The intimate connection between antisocial personality and substance abuse

There is a powerful association between antisocial behavior and substance abuse. What is still uncertain is whether the association between the two is causal, so that one disorder leads to the other, or is explained by shared symptoms or shared risk factors, or suggests that the two disorders are not distinct, but are actually variants of the same underlying disorder. Each of these hypotheses is shown to be plausible. The paper considers four criteria for causality: precedence, coherence with existing knowledge, dose-related liability, and understandability of mechanisms. Problems are noted with each of these criteria. Conduct disorder as a cause of substance abuse fulfills these criteria more obviously than does substance abuse as a cause of antisocial behavior, but both have plausibility. A similarity is noted between the tasks of deciding whether one disorder causes another and deciding whether early symptom patterns predict the later course of a single disorder. The dearth of information about effect of the early symptom profile on the later course can be overcome with careful study design. Such studies promise important gains in patient management. The necessary data are outlined and instruments to collect such data are noted to be newly published or in development. Received: 18 February 1998     

Increased height and bulk in antisocial personality disorder and its subtypes

Research suggests that those with antisocial tendencies are larger than controls, but studies have not assessed this association in antisocial personality disorder (APD) or its hypothesized sub-types (i.e. adolescence-limited, late-onset). Height, weight, body mass index, bulk, and psychosocial adversity were assessed in 44 controls, nine adolescent-limited antisocials, 21 APDs, and 13 late-onset antisocials from the community. Adult antisocial individuals, regardless of age of onset, were significantly taller and had greater body bulk than controls. Although groups tended to differ on weight, they did not differ on body mass index. In addition, APDs and adolescent-limited individuals reported greater psychosocial adversity than the other groups. Adversity did not account for height or bulk differences. Results suggest prior findings on height and bulk may apply to APD and support differentiating adolescent-limited and life-course persistent subgroups.     

Schema modes and childhood abuse in borderline and antisocial personality disorders

Complex personality disorders (PDs) have been hypothesized to be characterized by alternating states of thinking, feeling and behavior, the so-called schema modes (Young, Klosko, & Weishaar (2003). Schema therapy: A practioner's guide. New York: Guilford). The present study tested the applicability of this model to borderline personality disorders (BPD) and antisocial personality disorders (APD), and related it to a presumed common etiological factor, childhood trauma. Sixteen patients with BPD, 16 patients with APD and 16 nonpatient controls (all 50% of both sexes) completed a Schema Mode Questionnaire assessing cognitions, feelings and behaviors characteristic of six schema modes. Participants were interviewed to retrace abusive sexual, physical and emotional events before the age of 18. BPD as well as APD participants were characterized by four maladaptive modes (Detached Protector, Punitive Parent, Abandoned/Abused Child and Angry Child). APD displayed most characteristics of the Bully/Attack mode, though not significantly different from BPD. The Healthy Adult mode was of low presence in BPD and of high presence in APD and the nonpatients. Frequency and severity of the three kinds of abuse were equally high in both PD groups, and significantly higher than in nonpatients.     

Trait impulsivity and response inhibition in antisocial personality disorder

Background

Impulsive behavior is a prominent characteristic of antisocial personality disorder. Impulsivity is a complex construct, however, representing distinct domains of cognition and action. Leading models refer to impulsivity as an inability to evaluate a stimulus fully before responding to it (rapid-response impulsivity), and as an inability to delay responding despite a larger reward (reward-delay impulsivity). We investigated these models in terms of the diagnosis and severity of antisocial personality disorder.

Methods

Thirty-four male subjects on probation/parole who met DSM-IV criteria for ASPD, and 30 male healthy comparison subjects, matched by ethnicity, were recruited from the community. The Barratt Impulsiveness Scale (BIS-11) provided an integrated measure of trait impulsivity. Rapid-response impulsivity was assessed using the Immediate Memory Task (IMT), a continuous performance test. Reward delay impulsivity was assessed using the Two-choice Impulsivity Paradigm (TCIP), where subjects had the choice of smaller-sooner or larger-delayed rewards, and the Single Key Impulsivity Paradigm (SKIP), a free-operant responding task.

