Antisocial personality disorder (APD)

1. Antisocial personality disorder (APD) J.J. Deogracias University of Toronto at Mississauga

2. DSM-IV Criteria for APD • Part of the Cluster B (i.e., dramatic/erratic cluster) of personality disorders • There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following • failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest • deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure • impulsivity or failure to plan ahead

3. DSM-IV Criteria for APD (cont’d) • irritability and aggressiveness, as indicated by repeated physical fights or assaults • reckless disregard for safety of self or others • consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations • lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

4. DSM-IV Criteria for APD (cont’d) • The individual is at least 18 years old (under 18, see Conduct Disorder ) • There is evidence of Conduct Disorder with onset before age 15 years. • The occurrence of antisocial behaviour is not exclusively during the course of Schizophrenia  or a Manic Episode  (APA, 1994)

5. Psychopathy • “a clinical construct characterized by a cluster of interpersonal, affective, and lifestyle features, including egocentricity, grandiosity, deceptiveness, shallow emotions, lack of empathy, guilt, or remorse, impulsivity, irresponsibility, and the ready violation of social and legal norms and expectations” (Hare, 1996, p.25)

6. Psychopathy Checklist – Revised (PCL-R) • Glibness / Superficial Charm • Grandiose Sense of Self Worth • Need for Stimulation/Prone to Boredom • Pathological Lying • Conning/Manipulative • Lack of Remorse or Guilt • Shallow Affect • Callous/Lack of Emotion • Parasitic Lifestyle • Poor Behavioural Controls

7. PCL-R (cont’d) • Promiscuous Sexual Behaviour • Early Behavioural Problems • Lack of Realistic, Long-term goals • Impulsivity • Irresponsibility • Failure to Accept Responsibility for Actions • Many Short-term Marital Relationships • Juvenile Delinquency • Revocation of Conditional Release • Criminal Versatility

8. Psychopathy in DSM-IV definition • Addition note for prison or forensic settings: • Features common in psychopathy (i.e., lack of empathy, inflated self-appraisal and superficial charm) may distinguish individuals with APD in prison or forensic settings (p. 647).

9. Difference between APD & Psychopathy • DSM-IV only identifies people with antisocial behaviour, who are not necessarily psychopath • 20% of people with APD scored high on PCL-R • DSM-IV stated that features common in psychopathy (i.e., lack of empathy, inflated self-appraisal and superficial charm) may distinguish individuals with APD in prison or forensic settings (p. 647). • Person diagnosed with APD outside forensic settings may not be diagnosed with APD within forensic settings unless they exhibits traits of psychopathy • For this presentation, terms will be interchangeable

10. Epidemiology • Prevalence • General population: ~1.0% - 3.5% • Drug / alcohol abusers: 18 - 53% • Prison inmates: 20% • Gender: 3% in men, 1% in women (US) • Other interesting statistics • responsible for more than 50% of serious crimes • 44% of offenders who killed a law enforcement officer had APD

11. COMORBIDITY

12. Alcohol and Drug Abuse • 80% of individuals with APD abuse drugs • Review by Mulder (2002) • Cross-sectional: alcoholics have high scores on measures of impulsivity and novelty seeking, as well as high rates of APD • Longitudinal studies: Antisocial behaviour related to later alcoholism, including antisocial activity, aggressive and sadistic behaviour, and rebellion and hostility • Genetic epidemiology: In women, the strongest association with alcohol dependence was childhood conduct disorder; in men, this association was weaker

13. Major Depression (MD) • History of APD predicted fourfold increase in probability of reporting a history of MD • 38% of total genetic variance in risk of MD was associated with APD • APD -- major determinant of genetic risk between MD and alcohol dependence, and between MD and marijuana dependence (Fu et al., 2002) • in the absence of anxiety disorders, major depression is no longer significantly associated with APD (Goodwin & Hamilton, 2003)

14. Anxiety Disorders • 54.3% of adults with APD met criteria for an anxiety disorder during their lifetime • any anxiety disorder (especially social phobia and PTSD) increases likelihood of APD • Anxiety disorder important in the link between major depression and APD • In the absence of anxiety disorders, major depression is no longer significantly associated with APD (Goodwin & Hamilton, 2003)

15. Attention Deficit Hyperactivity Disorder (ADHD) • 21% of hyperactive probands qualified for ASPD, a fivefold increase in risk over control group • risk for APD among ADHD children is substantially influenced by severity of childhood conduct problems, and by severity of teen conduct disorder (CD) (Fischer et al., 2000)

16. Conduct Disorder (CD) • boys with ADHD+CD showed a decrease in autonomic responses (e.g., skin conductance response) compared with ADHD matched children and controls • this group showed a pattern similar to that reported from studies with psychopathic antisocial personalities (Herpertz et al., 2001)

