Antisocial personality disorder

• 1. Introduction

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  Antisocial personality disorder, abbreviated ASPD, is diagnosed in somewhere between 1 and 4 percent of people in the general population. Among prisoners, the share climbs to just under 50 percent. That gap is one of the first things to understand about a condition defined by a chronic pattern of disregarding the rights and well-being of others. People with ASPD often behave in ways that clash with social norms, and the consequences ripple through relationships, work, and encounters with the law. The label is tangled up with older and louder words, such as psychopath and sociopath, and clinicians still argue about where one idea ends and another begins. This documentary asks what ASPD looks like from the inside and the outside, where it seems to come from, why its name keeps changing, and whether anything can be done about it.

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• 2. Daily Signs

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  Chronic boredom appears in the clinical descriptions of people with ASPD, alongside a flattened emotional life. Patients have been documented describing their feelings with ambivalence, and they often show heightened coldness and detachment. They may feel happiness and fear less clearly than other people do. Anger and frustration, by contrast, may register more often and more sharply. Empathy tends to be limited, and a person with the disorder may care more about personal gain than about avoiding harm to others. Relationships can come to revolve around exploiting and abusing other people.

  Theory of mind research has produced a surprising split. Some people with ASPD struggle with mentalizing, which means working out what another person is thinking or feeling. Others keep a fully intact theory of mind but cannot grasp how an aggressive act will affect someone else. Many remain skilled at social cognition, the processing and storing of information about other people, and that skill can sharpen their ability to manipulate. Some manipulate through a façade of superficial charm, while others rely on intimidation and violence.

  Addiction is where the disorder leaves its clearest mark. ASPD is the personality disorder most likely to be associated with addiction, and recklessness and impulsivity push people toward drugs and alcohol at a young age. Documented risks include illegal drug use, blood-borne diseases, HIV, shorter periods of abstinence, and compulsive gambling. The same impulsivity is tied to domestic violence, pervasive anger, and violent crime, as well as sexual risk-taking such as frequent unprotected sex. Arson and the destruction of other people's property are also commonly associated with the condition.

  People with ASPD are approximately 13 times more likely to be diagnosed with a substance use disorder than people without it. They are also about four times as likely to experience major depressive disorder. Anxiety disorders, particularly post-traumatic stress disorder and social anxiety disorder, affect up to 50 percent of those with the diagnosis. When alcoholism is added, frontal brain function deficits on neuropsychological tests can exceed those linked to either condition alone.

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• 3. Childhood Roots

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  The age of 15 is the line the DSM-5 draws through every ASPD diagnosis. To qualify, a person must be at least 18 and must show evidence that conduct disorder began before that fifteenth birthday. Conduct disorder is the childhood pattern of repeatedly violating the basic rights of others or major age-appropriate norms. Affected children may be impulsive, aggressive, callous, and deceitful. They may steal, vandalize, or fight with other children and adults. About 25-40 percent of youths with conduct disorder are diagnosed with ASPD as adults.

  Age 10 separates two developmental courses of conduct disorder. The childhood-onset type begins before 10 and is linked to a more persistent life course, with more ADHD symptoms, neuropsychological deficits, academic problems, and family dysfunction. These children are also more likely to be aggressive and violent. The adolescent-onset type appears after 10, involves less impairment in cognitive and emotional functioning, and may fade by adulthood. The DSM-5 adds a specifier for a callous and unemotional interpersonal style, which mirrors characteristics seen in psychopathy.

  Oppositional defiant disorder, or ODD, is a close cousin that is easy to confuse with conduct disorder. Children with ODD do not commit aggressive or antisocial acts against people, animals, or property, though many are later re-diagnosed with conduct disorder. Behavior in conduct disorder is typically persistent and can be hard to deter with either threat or punishment.

  Boys are almost twice as likely as girls to meet all the diagnostic criteria for ASPD, and they often show symptoms much earlier. Children who show no symptoms through age 15 will almost never develop the disorder later. Fire-setting and cruelty to animals during childhood are also linked to its development. Professor Emily Simonoff of the Institute of Psychiatry, Psychology and Neuroscience lists variables consistently connected to ASPD: childhood hyperactivity, conduct disorder, adult criminality, lower IQ scores, and reading problems. Children with a predisposition who mix with other delinquent children are likely to be diagnosed later.

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• 4. Genes And Brain

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  Twin studies, which are designed to separate genetic from environmental effects, have found significant genetic influence on antisocial behavior and conduct disorder. ASPD is also more common in people related to someone who has it. One gene has drawn particular attention. It encodes monoamine oxidase A, or MAO-A, an enzyme that breaks down neurotransmitters such as serotonin and norepinephrine. Variants that produce less MAO-A, including the 2R and 3R alleles of the promoter region, are associated with aggression in men.

  Childhood experience changes what that gene does. Children with the low-activity variant, MAOA-L, who meet negative circumstances are more likely to develop antisocial behavior than children with the high-activity variant, MAOA-H. A small association between MAOA-L and aggression remains even when environmental factors such as emotional abuse are taken out of the equation.

