What is antisocial personality disorder (ASPD)?

Introduction

By personality disorder, psychologists mean a disorder in which an individual’s style of dealing with the world, relationship with self, problem solving, and management of emotions are inflexible to situations. As a result, the individual creates a maladaptive pattern of behavior and thinking that produces considerable impairment and distress. In the case of antisocial personality, these traits are thought to be manifested in criminal and otherwise irresponsible behaviors, which create problems for the individual and, more important, for society—hence the term “antisocial.”

Individuals of all ages with an antisocial personality often have a childhood history of conduct disorder or oppositional defiant disorder. Conduct disorder is a pattern of behavior in which both the rights of others and age-appropriate social norms or rules are repeatedly violated. Oppositional defiant disorder is characterized by a pattern of hostile behavior toward authority figures in which the child is deliberately defiant, negative, hostile, annoying, and possibly vindictive, beyond what might be expected in children. Noteworthy antisocial behaviors include theft, school truancy, fire setting, vandalism, physical cruelty toward animals and people, financial irresponsibility, repeated lying, reckless driving, sexual promiscuity, and poor parenting. Not surprising, a large percentage of incarcerated criminals fulfill the criteria for antisocial personality disorder.

Symptoms and Prevalence

Many of the symptoms of antisocial personality were identified by the sociologist Lee Robins in her influential work Deviant Children Grown Up (1966). Robins found that between 20 and 30 percent of children with conduct disorder develop antisocial personality in adulthood. There is also evidence that a subset of children with hyperactivity (attention-deficit hyperactivity disorder) develop antisocial personality in adulthood. Nevertheless, because many of these same children have conduct disorder, it may be conduct disorder, rather than hyperactivity, that is the major determinant of antisocial personality.

In addition to the behaviors mentioned above, persons with antisocial personality disorder have a number of other psychological and interpersonal difficulties. For example, they have high rates of alcohol and drug abuse, divorce, sexually transmitted diseases, out-of-wedlock pregnancies, and depression. In addition, individuals with this disorder are more likely than those in the general population to die prematurely from violent crimes and accidents. Antisocial personality is also associated with criminal recidivism: Individuals with this disorder who are released from prison are at high risk for subsequent incarceration.

In the United States, about 3 percent of men and 1 percent of women have antisocial personalities. The reason for this sex difference is unknown. Some researchers have speculated that men and women may express antisocial tendencies in different ways. For instance, men may commit crimes more likely to be visible and prosecuted than women. Others have speculated that women who are predisposed to antisocial personality may be likely to develop somatization disorder, a condition characterized by multiple physical complaints lacking any demonstrated medical basis. Indeed, somatization disorder is found among many of the female relatives of antisocial personalities. Thus, somatization disorder may be an alternative manifestation of antisocial personality that is found primarily among women, although considerably more research will be needed to corroborate this hypothesis. Finally, antisocial personality is also associated with low social class, although the causes of this relationship are unknown and controversial. For instance, it may be that individuals in lower social classes are more likely to be prosecuted for criminal behavior than those in upper classes and therefore more likely to get labeled as antisocial.

The Antisocial Life

What happens to antisocial personalities over time? There is evidence that many such individuals “burn out” in middle age: Their antisocial behaviors decrease in frequency and severity in later adulthood. The reasons for this burnout phenomenon are unclear, but it may be a consequence of the decline in activity level and energy seen in most individuals with age. It is also important to consider that participation in dangerous activities such as crime and risk taking may cause many individuals with antisocial personality disorder to die at young ages.

Little is known about the treatment of antisocial personality except that no clearly effective treatment has been found. A number of therapies have been attempted, including psychoanalysis, behavior therapy, group therapy, and medication, but there is little evidence that any of them have been especially successful. As the symptoms of antisocial personality begin early in life and are easily identifiable, it may be prevention, rather than treatment, that holds the greatest promise for reducing the prevalence of this disorder.

Many individuals with antisocial personality disorder possess a constellation of personality traits known as the psychopathic personality. In his classic book The Mask of Sanity (1941), psychiatrist Hervey Cleckley provided a detailed description of this syndrome. According to Cleckley, psychopathic personalities (or, as they are sometimes called, psychopaths) tend to be superficially charming individuals who are relatively free of anxiety and seem possessed of excellent reason. Nevertheless, they also tend to be guiltless, callous, dishonest, and self-centered persons who rarely learn from their mistakes or take responsibility for their behavior.

