2009
University of Louisville
Psychopathology
Drusilla Kemp
Tenesha L Curtis
SUBSTANCE ABUSE
COMORBIDITY: ANTISOCIAL
PERSONALITY DISORDER
This paper explores the development, effects, and treatment of substance abuse, antisocial
personality disorder, and substance abuse comorbid with antisocial personality disorder. Concerning
etiology, neither genetics nor environmental factors can be held solely accountable for the
development of these disorders. The author posits that genetics makes available a predisposition
towards these disorders which must be activated by certain environmental factors.
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ANTISOCIAL PERSONALITY DISORDER
Antisocial personality disorder (also termed psychopathic
or sociopathic personality) is a condition in which a person
regularly engages in activities that are considered non- or
anti-social by the society in which they live. In the United
States, anti-social behavior includes manipulation and
exploitation of others. Antisocial personality disorder is
diagnosed when such behavior is long-term and interferes with a
client’s personal relationships and everyday functioning
(Mathias 1996).
ETIOLOGY
Though not the single originator, poverty is thought to be
a distinctive factor in the development of antisocial
personality disorder (Maxmen, Ward, and Kilgus, 2009). Poverty
may serve as a risk increaser for the development of antisocial
personality disorder, but not all people who come from a lowincome background have antisocial personality disorder. People
from higher socioeconomic classes, and children who are ‘too’
young for a sociological factor (such as income) to have much
effect on them, also show signs of antisocial personality
disorder, or it’s antecedent conduct disorder (Maxmen et al.,
2009).
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Some people who have antisocial personality disorder do
have unstable childhoods; but some have very stable, structured,
and consistent lives while growing up (Maxmen et al., 2009).
These variances lend way to the belief that antisocial
personality disorder is a genetic trait passed down from a
parent (Maxmen et al., 2009).
EPIDEMIOLOGY
Antisocial personality disorder is more common in people of
lower socioeconomic status and people who live in cities. About
6% of people in the United States have antisocial personality
disorder, and about 20% of people receiving treatment for a
psychiatric disorder do so because of antisocial personality
disorder (Maxmen et al., 2009).
TREATMENT
There is currently no “go to” treatment for managing
antisocial personality disorder. The very criteria that qualify
a person as having antisocial personality disorder keep them
from seeking treatment and being treated effectively. Mainly, a
fear of feeling or seeming inferior, and total disregard for
authority figures and their own future well-being (Maxmen et
al., 2009). This would explain phenomena such as that found in a
study by O’Reilly, Freeland, and Cernovsky (1993). Clients with
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antisocial personality disorder were overwhelmingly
“unsatisfied” with the treatment program they were part of, when
compared to clientele without antisocial personality disorder.
Maxmen, Ward, and Kilgus (2009) recommend a “tough love”
approach. By making it understood to the client that the
therapist will not be “conned, threatened, seduced, or used” for
the client’s own motives, but also that the therapist is focused
on helping the client as much as possible. Even then, this type
of therapeutic activity only decreases some of the issues the
client is having due to their behavior, and does not necessarily
change their frame of mind, or the inner emotions that may drive
the things that they do.
Maxmen et al. (2009) suggest that prevention is probably
the most helpful to someone who may be showing signs of
antisocial personality disorder. Guiding the child or adolescent
towards more constructive means of fulfilling their desires
(such as being a leader or gaining respect) can keep them on a
path of habits that will lead them to living a stable life and
help halt the development of severe antisocial personality
disorder.
SUBSTANCE ABUSE
Someone who uses illegal substances or misuses
prescriptions they get from their doctor, or that they buy over
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the counter, are considered substance abusers (Vorvick, 2009).
The vast majority of substances abused are chemical, and alter
the mental state or mood of the user. An exception to these
criterion would be performance enhancers, such as anabolic
steroids, most often procured and used illegally in order to
boost physical performance amongst athletes.
ETIOLOGY
The abuse of mind- or mood-altering substances most often
originates from the attempt of the client to medicate their own
mental illness (Maxmen et al., 2009). The client may not overtly
understand that they need aid for a particular mental condition,
they simply know that taking their drug of choice makes them
feel ‘better’ temporarily. Eventually, this temporary boost in
mood becomes an obsession of the client’s. In most cases, the
client eventually spends all, or at least the vast majority, of
their time (1) engaging in activities that will allow them
(better) access to their drug of choice; (2) using their drug of
choice; and (3) dealing with the after effects of their drug
abuse. In the example of a heroin addict, a client might get
involved in black market sales in order to obtain large enough
amounts of money to sustain their habit; spend any free time
that they have purchasing or using heroin; and the times that
they are not “working” or using, they spend dealing with family
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members that resent them, keeping up appearances for whoever is
left in their non-familial social circle, and participating in
various activities in order to prove to themselves that they do
not have a problem (i.e. going to the park and scaring the young
people by attempting to “play basketball just like I use to”,
but falling all over themselves and not being able to make a
basket).
