ADHD and sleep in homicidal men with antisocial personality disorder

A history of attention deficit hyperactivity disorder (ADHD) is commonly found in subjects with antisocial personality disorder (ASP). Besides ASP, childhood ADHD also predicts drug abuse disorders and criminal activity in adulthood. Childhood ADHD and ASP appear to be the only psychiatric disorders reported to be associated with an increase in deep sleep. The aims of the present study were to retrospectively measure the childhood ADHD of habitually violent men with ASP and Cloninger type 2 alcoholism, and to characterize the possible relationship between childhood ADHD and sleep architecture in these men. The subjects of the study consisted of 14 homicidal offenders recruited from a forensic psychiatric examination. Ten age- and gender-matched healthy volunteers served as controls. Childhood ADHD symptoms were measured using the Wender-Utah Rating Scale (WURS). The main findings were that violent offenders with ASP had significantly higher mean WURS scores compared with controls, and both the absolute and percentage amount of stage 4 sleep as well as delta and theta powers in this sleep stage were positively correlated with the WURS scores. The present study supports the idea that childhood ADHD is associated with the abnormal sleep architecture in habitually violent men with ASP. These two disorders seem to share, at least partly, the same central nervous system deficit.     

Quantitative electroencephalographic measures in homicidal men with antisocial personality disorder

Many symptoms of antisocial personality disorder have been proposed to be related to decreased daytime vigilance. To explore this hypothesis, quantitative analyses were conducted of the electroencephalographic (EEG) activity of drug-free and detoxified homicidal male offenders with antisocial personality disorder as the primary diagnosis. Subjects comprised 16 men recruited from a forensic psychiatric examination in a special ward of a university psychiatric hospital. Fifteen healthy age- and gender-matched controls with no criminal record or history of physical violence consisted of hospital staff and students. An overall reduction of alpha power was observed in the waking EEG of offenders. A bilateral increase in occipital delta and theta power was also found in these individuals. This study provides further support to the growing evidence of brain dysfunction in severe aggressive behavior. Homicidal offenders with antisocial personality disorder seem to have difficulties in maintaining normal daytime arousal. Decreased vigilance, together with social and psychological variables, may explain their aberrant behavior in everyday life. New studies are, however, needed to specify the vigilance problems of this patient group.     

Neurological soft signs in homicidal men with antisocial personality disorder.

Neurological soft signs (NSS) are characterized by abnormalities in motor, sensory, and integrative functions. NSS have been regarded as a result of neurodevelopmental dysfunction, and as evidence of a central nervous system defect, resulting in considerable sociopsychological dysfunction. During the last decade there has been growing evidence of brain dysfunction in severe aggressive behavior. As a symptom, aggression overlaps a number of psychiatric disorders, but it is commonly associated with antisocial personality disorder. The aim of the present study was to examine NSS in an adult criminal population using the scale by Rossi et al. [29]. Subjects comprised 14 homicidal men with antisocial personality disorder recruited from a forensic psychiatric examination. Ten age- and gender-matched healthy volunteers as well as eight patients with schizophrenia, but no history of physical aggression, served as controls. The NSS scores of antisocial offenders were significantly increased compared with those of the healthy controls, whereas no significant differences were observed between the scores of offenders and those of patients with schizophrenia. It can be speculated that NSS indicate a nonspecific vulnerability factor in several psychiatric syndromes, which are further influenced by a variety of genetic and environmental components. One of these syndromes may be antisocial personality disorder with severe aggression.     

Volumetric structural brain abnormalities in men with schizophrenia or antisocial personality disorder

Brain abnormalities are found in association with antisocial personality disorder and schizophrenia, the two mental disorders most implicated in violent behaviour. Structural magnetic resonance imaging was used to investigate the whole brain, cerebellum, temporal lobe, lateral ventricles, caudate nucleus, putamen, thalamus, hippocampus, amygdala and the prefrontal, pre-motor, sensorimotor, occipito-parietal regions in 13 men with antisocial personality disorder, 13 men with schizophrenia and a history of violence, 15 men with schizophrenia without violent history and 15 healthy non-violent men. Compared to controls, the antisocial personality disorder group displayed reductions in whole brain volume and temporal lobe as well as increases in putamen volume. Both schizophrenia groups regardless of violence history exhibited increased lateral ventricle volume, while the schizophrenia group with violent history showed further abnormalities including reduced whole brain and hippocampal volumes and increased putamen size. The findings suggest that individuals with antisocial personality disorder as well as those with schizophrenia and a history of violence have common neural abnormalities, but also show neuro-anatomical differences. The processes by which they came to apparently common ground may, however, differ. The finding of temporal lobe reductions prevalent among those with antisocial personality disorder and hippocampal reduction in the violent men with schizophrenia contributes support for the importance of this region in mediating violent behaviour.     