17. NEUROTRANSMITTERS

18. Serotonin (5-HT) • mediating impulsive and aggressive behaviours • Association between low 5-HT function and aggressive behaviour • inverse relationship between 5-HT metabolite 5-hydroxy indoleacetic (5-HIAA) and impulsivity, irritability, hostility and aggression • tryptophan depletion • men with higher basal levels of hostility or antisocial traits experience increased hostility • patients diagnosed with APD, alcohol dependence, or drug dependence • chronic ethanol administration decreases 5-HT levels, leading to behavioural disinhibition, including impulsive aggression • antisocial alcoholics with lower basal CSF 5-HIAA levels than controls

19. 5-HT (cont’d) • Possible genetic connection: genes encoding 5-HT receptors (especially HTR1B) are likely candidates for both substance dependence and APD • Inconsistent results

20. Dopamine (DA) • Significant associations with D2 & D4 receptor gene polymorphism and sensation seeking • D2 & D4 combined contribute more to this behaviour than separately • May also be related due to comorbid drug abuse: Abused drugs (e.g., cocaine) release DA in nucleus accumbens (NA) and ventral tegmental area (VTA) for reinforcement • 5-HT plays role by modulating DA activity and its effect on neurons of the VTA • No empirical data to support this to my knowledge

21. NEUROANATOMY

22. Review by Martens (2001) • Neurological dysfunctions, such as brain injuries and cerebrovascular disorders • Frontal lobe lesions • Reduction in prefrontal grey matter volume • EEG abnormalities • Reduced cortical arousal • Frontal-limbic neural circuit (not mentioned in review)

23. Frontal Lobe Lesions • Orbitofrontal and/or ventromedial frontal cortex • implicated in cognitive, linguistic behavioural, and affective processes of psychopaths • Implicated in aggression and violence • “acquired sociopathic” syndrome following ventromedial frontal lobe lesions; may contribute to poor impulse control in APD • activation in posterior orbitofrontal cortex during response inhibition (Horn et al., 2003)

24. Prefrontal Cortex • MRI: people with APD showed significant reduction in volume of prefrontal gray matter • However, may not be the whole story • 13-year-old boy with history of conduct disorder, and co-morbid ADHD sustained a self-inflicted gunshot wound to medial PFC • conduct disorder did not change much after injury • No distinct neuropsychological impairment on tests thought to be sensitive to frontal function after injury

25. Prefrontal-limbic circuit • including the amygdala, anterior cingulate, and orbitofrontal cortex • anticipating aversive stimuli, and mediating anticipatory planning & emotion regulation • Lesions of this circuit result in so-called ‘acquired sociopathy’ • Psychopaths show hypoactive frontolimbic circuitry during aversive conditioning (Veit et al., 2002)

26. Reduced Cortical Arousal • leading to excessive need for stimulation (i.e., sensation seeking) • low heart rate associated with aggressive forms of antisocial behaviour • low heart rate and low skin conductance with fearlessness and stimulation & sensation seeking in antisocial behaviour or APD • persons with APD who had prefrontal gray matter volume reductions had lower skin conductance activity during stressor than those without reduced prefrontal gray volume (Raine et al., 2000) • psychopaths failed to show anticipatory skin conductance response in aversive stimuli (Veit et al., 2002)

27. PHARMACOTHERAPY

28. Treatment Problems • Few treatments, or little research on treatments for individuals with APD • rarely treated in hospitals because of their troublesome behaviours • patient trying to manipulate the mental health professional or physician (e.g., get doctor to prescribe medication they abused in past) • APD was found to be negative predictor for success of psychotherapy in opiate addicts • May attempt to manipulate Will reject medications that do not produce euphoria, especially if have unpleasant adverse effects

29. Risperidone • Antipsychotic -- combined dopamine D2 and serotonin 5-HT2 receptor antagonism • Placebo-controlled trials of risperidone reported significant decreased in aggression in adults with dementia in adults with autism, and in children with CD • Also reported effectiveness against impulsivity in borderline personality disorder • However, no official study on treating APD

30. Risperidone (cont’d) • Case study for APD: • 32-year old male fulfilling DSM-IV diagnosis for APD • major problems: severe aggression and impulsive violence • started on risperidone (6 mg/day) • abatement of aggression and impulsivity rapid following risperidone 4 days later • Side effects: antipsychotic-induced akathisia (restless and fidgety) • lower dosage of risperidone, and adding other anti-akathisia agents (biperidon, propranolol and diazepam) to control it

31. Quetiapine • Atypical antipsychotic agent to treat impulsivity, irritability and aggression • From four case studies (30-60 day treatment), • effective dosage: 600 to 800 mg once daily • patients attribute treatment compliance to its effectiveness and its favourable adverse-effect profile • successfully used in combination with mood stabilizers, particularly gabapentin, in patients with affective instability • because of treatment cost, it has been discontinued leading to reoccurrence of aggression and other dangerous manifestations

32. Conclusion • Contradictions behind the neurobiology of APD • Methodological improvements (i.e., larger sample sizes in MRI/fMRI studies) • More studies needed • Lack of research in pharmacological treatments • Only efficacious “studies” lacked larger sample size, control groups, etc. • More studies needed