  The serotonin transporter gene, SLC6A4, adds a twist. Its short "S" allele is associated with impulsive antisocial behavior and ASPD in inmates. Psychopathy research, however, links the long "L" allele to Factor 1 traits, the core lack of empathy and fearlessness, along with grandiosity and manipulativeness. That hints at two forms of the disorder. One is tied to impulsivity and emotional dysregulation, and the other to predatory aggression and affective disturbance.

  A genome-wide association study published in 2016 identified further candidate genes, several of them shared with ADHD, which often occurs alongside ASPD. People who carry four mutations on chromosome 6 were 50 percent more likely to develop the disorder than people who do not.

  A meta-analysis of 20 studies found significantly lower levels of 5-HIAA, a sign of lower serotonin, especially in people younger than 30. Reduced serotonin function is also strongly tied to impulsiveness and aggression across many experimental setups. The DSM lists "impulsivity or failure to plan ahead" and "irritability and aggressiveness" among the seven sub-criteria of its category A. Hormones play a part too. Men who have committed violent crimes tend to have higher testosterone, which may help explain why men are diagnosed more often. Cortisol pushes the other way, because it supports cognitive control of impulsive tendencies.

  Popular culture loves the "psychopathic genius", but the research points the opposite direction. ASPD is associated with reduced overall intelligence and specific reductions in individual aspects of cognitive ability. Scans show reduced grey matter in prefrontal regions, including the ventromedial prefrontal cortex, and in the amygdala and insula. Those regions help govern emotional regulation, response inhibition, and decision making. One study of cavum septi pellucidi, a marker of limbic neural maldevelopment, found that people with it had significantly higher antisocial personality scores, more psychopathy, and more arrests and convictions than controls. Some investigators question whether reduced prefrontal volume comes from ASPD itself or from substance use disorder and childhood maltreatment. It remains an open question whether the anatomy causes the behavior or the reverse.

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• 5. Home And Culture

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  Dr. Bruce Perry, in his book The Boy Who Was Raised as a Dog, describes what an unpredictable early home does to a developing brain. A lack of parental stimulation and affection can produce high cortisol without balancing hormones such as oxytocin. That overloads the child's stress response systems and is thought to leave underdeveloped the part of the brain handling emotion, empathy, and emotional connection. In Perry's words: "An environment of intermittent care punctuated by total abandonment may be the worst of all worlds for a child."

  Emotional and physical abuse in childhood are highly comorbid with ASPD, and physical neglect correlates significantly with it. Poor parental bonding raises the risk, and so does parental overprotection. Reported childhood experiences include sexual abuse, coercion, abandonment, community violence, acts of terror, bullying, and life-threatening incidents. Having an antisocial or alcoholic parent also raises the risk. None of these alone is likely to be the sole cause, and relating to one does not mean a person should be identified as having ASPD.

  Robert D. Hare has suggested that the rise in ASPD reported in the United States may be linked to changing cultural norms. He is cautious, since the rise may partly reflect the widening use of diagnostic techniques. Psychiatrist Eric Berne divided people into active and latent cases, and the latent ones keep themselves in check through an external source of control such as the law, tradition, or religion. On that view, eroding collective standards could release latent individuals from their prosocial behavior.

  The controversial clinical psychiatrist Pierre-Édouard Carbonneau has weighed in on forced admission. He warns that wrongly diagnosing someone and coercing them into medication could be potentially disastrous. Yet he argues a psychiatrist cannot ignore the risk of leaving a real case untreated, and in his words must "play it safe".

  In Western, individualistic societies such as the United States and much of Europe, ASPD is usually treated as a problem of personal behavior, often tied to criminal actions. In collectivist cultures such as China, Japan, and South Korea, the same behaviors may be seen as damage to family and community bonds. Doctors there may diagnose them differently or less often, partly because of stigma. Treatment follows the pattern. Western care leans on cognitive behavioral therapy and legal supervision, while collectivist settings may involve more family and community effort.

  In Ethiopia, a study of incarcerated men found that approximately 31 percent met criteria for ASPD. The disorder was strongly associated with substance use disorders, particularly alcohol and khat. People with ASPD tend to be convicted more often and receive longer sentences, with assault and other violent crimes the most common charges. Researchers drawing on Moffitt's life-course-persistent framework argue that prison prevalence reflects developmental pathways shaped by poverty, maltreatment, and institutions, and not only clinical diagnosis. They add the concept of the "mindful body", which treats ASPD as an individual condition, a reflection of social norms about deviance, and a product of political systems such as incarceration.

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• 6. Names And Labels

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  The first DSM, published in 1952, did not use the name antisocial personality disorder at all. It listed "sociopathic personality disturbance", for people "ill primarily in terms of society and of conformity with the prevailing milieu". There were four subtypes, called reactions: antisocial, dyssocial, sexual, and addiction. People in the antisocial reaction were described as "always in trouble" and having "no loyalties". The category was meant to be narrower than the older, very broad ideas of the "constitutional psychopathic state" and "psychopathic personality". That narrower approach followed criteria advanced by Hervey M. Cleckley from 1941. The term sociopathic had been advanced by George Partridge in 1928, and Partridge found a correlation with parental rejection in early childhood.