Results

Compared to controls, subjects with ASPD had higher BIS-11 scores (Effect Size (E.S.) = 0.95). They had slower reaction times to IMT commission errors (E.S. = 0.45). Correct detections, a measure of attention, were identical to controls. On the SKIP, they had a shorter maximum delay for reward (E.S. = 0.76), but this was not significant after correction for age and education. The groups did not differ on impulsive choices on the TCIP (E.S. < 0.1). On probit analysis with age and education as additional independent variables, BIS-11 score, IMT reaction time to a commission error, and IMT positive response bias contributed significantly to diagnosis of ASPD; SKIP delay for reward did not. Severity of ASPD, assessed by the number of ASPD symptoms endorsed on the SCID-II, correlated significantly with commission errors (impulsive responses) on the IMT, and with liberal IMT response bias. This relationship persisted with correction for age and education.

Discussion

These results suggest that ASPD is characterized by increased rapid-response impulsivity. Aspects of impulsivity related to reward-delay or attention appear relatively intact.     

Serotonergic responsivity and behavioral dimensions in antisocial personality disorder with substance abuse

In order to assess the possibility of altered serotonergic responsivity in antisocial personality disorder with substance abuse (ASP), 15 men with ASP and 12 controls were challenged with the serotonin agonist, m-chlorophenylpiperazine (m-CPP), and prolactin and cortisol responses were evaluated. Psychometric measures of hostility and aggression, impulsivity, cognitive tempo, and various aspects of sociopathy were also obtained. ASP subjects had a significantly reduced prolactin response to m-CPP compared with controls, and a significantly greater cortisol response. The prolactin responses showed a significant inverse correlation with measures of assaultive aggression, hypophoria (negative affects), and increased needs. There was no significant correlation found between cortisol responses and any of the psychometric measures. Impulsivity as characterized either by behavioral self-report or measurement of cognitive tempo did not correlate with either prolactin or cortisol responses. A discriminant function analysis depicted ASP subjects as displaying resentment towards others and having poor test-taking efficiency, heightened irritability, and diminished prolactin response to m-CPP. Using these four criteria, nearly 93% of subjects were successfully classified. These results suggest that altered serotonergic function is associated with assaultiveness and dysphoria but not impulsivity in individuals with ASP.     

Screening for antisocial personality disorder in drug users--a qualitative exploratory study on feasibility

Knowledge about co-occurring personality disorders in drug users is important for planning therapy and prevention. The objective of this study was to assess whether the SCID-II (Structured Clinical Interview for DSM-III-R) Screen for antisocial personality disorder was feasible and acceptable in a population of opioid users. A qualitative study on veridicality and emotional quality in responses to SCID-II Screen was carried out by personal interview in a multifunctional addiction centre. The subjects were 10 outpatient participants (six female, four male) in methadone substitution treatment. The SCID-II Screen triggered a high level of emotions. Some questions were mainly interpreted from a victim's perspective, even though the intention was the perpetrator's view. Questions were seen as sex-biased. Provision of support to deal with potential emotional problems should be supplied. Potential revision should be considered to include the female perspective in the screen.     

Monoamine oxidase A regulates antisocial personality in whites with no history of physical abuse

Objective

Preclinical and human family studies clearly link monoamine oxidase A (MAOA) to aggression and antisocial personality (ASP). The 30–base pair variable number tandem repeat in the MAOA promoter regulates MAOA levels, but its effects on ASP in humans are unclear.

Methods

We evaluated the association of the variable number tandem repeat of the MAOA promoter with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, ASP disorder (ASPD) traits in a community sample of 435 participants from the Hopkins Epidemiology of Personality Disorders Study.

Results

We did not find an association between the activity of the MAOA allele and ASPD traits; however, among whites, when subjects with a history of childhood physical abuse were excluded, the remaining subjects with low-activity alleles had ASPD trait counts that were 41% greater than those with high-activity alleles (P < .05).

Conclusion

The high-activity MAOA allele is protective against ASP among whites with no history of physical abuse, lending support to a link between MAOA expression and antisocial behavior.     