EPIDEMIOLOGY
Substance abuse directly affects about 20% of the United
States population (Maxmen et al., 2009). Males who live in an
urban area and have not graduate from college are the most
likely candidates for becoming dependent upon a substance,
especially alcohol. Women who live in rural settings and have a
college degree are least likely to have a substance disorder of
any kind. Substance abusers are more likely to have mood and
anxiety disorders than the general population of the United
States (Maxmen et al., 2009).
TREATMENT
The only real treatment for substance abuse is for the
abuser to remain abstinent. This means not using any mood- or
mind-altering substances, not just their original drug of
choice. Unfortunately, simply not using is not enough. The lack
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of proper coping mechanisms, medication for underlying problems,
and positive world view is what led the client to using, and
then abusing, substances in the first place. This means that,
without the proper sustained support, the client will eventually
return to using, or ‘relapse’. There are two major programs that
help to guide substance users after they have conquered the
physical aspect of their problem.
In order for an alcoholic or addict live a stable and
productive life, most agencies will recommend an Alcoholics
Anonymous (AA) or Narcotics Anonymous (NA) program. These
programs use a ‘disease’ model for substance abuse. That is, the
act of abusing drugs is seen as something that the afflicted
person has no control over once they begin to use, therefore
complete abstinence from mind- and mood-altering substances is
the only way to live a healthy life. There are other sub-groups
for specific substances, such as CA for Cocaine Anonymous. In
these groups, someone with a substance abuse problem will find
three things that can help them recover: a plan, a support
group, and an outlet for feelings directly related to substance
abuse. The plan comes from the twelve steps used in these
programs to help a substance abuser come to terms with their
‘disease’, apologize and make amends to those they have harmed
while under the influence of their drug of choice, and help
other people with substances abuse issues become sober and
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healthy. The support group comes in the form of meetings held
with at least two substance abusers. In these meetings, members
speak about what they are going through as a substance abuser.
In this way, members share methods and suggestions of how to
cope with “life on life’s terms” (Alcoholics Anonymous, 2001)
instead of resorting to the usual manipulative tactics (lying,
cheating, stealing, etc.) that so many of the chemically
dependent are used to employing just to survive their own
existence. At the meetings is also where the recovering
substance abuser gets a chance to express what they feel with
people with the same ailment. It can be difficult for substance
abusers to explain to non-users (such as their family members,
co-workers, or friends) emotions or thought patterns that may
not make sense to them.
An alternative treatment program for substance abusers is
the SMART (Self-management and Recovery Training) Recovery
Program. Though the basic mechanics of the program are very
similar to AA and NA, it completely removes the idea of a
‘Higher Power’ from the path of recovery. The Higher Power is a
central motif of AA and NA. The SMART program is based on
Cognitive Behavioral Theory. SMART focuses on rational thought,
thinking before acting, and reflecting after acting (SMART
Recovery, 2009).
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SUBSTANCE ABUSE AND ANTISOCIAL PERSONALITY DISORDER: COMORBIDITY
For substance abusers, antisocial personality disorder is
one of the five most common comorbid disorders, along with
conditions such as anxiety disorder and dysthymia (Maxmen et
al., 2009). Chronological substance abuse appears after or
alongside antisocial personality disorder, but not before.
There is no evidence to suggest that substance abuse occurs
before the onset of antisocial personality disorder in people
who are dually diagnosed with both. Substance abuse may foster
incidences of antisocial behavior such as breaking the law or
lying. In people who actually qualify for an antisocial behavior
diagnosis, the stealing, law-breaking, and manipulative behavior
would have been persistently present years before they ever
first started abusing a substance.
It is possible for antisocial behavior disorder and
substance abuse to seem to begin at about the same time. Talking
to a client’s family may reveal that certain tell-tale behaviors
had actually begun earlier than the substance abuse. But in
cases of very young people (around the age of eight) abusing
drugs, the onset of the antisocial behavior and the substance
abuse may have begun very near each other in the client’s life.
The argument that substance abuse can only develop after
antisocial personality disorder is present is the most logical
of views about this comorbidity coupling. Drug use, especially
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illegal, would be a manifestation of the client’s disregard for
the social norms of drug usage, such as drinking to excess.
Disregard for authority is shown by breaking the law through
using illegal substances. Substance abuse as a manifestation of
antisocial personality disorder lends itself well to AA and NA
ideology of their being a present disease before a person starts
using. Therefore, if the antisocial personality disorder can be
redirected early on, substance abuse never has to develop.