Childhood trauma history and dissociative experiences among Turkish men diagnosed with antisocial personality disorder

Objective This study investigated the association between antisocial personality disorder (APD), childhood trauma history, and dissociative symptoms in a sample of Turkish recruits. Methods A total of 579 male patients diagnosed with APD were examined in a military hospital setting. An age and gender matched control group of 599 normal persons with no known medical or psychiatric disorder were also chosen among military personnel. The subjects were evaluated with an assessment battery using a semi-structured interview for socio-demographic characteristics, APD section of SCID-II, an adapted version of the Structured Trauma Interview, and Dissociative Experiences Scale. Results Childhood sexual abuse, physical abuse, neglect, and early separation from parents were significantly more common among antisocial subjects than among controls. APD group reported significantly more dissociative symptoms and 50.4% of them reported pathological level of dissociation. Overwhelming childhood experiences of all four types were significant predictor of the APD diagnosis. Analyses also showed that childhood traumatic events and comorbid psychopathological features relevant to antisocial personality were significantly associated with pathological level of dissociation. Conclusion These results revealed the importance of inquiring about patient’s history of childhood traumatization and dissociative experiences when diagnosed with APD.     

A Comparison of adults with antisocial personality traits with and without childhood conduct disorder.

BACKGROUND: Antisocial personality disorder (ASPD) in DSM-IV is unique among personality disorder diagnoses in requiring the individual to satisfy a number of childhood criteria in addition to relevant traits exhibited in adulthood. We examined the validity of this childhood requirement. METHODS: Personality disordered individuals assessed using the International Personality Disorder Examination and exhibiting a sufficient number of adult antisocial traits to meet criterion A of DSM-IV were subdivided into those who exhibited antisocial traits in both adulthood and childhood and those who had such traits in adulthood only. The two groups were then compared on a number of historical, clinical, and self-report measures. RESULTS: Thirty individuals meeting both childhood and adult criteria (ASPD) were compared with 39 meeting adult antisocial criteria only (ASS). Few differences were found between the two groups on the measures examined, although those in the ASPD group appeared more severe and had higher anger scores on the STAXI-2 psychometric test. CONCLUSIONS: This failure to find clinically important differences between the two groups is in agreement with previous reports and needs to be taken into account in future revisions of ASPD in DSM.     

Frontal P300 decrements, alcohol dependence, and antisocial personality disorder.

BACKGROUND: The purpose of this study was to examine the independent and interactive effects of alcohol dependence, antisocial personality disorder (ASPD), and age on brain function. METHODS: P300 event-related potentials (ERPs) were recorded from 393 alcohol-dependent and 170 non-alcohol-dependent adults while they performed a visual oddball task. The two subject groups were further subdivided based upon age and the presence/absence of ASPD. RESULTS: Alcohol dependence was associated with a significant P300 amplitude decrement at anterior electrode sites only. Antisocial personality disorder was also associated with reduced P300 amplitudes at anterior electrode sites; however, the effects were only significant among subjects 30 years of age or younger. To validate this association between ASPD and P300 amplitude a correlational analysis was performed; the correlation between anterior P300 amplitude and the total number of childhood conduct disorder and adult ASPD symptoms was significant. CONCLUSIONS: The P300 amplitude decrement found at anterior electrode sites among subjects with ASPD is consistent with the results of numerous ERP, neuroimaging, or neuropsychologic studies of anterior brain function. Our study is unique in suggesting that the effects of ASPD on anterior brain function are best detected during early adulthood. The study also suggests that the detrimental neurophysiologic effects of alcohol dependence predominantly involve the anterior brain.     