The epidemiology of antisocial personality disorder

This paper reviews the current state of knowledge about the frequency, natural history, risk factors and associations of antisocial personality disorder. Important recent developments are discussed, and where possible, findings have been tabulated. Epidemiological surveys have shown that antisocial personality disorder is a common disorder, with a prevalence rate of between 2 and 3% among community samples, rising to 60% among male prisoners. Antisocial personality disorder is a chronic condition, and is associated with a multitude of medical and social problems. These include substance abuse, deliberate self harm and crime. Genetic and environmental factors have been implicated in the aetiology of the disorder. However, despite the large amount of research into antisocial personality disorder, longitudinal data are missing and the validity of the diagnosis, therefore, remains questionable. The paper concludes with recommendations for future research. Accepted: 1 March 1999     

EEG does not predict response to valproate treatment of aggression in patients with borderline and antisocial personality disorders.

Previous investigations of the role of EEG in predicting response of aggressive patients to valproate therapy have yielded mixed results. In this study of borderline and antisocial personality disorder patients hospitalized with aggressive behavior, EEGs were obtained prior to treatment with valproate. Eight of 22 (36.4%) patients subsequently responsive to valproate had nonepileptiform EEG abnormalities, while 5 of 20 (25%) patients not responsive to valproate had nonepileptiform EEG abnormalities. Although more of the valproate responders than nonresponders had EEG abnormalities, the presence of nonepileptiform EEG abnormalities was not a statistically significant (X2 = 0.213, df = 1, p = 0.64) predictor of valproate response in personality disorder patients with aggression.     

Predictors of response of antisocial patients to hospital treatment

Although clinicians generally agree that patients with antisocial personality disorder should not be treated on general psychiatry units, little is known about the response to hospital treatment of personality disorder patients who have antisocial features or traits. In a study to identify predictors of positive and negative response to hospitalization, charts of all patients discharged from a private hospital with diagnoses of antisocial personality disorder or antisocial features over 52 months were reviewed. As a group the 33 patients did not respond well to treatment, and 70 percent left treatment prematurely. Significant predictors of negative response were histories of felony arrest and conviction; a history of repeated lying, aliases, and conning; and an unresolved legal situation at admission. Positive response was related to the presence of anxiety and an axis I diagnosis of depression. The authors believe that antisocial personality disorder is often underdiagnosed and that countertransference can present a significant obstacle to treatment of antisocial patients.     

Antisocial behavior of intravenous drug abusers: implications for diagnosis of antisocial personality disorder.

OBJECTIVE: A pattern of chronic adult antisocial behavior is not sufficient for the DSM-III-R diagnosis of antisocial personality disorder unless the early-onset criteria are satisfied, even if the adult criteria are met. The utility of the early-onset requirement for the diagnosis was examined in intravenous drug abusers, a population known to have high rates of irresponsible, aggressive, and criminal behavior. METHOD: The subjects were 237 drug abusers who had volunteered for an outpatient study of psychopathology and HIV risk behavior and infection. They completed a structured psychiatric interview as part of their participation in that study. The adult antisocial behavior of the group that met both the early-onset and the adult criteria for antisocial personality disorder, the group that met only the adult criteria, and the group that met neither the early-onset nor the adult criteria was then compared. RESULTS: Antisocial personality disorder (meeting the early-onset and adult criteria) was diagnosed in 44% of the sample; an additional 24% met only the adult criteria. The group with the diagnosis of antisocial personality disorder reported a more pervasive and more serious pattern of adult antisocial behavior than did the other groups, although antisocial behavior was commonplace in all three groups. CONCLUSIONS: Early onset of multiple antisocial behaviors identified a subset of drug abusers with important differences in the extent and severity of their adult antisocial behavior. The antisocial behavior of the group that met only the adult criteria suggests the possibility of a late-onset and less severe form of antisocial personality disorder.     

Methylphenidate in the treatment of aggression in two patients with antisocial personality disorder

Two hospitalized patients with antisocial personality disorder (by DSM-III) and histories of childhood attention deficit disorder became less aggressive during trials of methylphenidate. The authors suggest a link between the childhood disorder and one subgroup of antisocial personality disorder.     

Treatment and prevention implications of antisocial personality disorder

Recent research efforts have focused on understanding the developmental nature of antisocial personality disorder (APD) in order to better develop intervention strategies. This article reviews what is known about biologic and environmental risk factors for the development of APD as well as issues surrounding treatment. Insights into how these factors may work together, and issues involving approaches to researching them, are discussed. Given the impact of this disorder on the lives of the affected individuals as well as society, prevention of this disorder may be a more important focus than intervention.