Some more radical thinkers may even argue that there is no
such thing as a disease or condition called ‘addiction’. There
are only the symptoms of the underlying issue: antisocial
personality disorder (or anxiety, or dysthymia, or any other
disorder comorbid with substance abuse).
EPIDEMIOLOGY
About 25% of opiate abusers (Mathias, 1996) and 21% of
alcohol abusers (National Institute on Alcohol and Alcoholism,
2007) have antisocial anxiety disorder. If these numbers imply
that somewhere near 40% of all people engaged in substance abuse
treatment have antisocial personality disorder, which cannot be
cured, only possibly subdued, that is a large number of people
who will not be able to successfully complete treatment because
of the level of structure and subordination of self that comes
along with most treatment programs and facilities.
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FAMILY INTERACTION
Within the family, substance abuse has always been a
destructive force within the unit. People with a family history
of substance abuse are more likely to develop antisocial
personality disorder and / or chemical dependency themselves
(Westermeyer, Bennett, Thuras, and Yoon, 2007). The major
similarities between the disorders of substance and antisocial
personality often lead to the misdiagnosis of patients as having
one when they have both, or one when they have the other
(Robins, 1998).
According to Moss, Lynch, Hardie, and Baron (2002),
children with a father who is substance dependent along with
having antisocial personality disorder fair no better or worse
than children of fathers with only a substance disorder, or only
antisocial personality disorder. Both exhibit the same problems
that their father’s exhibit pertaining to rule breaking and
general disregard for the feelings and rights of others; and
both reached out to other peers who had some sort of
psychopathology or psychopathological history.
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THEORIES OF ETIOLOGY
GENETICS
About 17% of works having to do with psychiatric disorders
cite genetics in some fashion (Joober, 2009). What works in
favor for the general argument that substance abuse comorbid
with antisocial personality disorder might be an issue of
genetics (Utah Addiction Center, 2009; Lee, 2008), is the fact
that there is a pattern of the disorders developing in offspring
and close relatives (Maxmen et al., 2009). However, every child
that is born without a substance disorder and / or antisocial
personality disorder quakes the foundation on which this theory
stands. If these disorders were truly only genetic, children
adopted by parents with substance abuse and antisocial
personality disorders would never develop either condition. At
the same time, children born of people with substance disorders
and / or antisocial personality disorder would never have a
child that was not born with the same problems. Also, the fact
that there are non-surgical treatment options available to
substance abusers and people with antisocial personality
disorder means that some level of the development of the
conditions must be environmental.
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ENVIRONMENT
The argument for a person’s social environment being the
source of their development of substance abuse (Denisco, 2009)
and / or antisocial personality disorder covers a much broader
array of situations the may lead to disorder development. The
notion of environment being a causal factor helps to explain the
phenomena of children who abuse drugs or develop antisocial
personality disorder while growing up in the same home as other
people who also have these disorders. Social environment also
explains why people can get help by changing the people around
them. By moving from a downtrodden area of their town into a
recovery community, it is no longer ‘normal’ nor ‘acceptable’
for them to abuse substances or act in antisocial manners. But
environmental factors alone would not explain why families
riddled with multiple members having antisocial personality
disorder and substance disorders can produce children that go on
to lead productive, healthy, sober lives. Or, on the other end
of the spectrum, why adoptees raised in non-substance disorder
homes become dependent upon, and abuse, drugs (Westermeyer et
al., 2007).
BIOPSYCHOSOCIAL
In answering the question of etiology of substance
disorders, antisocial personality disorder, and substance
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disorders comorbid with antisocial personality disorder, viewing
biology, psychology, and sociology as intermingling factors is
the most efficient explanation. In essence, a person can be
genetically predisposed to become dependent upon a substance or
develop antisocial personality disorder, but until certain
aspects of their psychological development and social
environment sync up to aid in the development of these
conditions, nothing will happen. For example, a child of an
alcoholic may be genetically positioned to become an alcoholic.
This means that if the child takes a drink, they will follow the
same path their parent did to becoming addicted to alcohol. But
if there is no alcohol available to the child (for instance, if
the parent is in recovery) in the home, nor at school or other
recreation activities, then the child will never have access to
the substance that will trigger eventual addiction. Also, even
if the child does have access to alcohol in some form, if the
child does not believe that drinking is something they ought, or
want, to do, they will not take the first drink, and therefore
cannot possibly become addicted to something they have never
even ingested.
Concerning antisocial personality disorder, a child can be
helped early on (Maxmen et al., 2009), meaning that even if the
genetic component is triggered early, through psychological and
social redirection of behavior, the child would be pulled away
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from their conduct disorder behavior, and it could never blossom
into antisocial personality disorder.
NEEDED RESEARCH
Much of the research for this paper was either very
relevant, but dated; or slightly relevant, and recent. More
current research on people with this comorbidity needs to be
done. The benefits for such research are two-fold.