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     

Discriminant efficiency of antisocial and borderline personality disorder criteria in Hispanic men with substance use disorders

The authors examined the discriminant efficiency of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV ) criteria for borderline personality disorder (BPD) and antisocial personality disorder (APD). Subjects were 74 men admitted to an outpatient substance abuse program for monolingual Hispanic adults. All were reliably assessed with the Spanish-language version of the Diagnostic Interview for DSM-IV Personality Disorders. Conditional probabilities were calculated to determine the diagnostic efficiency and discriminant efficiency of BPD and APD symptoms. Twenty-five (34%) subjects met diagnostic criteria for BPD, and 16 (22%) met criteria for APD. The diagnostic co-occurrence of these disorders was statistically significant. Whereas the diagnostic efficiency of the BPD criterion set was comparable to that reported in other clinical studies, these criteria were not significantly more efficient in diagnosing BPD than APD. By contrast, the APD criteria were more efficient in diagnosing APD than BPD; this was true for both the "adult" and the "conduct disorder" APD criterion subsets. In male Hispanic outpatients with substance use disorders, BPD and APD show significant diagnostic overlap. The APD criteria are useful in discriminating these 2 disorders, whereas the BPD criteria are not. These findings have implications for the discriminant validity of the BPD and APD criteria and support the value of the conduct disorder criteria in predicting APD in adulthood.     

Association of alcoholism with antisocial personality in urban men

The association of alcoholism with antisocial personality is important from a research and a therapeutic standpoint. In a sample of urban black men, it was found that those with antisocial personality had a higher rate of alcoholism than those without. In addition, a family history of problem drinking, low educational level, and excessive irritability were also closely associated with alcoholism. The clinical, genetic, and neurophysiological implications of these findings are discussed.     

Shared genetic risk of major depression,alcohol dependence,and marijuana dependence: contribution of antisocial personality disorder in men

BACKGROUND: Little is known about genetic factors that underlie the interrelationships among antisocial personality disorder (ASPD), major depression (MD), alcohol dependence (AD), and marijuana dependence (MJD). We examined the contribution of genetic effects associated with ASPD to the comorbidity of MD and substance use disorders. METHODS: The Vietnam Era Twin Registry is a general population registry of male veteran twins constructed from computerized Department of Defense files and other sources. A telephone diagnostic interview was administered to eligible twins from the Registry in 1992. Of 5150 twin pairs who served on active military duty during the Vietnam era, 3360 pairs (1868 monozygotic and 1492 dizygotic) in which both members completed the pertinent diagnostic interview sections were included. The main outcome measures were lifetime DSM-III-R ASPD, MD, AD, and MJD. RESULTS: Structural equation modeling was performed to estimate additive genetic, shared environmental, and nonshared environmental effects common and specific to each disorder. The heritability estimates for lifetime ASPD, MD, AD, and MJD were 69%, 40%, 56%, and 50%, respectively. Genetic effects on ASPD accounted for 38%, 50%, and 58% of the total genetic variance in risk for MD, AD, and MJD, respectively. After controlling for genetic effects on ASPD, the partial genetic correlations of MD with AD and with MJD were no longer statistically significant. Genetic effects specific to MD and AD and familial effects specific to MJD remained statistically significant. Nonshared environmental contributions to the comorbidity in these disorders were small. CONCLUSIONS: In this sample, the shared genetic risk between MD and both AD and MJD was largely explained by genetic effects on ASPD, which in turn was associated with increased risk of each of the other disorders.     

Use of health care services among persons who screen positive for bipolar disorder

OBJECTIVE: This study examined patterns of diagnosis, consultation, and treatment of persons who screened positive for bipolar disorder. METHODS: An impact survey was mailed to a representative subset of 3,059 individuals from a large U.S.-population-based study that utilized the Mood Disorder Questionnaire (MDQ). RESULTS: Respondents who screened positive on the MDQ (reported the presence of seven of 13 symptoms of bipolar disorder, the co-occurrence of at least two symptoms, and moderate or severe symptom-related impairment) (N=1,167) had consulted a health care provider more often in the previous year than those who screened negative (reported six or fewer symptoms regardless of symptom co-occurrence or impairment) (N=1,283). Psychiatrists and primary care physicians failed to detect or misdiagnosed bipolar disorder among 53 percent and 78 percent of patients, respectively, who screened positive for bipolar disorder. The most commonly used psychotropic medications during the previous 12 months among those who screened positive were antidepressants alone (32 percent), followed by lithium and anticonvulsant mood stabilizers (20 percent), antidepressants in combination with other psychotropics (19 percent), hypnotics (19 percent), and antipsychotics (9 percent). In the preceding 12 months, respondents who screened positive on the MDQ had greater use of psychiatric hospitals, emergency departments, and urgent care centers and also had more outpatient visits to primary care physicians, psychiatrists, and alcohol treatment centers than those who screened negative. CONCLUSIONS: The results of this study suggest that bipolar disorder is an underdiagnosed and often inappropriately treated illness associated with significant use of health care resources.     

