Antisocial Personality Disorder Karin Neufeld, MD MPH Addiction Treatment Services Department of Psychiatry Johns Hopkins University School of Medicine

Antisocial Personality Antisocial Personality DisorderDisorder

Karin Neufeld, MD MPHKarin Neufeld, MD MPHAddiction Treatment Services Addiction Treatment Services

Department of Psychiatry Department of Psychiatry

Johns Hopkins University School of MedicineJohns Hopkins University School of Medicine

Copyright Alcohol Medical Scholars Copyright Alcohol Medical Scholars ProgramProgram

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http://indice.elpais.es/2004/11/13/http://indice.elpais.es/2004/11/13/

Who was Who was Gary Gary Gilmore?Gilmore?

http://www.elpais.es/buscadores/articulo/20041113elpbabnar_2/Tes/elpbabnar/


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History of IdentificationHistory of Identification

1835 Moral insanity1835 Moral insanity 1900 Psychopathic character1900 Psychopathic character 1930 Sociopathic personality1930 Sociopathic personality 1980 Antisocial personality disorder 1980 Antisocial personality disorder

(ASPD)(ASPD)


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Validity and ReliabilityValidity and Reliability

Empirical dataEmpirical data Childhood precursorChildhood precursor

– Conduct disorder (CD)Conduct disorder (CD)

Good reliabilityGood reliability


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Societal Impacts of ASPDSocietal Impacts of ASPD Risk of deathRisk of death

– 6x teens/young adults6x teens/young adults Psychiatric comorbidity Psychiatric comorbidity

–80% substance use disorder (SUD)80% substance use disorder (SUD) High legal costHigh legal cost

–40% of prisoners40% of prisoners

–$41 billion/yr for US prison system$41 billion/yr for US prison system


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ObjectivesObjectives

Review diagnosisReview diagnosisDescribe epidemiologyDescribe epidemiologyReview risk factorsReview risk factorsDescribe the courseDescribe the courseReview treatment Review treatment


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Key PointsKey Points

Very common in SUD patientsVery common in SUD patients Genes and environment involvedGenes and environment involved Associated with great sufferingAssociated with great suffering Treatment is helpfulTreatment is helpful


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Review diagnosisReview diagnosis

Describe epidemiologyDescribe epidemiology

Review risk factorsReview risk factors

Describe the courseDescribe the course

Review treatment Review treatment


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DSM-IV Diagnosis 1DSM-IV Diagnosis 1 Persistent violation of others’ rights Persistent violation of others’ rights

with 3+ of: with 3+ of: - Disobey the lawDisobey the law- Lying or conningLying or conning- ImpulsivityImpulsivity- Irritability, aggressiveness, physical fightsIrritability, aggressiveness, physical fights- Disregard for safetyDisregard for safety- No sustained work historyNo sustained work history- Lack of remorseLack of remorse


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DSM-IV Diagnosis 2DSM-IV Diagnosis 2 >18 y/o18 y/o Early CD < 15yrsEarly CD < 15yrs

– Aggression to people or animalsAggression to people or animals

– Destruction of propertyDestruction of property

– Deceitfulness or theftDeceitfulness or theft

– Serious violation of rulesSerious violation of rules

R/O other major mental illnessR/O other major mental illness


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Review diagnosisReview diagnosisDescribe epidemiologyDescribe epidemiology

Review risk factorsReview risk factors




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ASPD PrevalenceASPD Prevalence General population ~ 3%General population ~ 3%

– M ~ 6%; F ~ 1%M ~ 6%; F ~ 1%

General medical clinics ~ 8%General medical clinics ~ 8% Mental health settings ~ 10%Mental health settings ~ 10% SUD treatment ~ at least 25%SUD treatment ~ at least 25% Prisoners ~ 40%Prisoners ~ 40%

– M ~ 50%; F ~ 20%M ~ 50%; F ~ 20%


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Associated DemographicsAssociated Demographics M:F = 6:1M:F = 6:1 Young (25 – 44) > Older (45 +)Young (25 – 44) > Older (45 +) Race: no differenceRace: no difference School drop-out: 5x by 11 yrs School drop-out: 5x by 11 yrs Abuse/neglect in childhood Abuse/neglect in childhood

– 50% 50% risk of adult criminal behavior risk of adult criminal behavior


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Review diagnosisReview diagnosisDescribe epidemiologyDescribe epidemiologyReview risk factorsReview risk factors




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GeneticsGenetics

Family studies: Family studies: ASPD ASPD Twin studies: ~ 70% heritabilityTwin studies: ~ 70% heritability

– Vulnerability Vulnerability CD, ASPD, SUDCD, ASPD, SUD Adoption studies: Adoption studies: (Cadoret)(Cadoret)

– CD, ASPD, SUDCD, ASPD, SUD


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Genetic and Environmental Genetic and Environmental ImpactImpact

ASPD ASPD Biological Biological

ParentParent

Childhood Childhood AggressionAggression

ASPDASPD SUDSUD

4x4x 9x9x 7x7x

Adverse Adoptive Home

8x8x (Cadoret 1995, 1997)(Cadoret 1995, 1997)


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EEG StudiesEEG Studies

Event related Event related potential ERP potential ERP

Amplitude Amplitude (P300)(P300)

Not specificNot specific Attentional Attentional

problemsproblems300 msec300 msec

StandardStandardTargetTarget

300 msec300 msec


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NeuroimagingNeuroimaging MRI: MRI:

