
Describe the course
Review treatment
Copyright Alcohol Medical
Scholars Program
14
Genetics
 Family studies: h ASPD
 Twin studies: ~ 70% heritability
– Vulnerability gCD, ASPD, SUD
 Adoption studies: (Cadoret)
– h CD, ASPD, SUD
Copyright Alcohol Medical
Scholars Program
15
Genetic and Environmental
Impact
4x
ASPD
Biological
Parent
9x
Childhood
Aggression
7x
ASPD
SUD
Adverse Adoptive
Home
8x
Copyright Alcohol Medical
Scholars Program
(Cadoret 1995, 1997)
16
EEG Studies




Event related
potential ERP
i Amplitude
(P300)
Not specific
Attentional
problems
Standard
Target
300 msec
300 msec
Copyright Alcohol Medical
Scholars Program
17
Neuroimaging
 MRI: i
Prefrontal
volume
 PET & SPECT:
i Prefrontal
function
 Poor executive
function
www.brainexplorer.org
Copyright Alcohol Medical
Scholars Program
18
ASPD Biologic Markers
 Increased aggression:
– i synaptic serotonin (5HT)
 Serotonin transporter protein (STP)
– h STP activity ~ h aggression Cadoret ’03
– Opposite findings exist
 Monoamine oxidase (MAO)
– Neuronal 5HT metabolism
Copyright Alcohol Medical
Scholars Program
19
MAO
Transporter
Intrasynaptic Serotonin
www.drugabuse.gov
Copyright Alcohol Medical
Scholars Program
20
MAOA Genotype and
Environmental Interaction
ASPD Behaviors
Low MAOA
Caspi et al, 2002 Science, 297, p851-4.
None
Probable
Severe
Childhood Maltreatment
Copyright Alcohol Medical
Scholars Program
21
MAOA Genotype and
Environmental Interaction
ASPD Behaviors
Low MAOA
High MAOA
Caspi et al, 2002 Science, 297, p851-4.
None
Probable
Severe
Childhood Maltreatment
Copyright Alcohol Medical
Scholars Program
22
Objectives
Review diagnosis
Describe epidemiology
Review risk factors
Describe the course
Review treatment
Copyright Alcohol Medical
Scholars Program
23
Childhood
 Irritable/impulsive temperament 3 y/o
– ASPD 3 X’s more likely
 Conduct disorder (CD)
– 25% develop ASPD
– h educational difficulties
– Earlier the CD: h ASPD
Copyright Alcohol Medical
Scholars Program
24
Adulthood
 Data limited (Black et al 1995)
 29 yr follow-up of hospitalized ASPD
 24% of sample died
 Of remainder alive:
–27% remission
–31% improved
–42% no change
Copyright Alcohol Medical
Scholars Program
25
Psychiatric Comorbidity
 Lifetime prevalence in ASPD:
– 70% alcohol use disorder
– 50 % drug use disorder
 80% of ASPD in tx: multiple SUD
 h Severity of SUD
 4x SUD treatment episodes
Copyright Alcohol Medical
Scholars Program
26
Morbidity and Mortality
 Morbidity
– h HIV and high risk behaviors
– h Medical problems
– h Injuries
 Mortality
– h Risk of violent death (6x in youth)
– h Risk of suicide
Copyright Alcohol Medical
Scholars Program
27
Objectives
Review diagnosis
Describe epidemiology
Review risk factors
Describe the course
Review treatment
Copyright Alcohol Medical
Scholars Program
28
Treatment of ASPD
 Effectiveness?
 Clinical fatalism
 Patients rarely ask for ASPD tx
–Poor insight
–Lifelong disturbance
 Often come for tx of SUD
Copyright Alcohol Medical
Scholars Program
29
Treatment Elements
 Thorough history and exam
 Therapeutic relationship
–Firm behavioral limits
–Professional boundaries
–Maintain your empathy
–Negotiate behavioral goals in advance
Copyright Alcohol Medical
Scholars Program
30
Treatment Expectations
 Not curative
 Focus on improved function
 Decrease problem behaviors
– i Impulsive actions
– Anticipate novelty seeking
– h Empathy in patient
Copyright Alcohol Medical
Scholars Program
31
Treatment Outcomes
 SUD literature = best impact data
 ASPD and opioid dependence
–Same retention in methadone tx
– i Drug use
– i High risk behaviors
 Psychotherapy response mixed
 Good response to behavioral tx
Copyright Alcohol Medical
Scholars Program
32
Pharmacotherapy
 Poor to no data
 Mood stabilizers ~ i impulsive
aggression
 SSRI’s ~ maybe i aggression
 Antipsychotics not effective
 Avoid habit forming drugs
– i.e. benzodiazepines
Copyright Alcohol Medical
Scholars Program
33
Summary
 Very common in SUD patients
 Genes and environment involved
 Associated with great suffering
 Treatment is helpful
Copyright Alcohol Medical
Scholars Program
34