Pinpointing the exact biological, social, and psychological
factors that come together in order for someone to develop
substance or antisocial personality disorder means that
clinicians would be able to better prevent these problems from
developing. For both substance abuse and antisocial personality
disorder, the longer it takes to get treatment, the harder the
problem is to help with.
Being able to prevent these conditions from arising means
that fewer people will develop them, and fewer people will pass
the conditions on to family members or others living in their
household (through environmental means).
In order for the preventive treatment to be most effective,
treatment should begin with at-risk children through schools.
There may not be any harm done in providing any newly devised
treatment methods to all children. For children who are not
currently at risk, the programs would reinforce their already
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positive or neutral behaviors. For those that are at risk, the
program would help them without ostracizing them by having
‘special classes’ or ‘sessions’ that only they must attend.
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References
Alcoholics Anonymous.
Alcoholics Anonymous. (2001), New York: Alcoholics Anonymous World
Services, Inc.
Aleman, Kristian.
(2007). OBJECT RELATION QUALITY, ALEXITHYMIA, AND DEFENSE
MECHANISMS OF DRUG ABUSERS WITH ANTISOCIAL PERSONALITY
DISORDER. Social Behavior and Personality. 35 (10), 1335-1352.
Denisco, R.A.; Chandler, R.K.;
Compton, W.M.
(2009). Prescription drug abuse linked to increased availability of pain meds.
Brown University Psychopharmacology Update. 20(2), 1-7.
Joober, Ridha; Boksa, Patricia.
(2009). A new wave in the genetics of psychiatric disorder: the copy number
variant tsunami. Journal of Psychiatry and Neuroscience. 34(1). 55-59
Kreek, Mary Jeanne; Nielsen,
David A.; Butelman, Eduardo
R.; LaForge, K. Steven.
(2005). Genetic influences on impulsivity, risk taking, stress responsivity and
vulnerability to drug abuse and addiction. Nature Neuroscience. 8(11), 14501457
Lee, Shannon.
(2008). Developing and Overcoming Antisocial Personality Disorder. Retrieved
June 17, 2009 from http://serendip.brynmawr.edu/exchange/node/1760
Lewis, Collins E.; Bucholz,
Kathleen K.
(1991). Alcoholism, antisocial behavior and family history. British Journal of
Addiction. 86, 177-194.
Mathias, Robert.
(1996). Specialized Approach Shows Promise for Treating Antisocial Drug
Abuse Patients. Retrieved June 17, 2009, from
http://www.nida.nih.gov/NIDA_Notes/NNVol11N4/Antisocial.html
Maxmen, J.; Ward, N.; Kilgus,
Mark.
Essential Psychopathology and Its Treatment, 3rd Edition (2009), New York:
W.W. Norton and Company.
Moss, Howard B.; Lynch, Kevin
G.; Hardie, Thomas L.; Baron,
David A.
(2002). Family Functioning and Peer Affiliation in Children of Fathers With
Antisocial Personality Disorder and Substance Dependence: Associations With
Problem Behaviors. American Journal of Psychiatry. 159(4), 607-614
National Institute on Alcohol
Abuse and Alcoholism.
(2007). Researchers Identify Alcoholism Subtypes. Retrieved June 17, 2009,
from
http://www.niaaa.nih.gov/NewsEvents/NewsReleases/alcoholism_subtypes.htm
O’Reilly, R.; Smith, D.W.;
Freeland A.; Cernovsky, Z.Z.
(1993). Antisocial Attitudes and Consumer Satisfaction with Substance Abuse
Treatment Program. Social Behavior and Personality. 21(2), 159-162.
Robins, L.N.
(1998). The intimate connection between antisocial personality disorder and
substance abuse. Social Psychiatry and Psychiatric Epidemiology. 33, 393399.
SMART Recovery
(2009). http://smartrecovery.org/ Accessed July 17, 2009.
16
Stairs, Dustin J.; Bardo,
Michael T.
(2009). Neurobehavioral effect of environmental enrichment and drug abuse
vunerability. Biochemistry and Behavior. 92(3), 377-382.
Utah Addiction Center
(2009). Incidence and Prevalence of Substance Abuse. Retrieved June 17,
2009 from http://medicine.utah.edu/uac/training/module1.htm
Vorvick, Linda.
(May 27 2009). Antisocial Personality Disorder. Retrieved June 16, 2009, from
http://www.nlm.nih.gov/medlineplus/ency/article/000921.htm
Westermeyer, Joe; Bennett,
Linda; Thuras, Paul; Yoon,
Gihyun.
(2007). Substance Use Disorder Among Adoptees: A Clinical Comparative
Study. The American Journal of Drug and Alcohol Abuse. 33, 455-466.
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