Prefrontal Prefrontal volumevolume

PET & SPECT: PET & SPECT: Prefrontal Prefrontal functionfunction

Poor executive Poor executive functionfunction www.brainexplorer.org


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ASPD Biologic MarkersASPD Biologic Markers Increased aggression:Increased aggression:

– synaptic serotonin (5HT)synaptic serotonin (5HT)

Serotonin transporter protein (STP) Serotonin transporter protein (STP) – STP activity ~ STP activity ~ aggression aggression Cadoret ’03Cadoret ’03

– Opposite findings existOpposite findings exist

Monoamine oxidase (MAO) Monoamine oxidase (MAO) – Neuronal 5HT metabolismNeuronal 5HT metabolism


2020

www.drugabuse.govwww.drugabuse.gov

Intrasynaptic SerotoninIntrasynaptic Serotonin

MAO MAO

TransporterTransporter


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MAOMAOA A Genotype and Genotype and

Environmental InteractionEnvironmental Interaction

None Probable Severe

Childhood Maltreatment

AS

PD

Beh

avio

rs

Low MAOA

Caspi Caspi et alet al, 2002 Science, 297, p851-4., 2002 Science, 297, p851-4.


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MAOMAOA A Genotype and Genotype and

Environmental InteractionEnvironmental Interaction

None Probable Severe

Childhood Maltreatment

AS

PD

Beh

avio

rs

Low MAOA

High MAOA

Caspi Caspi et alet al, 2002 Science, 297, p851-4., 2002 Science, 297, p851-4.


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Review diagnosisReview diagnosisDescribe epidemiologyDescribe epidemiologyReview risk factorsReview risk factorsDescribe the courseDescribe the course



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ChildhoodChildhood

Irritable/impulsiveIrritable/impulsive temperament 3 y/o temperament 3 y/o– ASPD 3 X’s more likelyASPD 3 X’s more likely

Conduct disorder (CD)Conduct disorder (CD)– 25% develop ASPD25% develop ASPD

– educational difficultieseducational difficulties

– Earlier the CD: Earlier the CD: ASPD ASPD


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AdulthoodAdulthood

Data limited Data limited (Black et al 1995)(Black et al 1995)

29 yr follow-up of hospitalized ASPD29 yr follow-up of hospitalized ASPD 24% of sample died24% of sample died Of remainder alive:Of remainder alive:

–27% remission27% remission–31% improved31% improved–42% no change42% no change


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Psychiatric ComorbidityPsychiatric Comorbidity

Lifetime prevalence in ASPD:Lifetime prevalence in ASPD:– 70% alcohol use disorder70% alcohol use disorder

– 50 % drug use disorder50 % drug use disorder

80% of ASPD in tx: multiple SUD80% of ASPD in tx: multiple SUD Severity of SUDSeverity of SUD 4x SUD treatment episodes4x SUD treatment episodes


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Morbidity and MortalityMorbidity and Mortality

MorbidityMorbidity– HIV and high risk behaviorsHIV and high risk behaviors– Medical problemsMedical problems– InjuriesInjuries

MortalityMortality– Risk of violent death (6x in youth)Risk of violent death (6x in youth)– Risk of suicideRisk of suicide


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Review diagnosisReview diagnosisDescribe epidemiologyDescribe epidemiologyReview risk factorsReview risk factorsDescribe the courseDescribe the courseReview treatment Review treatment


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Treatment of ASPDTreatment of ASPD

Effectiveness? Effectiveness? Clinical fatalismClinical fatalism Patients rarely ask for ASPD txPatients rarely ask for ASPD tx

–Poor insightPoor insight

–Lifelong disturbanceLifelong disturbance

Often come for tx of SUDOften come for tx of SUD


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Treatment ElementsTreatment Elements Thorough history and examThorough history and exam Therapeutic relationshipTherapeutic relationship

–Firm behavioral limitsFirm behavioral limits

–Professional boundariesProfessional boundaries

–Maintain your empathyMaintain your empathy

–Negotiate behavioral goals in advanceNegotiate behavioral goals in advance


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Treatment ExpectationsTreatment Expectations Not curativeNot curative Focus on improved functionFocus on improved function Decrease problem behaviorsDecrease problem behaviors

– Impulsive actionsImpulsive actions

– Anticipate novelty seekingAnticipate novelty seeking

– Empathy in patientEmpathy in patient


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Treatment Outcomes Treatment Outcomes SUD literature = best impact dataSUD literature = best impact data ASPD and opioid dependenceASPD and opioid dependence

–Same retention in methadone txSame retention in methadone tx

– Drug use Drug use

– High risk behaviors High risk behaviors

Psychotherapy response mixedPsychotherapy response mixed Good response to behavioral txGood response to behavioral tx


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PharmacotherapyPharmacotherapy Poor to no dataPoor to no data Mood stabilizers ~ Mood stabilizers ~ impulsive impulsive

aggressionaggression SSRI’s ~ maybe SSRI’s ~ maybe aggression aggression Antipsychotics not effectiveAntipsychotics not effective Avoid habit forming drugsAvoid habit forming drugs

– i.e. benzodiazepinesi.e. benzodiazepines


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SummarySummary

Very common in SUD patientsVery common in SUD patients Genes and environment involvedGenes and environment involved Associated with great sufferingAssociated with great suffering Treatment is helpfulTreatment is helpful

Documents

Antisocial Personality Disorder Karin Neufeld, MD MPH Addiction Treatment Services Department of Psychiatry Johns Hopkins University School of Medicine