Some psychologists believe that psychopathic personality is a more valid category than antisocial personality. According to these researchers, many antisocial personalities lack the traits characteristic of psychopathic personality and instead exhibit antisocial behavior for a variety of other reasons. For example, some antisocial personalities may fall into a category known as dyssocial psychopathy, a syndrome in which antisocial behavior results from allegiance to a culturally deviant subgroup. Many gang delinquents or members of organized crime could probably be classified in this group. The behavior of still other antisocial personalities may result from neurotic psychopathy, a syndrome in which antisocial behavior is a consequence of internal psychological conflict and turmoil. Many neurotic psychopaths are probably socially anxious individuals who inhibit their anger for long periods of time and then erupt intermittently but violently.

Conversely, some critics of the antisocial personality diagnosis have argued that many psychopaths do not fulfill the criteria for antisocial personality. Indeed, some psychopaths may function highly in society and would thus not be detected by the antisocial personality criteria in many cases. Cathy Spatz Widom has found that many persons who possess the traits described by Cleckley can be found outside prisons and, in some cases, have socially valued occupations (for example, corporate executive). Further study of these “successful” psychopaths may shed light on factors that allow individuals at risk for antisocial personality to avoid legal and interpersonal problems. As a result, the diagnostic system used to identify this personality disorder has changed in recent years to bring in more of what Cleckley identified as problematic.

Research into Causes

One of the most active areas of research on antisocial personality concerns possible causes of the disorder. Psychologist David Lykken, for example, has theorized that the behavior of many antisocial personalities, particularly those who are psychopaths, can be traced to fearlessness.

Lykken has found that, compared with other individuals with antisocial behavior and with “normals,” psychopaths tend to exhibit less sweating of the palms prior to hearing a buzzer that has been repeatedly paired with a painful electric shock. Robert Hare has similarly shown that psychopaths tend to show relatively little palmar sweating during the countdown period prior to a painful electric shock or jarring blast of white noise. Because palmar sweating is often indicative of fear or arousal, the findings of Lykken and Hare can be interpreted to mean that psychopaths are not frightened or aroused by signals of impending punishment. This, in turn, might explain why many psychopaths engage in repeated antisocial behavior: The warning signs that would deter most people from performing such acts have little impact on the psychopath.

The average child or adult is prevented from committing antisocial acts largely by signals that punishment or danger is imminent: a parent or teacher saying “No” as a child reaches for a forbidden piece of candy, the watchful eye of a museum guard as one passes by a valuable painting, or a light turning yellow as one approaches a busy intersection. If such signals arouse little or no fear in a person, however, his or her threshold for committing antisocial acts will be lowered.

Lykken also constructed a “mental maze” task, in which subjects were required to learn a complex series of lever presses. On each trial, some errors were punished with painful shock, whereas others were not. Lykken found that, compared with other subjects, psychopaths did not make more errors overall, indicating that they can learn certain tasks as well as other individuals. Nevertheless, Lykken found that psychopaths made more punished errors than other individuals, suggesting that they have difficulty learning from punishment. Again, this finding is consistent with the fearlessness hypothesis, because the capacity to benefit from punishment largely depends on the capacity to become frightened of this punishment. Moreover, this finding has important implications; the psychopath’s failure to learn from punishment in the laboratory may be a useful model for the antisocial personality’s recidivism in the real world.

Arousal Levels

An alternative hypothesis for the behavior of antisocial personalities is that these individuals have unusually low levels of arousal. According to the Yerkes-Dodson law, moderate levels of arousal are optimal for performance and psychological functioning. Thus, as Herbert Quay and other psychologists have argued, many of the thrill-seeking and dangerous behaviors of antisocial personalities may represent attempts to bring their arousal to higher and thus more optimal levels. George Skrzypek has found that psychopathic delinquents, compared with other delinquents, have a greater preference for complex and novel stimuli. This is consistent with Quay’s hypothesis, because such stimuli would be expected to increase arousal. Skrzypek also found that after both groups were placed in sensory isolation, psychopaths’ preference for complex and novel stimuli increased more compared with nonpsychopaths.