Use of medical and behavioral health services by adolescents with bipolar disorder

OBJECTIVE: This study compared use of medical and behavioral health care by adolescents with bipolar disorder and other adolescents and identified areas in need of more clinical attention. METHODS: Medical and behavioral health insurance claims from 1996 for 100,880 adolescents were examined and categorized. Differences between and among various categories of disease were explored by using multivariate analyses. RESULTS: Among the 10,970 adolescents who used at least one behavioral health service, adolescents with bipolar disorder (N=326) had significantly higher behavioral health costs than those with mood or non-mood disorders, a result driven by these adolescents' significantly higher hospital admission rates for behavioral health care. Adolescents with bipolar disorder also had significantly higher medical admission rates compared with adolescents who had other behavioral health diagnoses. More than half of the 14 medical admissions for adolescents with bipolar disorder were due to drug overdose. CONCLUSIONS: Reallocation of medical and behavioral health resources to improve ambulatory treatment of bipolar disorder among adolescents has the potential to decrease the use and costs of health care while improving the welfare of these adolescents and their families.     

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.     

Sleep among habitually violent offenders with antisocial personality disorder

The aim of the present study was to characterize the subjective and objective sleep and sleep quality in habitually violent offenders with DSM-IV diagnosis of antisocial personality disorder using a sleep questionnaire, actigraphy, polysomnography and power spectral analysis. Subjects for the study were 19 drug-free males (mean age +/- SEM 30.7 +/- 2.58 years) recruited from a forensic psychiatric examination in a special ward of a university psychiatric hospital. The most striking finding was the high amount of slow-wave sleep, particularly the deepest S4 stage (17% as compared with 6% in healthy controls), in males with antisocial personality disorder. Moreover, in the spectral power analysis, both the delta and the theta power were significantly elevated. Whether this increase in persons with antisocial personality disorder reflects a specific brain pathology, or a delay in the normal development of sleep patterns in the course of ageing needs to be clarified with further experiments.     

Affective reactivity in heroin-dependent patients with antisocial personality disorder

The Antisocial personality disorder (ASPD), one of the most common co-morbid psychiatric disorders in heroin-dependent patients, is associated with a lack of affective modulation. The present study aimed to compare the affect-modulated startle responses of opioid-maintained heroin-dependent patients with and without ASPD relative to those of healthy controls. Sixty participants (20 heroin-dependent patients with ASPD, 20 heroin-dependent patients without ASPD, 20 healthy controls) were investigated in an affect-modulated startle experiment. Participants viewed neutral, pleasant, unpleasant, and drug-related stimuli while eye-blink responses to randomly delivered startling noises were recorded continuously. Both groups of heroin-dependent patients exhibited significantly smaller startle responses (raw values) than healthy controls. However, they showed a normal affective modulation: higher startle responses to unpleasant, lower startle responses to pleasant stimuli and no difference to drug-related stimuli compared to neutral stimuli. These findings indicate a normally modulated affective reactivity in heroin-dependent patients with ASPD.     

Interacting mechanisms of impulsivity in bipolar disorder and antisocial personality disorder

Background

Bipolar disorder and antisocial personality disorder (ASPD) overlap in clinical characteristics and behavioral consequences. Impulsivity is prominent in both, but there is little information on how specific mechanisms of impulsivity differentiate, bridge, or underlie the disorders.

Methods

Subjects, all males, were controls (n = 46), bipolar disorder without cluster B personality disorder (n = 21), ASPD without bipolar disorder (n = 50), and bipolar disorder with ASPD (n = 16). Impulsivity measures were the Immediate Memory Task (IMT), a continuous performance test of response inhibition measuring ability to evaluate a stimulus before responding, and the Two-Choice Impulsivity Paradigm (TCIP), a choice between smaller-sooner and larger-later reward. Data were analyzed using general linear models analysis.

Results

Subjects with bipolar disorder had fewer IMT correct detections and slower reaction times than controls. Reaction times were faster with combined diagnoses than in bipolar disorder alone. TCIP responding in either diagnosis alone resembled controls, but was more impulsive in combined disorders. These differences persisted after correction for age and education, which had significant independent effects. In combined ASPD and bipolar disorder, increased reaction speed, impulsive response bias, and reward-delay impulsivity occurred independent of substance-use disorder history.

Conclusions

Impulsivity was increased in the combined disorders over either disorder alone. Results were consistent with at least partially distinct mechanisms of impulsivity in ASPD and bipolar disorder. Compensatory mechanisms for impulsivity in uncomplicated ASPD or bipolar disorder appear to be compromised or lost when the disorders are combined.