One implication of these findings is that at least some antisocial personalities might benefit from treatments that boost their arousal levels. For example, antisocial personalities could be encouraged to find occupations (for example, combat soldier) or avocations (for example, skydiving) that might provide outlets for their risk-taking tendencies. Similarly, some researchers have explored the possibility that some antisocial personalities might be helped by stimulant medication. Stanley Schachter and Bibb Latané found that when psychopaths were asked to perform Lykken’s mental-maze task while taking adrenaline, a stimulant drug, they were as successful as were nonpsychopaths at learning to avoid punishment. Nevertheless, as these “arousal modification” approaches have not been adequately researched, their potential as treatments for antisocial personality remains speculative.

There is considerable evidence that antisocial personality is influenced by genetic factors. Identical twins (who share all their genes) with antisocial personality are much more likely than are fraternal twins(who share only half their genes on average) to have co-twins with the disorder. Nevertheless, many of the co-twins of identical twins with antisocial personality do not have the disorder, which indicates that environmental factors play an important role in the development of antisocial personality. In addition, adopted children whose natural parents had antisocial personality are more likely to develop the disorder than are adopted children whose natural parents did not. Again, this is consistent with a genetic influence on antisocial personality.

Nevertheless, several important questions concerning the genetics of antisocial personality remain. First, it is not known what factors are being genetically transmitted. Second, it is not known whether this genetic influence applies to all, or only some, individuals with antisocial personality. For example, this genetic influence might only play a role in individuals with psychopathic personality. Third, it is not known how environmental factors combine or interact with genetic factors to produce antisocial personality. These three questions are likely to occupy researchers for a number of years to come.

Changing Labels

Although the term “antisocial personality” did not enjoy widespread currency until the latter half of the twentieth century, individuals with chronic antisocial symptoms have been described by a variety of labels over the years. In 1809, Philippe Pinel discussed a syndrome called manie sans délire, or mania without delusion. Individuals with this syndrome, according to Pinel, are driven by strong instinctual forces but maintain good contact with reality. In 1835, James Pritchard coined the term “moral insanity” to refer to a condition characterized by severe deficits in ethical behavior.

In 1891, German psychiatrist August Koch referred to a group of conditions called “psychopathic inferiorities.” In doing so, Koch broadened the concept of the disorder to include a diverse spectrum of abnormalities, not all of which were characterized by moral depravity. Koch’s tradition was followed by the great German classifier Kurt Schneider, who in 1923 described a wide variety of psychopathic personalities, each of which was considered to be an exaggeration of a normal personality style. Thus, the German conceptualization was generally more inclusive than that of Morel and Pritchard, and it viewed psychopathic personality as a set of conditions that created problems for the individual, society, or both.

It was authors such as Cleckley and Benjamin Karpman who were largely responsible for shaping contemporary notions of psychopathic personality. These authors emphasized personality traits as the key features of the disorder, and they deemphasized antisocial and criminal behaviors. This view was reflected in the second edition of the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders
(DSM-II) in 1968, which focused on personality traits such as guiltlessness and selfishness as the primary criteria for the disorder.

This personality-based approach, however, came under attack in the 1970s and 1980s for its subjectivity. After all, what one diagnostician might view as a pathological absence of guilt might be viewed by another as a healthy absence of self-criticism. Thus, in 1980, the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) introduced “antisocial personality disorder,” a new diagnosis in which explicit references to personality traits were all but expunged. Instead, the emphasis in DSM-III (as well as in its 1987 revision, DSM-III-R) was on easily agreed-on transgressions against society. The advantage of this new approach was its objectivity: Clinicians could easily agree on whether an individual had committed a robbery or driven while intoxicated. However, the fourth edition, DSM-IV (1994), and its text revision, DSM-IV-TR (2000), brought psychopathic personality traits back into the list of diagnostic considerations to allow for the diagnosis of individuals without extensive criminal behavior, but who were, nonetheless, threats to the well-being of others and likely to be causing themselves unnecessary impairment or distress. The newest edition of the DSM, the DSM-5 (2013) lists antisocial personality disorder in two separate chapters: First, because of the disorder's close association with Conduct Disorder, it's diagnosis and treatment are discussed in two fifth edition chapters: "Disruptive, Impulse-Control, and Conduct Disorders" and "Personality Disorders."

Bibliography

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