  The DSM-II in 1967 rearranged the categories, and "antisocial personality" became one of ten personality disorders. Its description spoke of people who are "basically unsocialized", selfish, irresponsible, and unable to feel guilt or learn from experience. The preface instructed that antisocial personality should always be specified as mild, moderate, or severe. It also warned that a history of legal or social offenses was not enough to justify the diagnosis. The older dyssocial type was demoted to "dyssocial behavior", covering predatory people such as racketeers and dishonest gamblers. That word later resurfaced in the WHO's ICD as dissocial personality disorder, considered approximately equivalent to ASPD.

  The DSM-III in 1980 introduced the full term antisocial personality disorder. For the first time it came with a full checklist of observable behaviors, designed to make different psychiatrists agree more often, a goal called inter-rater reliability. The list rested on the Research Diagnostic Criteria, which grew from the Feighner Criteria of 1972. Credit largely goes to sociologist Lee Robins and her 1966 research, published as "Deviant Children Grown Up". Robins later clarified that the diagnostic criteria she and psychiatrist Patricia O'Neal used came from her husband, the psychiatrist Eli Robins, an author of the Feighner criteria.

  The DSM-IV kept the behavioral emphasis but noted that the pattern "has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder". It also restored some underlying personality traits to its summary of associated features. The DSM-5 kept the same diagnosis, yet it also introduced a second, alternative way of defining it.

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• 7. Diagnosis Today

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  Ten categories of personality disorder survive in section II of the DSM-5, carried over from the DSM-IV. ASPD is defined there by at least three of seven traits, and the behavior cannot be explained by schizophrenia or bipolar disorder. Critics point to excessive comorbidity among personality disorders and to heterogeneity within each category. They also object to the frequent use of the uninformative catch-all personality disorder-not otherwise specified, or PD-NOS.

  The DSM-5 Personality and Personality Disorders Work Group devised the Alternative DSM-5 Model for Personality Disorders, or AMPD, as a response. It judges the level of personality functioning in criterion A and the pathological traits present in criterion B. For ASPD, the identity impairment is described as "Egocentrism; self-esteem derived from personal gain, power, or pleasure". Criterion B requires at least six of seven traits, drawn from the domains of antagonism and disinhibition. A "with psychopathic traits" specifier can be added, defined by low anxiousness and withdrawal and high attention-seeking.

  The World Health Organization took a different path in ICD-11. It replaced the categorical ICD-10 scheme with one unified personality disorder rated by severity, plus specifiers for prominent traits. Dissocial personality disorder is consistently associated with the trait domains Dissociality and Disinhibition, which reflect callousness, lack of remorse, impulsivity, and risk-taking.

  Psychopathy is the loudest complication. Canadian researcher Robert D. Hare's Psychopathy Checklist, Revised, or PCL-R, measures it, but "psychopathy" is not the official title of any DSM or ICD diagnosis. Critics argue ASPD is not synonymous with psychopathy, because ASPD criteria emphasize personality traits less. The reason, according to the source, is that it was "easier to agree on the behaviors that typify a disorder than on the reasons why they occur". The ASPD diagnosis covers two to three times as many prisoners as psychopathy does. Hare nevertheless believes the PCL-R better predicts future criminality, violence, and recidivism, and he warns that confusion between the two can matter in courts, where psychopathy is often seen as aggravating a crime. The AMPD describes the psychopathic variant as marked by "a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviors (e.g., fraudulence)".

  Theodore Millon proposed five subtypes of ASPD, though neither the DSM nor the ICD recognizes them. They are nomadic, malevolent, covetous, risk-taking, and reputation-defending. The reputation-defending type needs to be seen as infallible and overreacts to slights. Elsewhere Millon describes ten subtypes that partly overlap, while stressing that "the number 10 is by no means special... Taxonomies may be put forward at levels that are more coarse or more fine-grained."

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• 8. Treatment And Outlook

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  ASPD is considered among the most difficult personality disorders to treat. Because remorse is very low or absent, patients often fail to see the costs of antisocial acts and lack motivation to change. They may simulate remorse, and they can be charming and dishonest, manipulating staff and fellow patients. Outpatient therapy is not likely to succeed, though the extent to which people with ASPD are unresponsive may have been exaggerated. Most treatment happens inside the criminal justice system, and patients may stay only as long as an external source, such as parole conditions, requires. Residential programs combining structure, supervision, and peer confrontation have been recommended.

  Schema therapy is being investigated for ASPD. A review by Charles M. Borduin highlights multisystemic therapy, which could help but requires the full cooperation of all family members. Mentalization Based Treatment, a psychodynamically oriented therapy for personality disorders, has shown potential for reducing aggression in patients under probation. Therapists may feel considerable negative emotion toward patients with long histories of exploitative and abusive behavior. Instead of trying to build a conscience, which is extremely difficult, they focus on rational and utilitarian arguments against repeating past offenses.

  No medication has been approved by the FDA specifically for ASPD. A 2020 Cochrane review of eight qualifying studies found the evidence inconclusive. Antipsychotics, antidepressants, and mood stabilizers can still be used to manage aggression and impulsivity, or to treat co-occurring disorders.

  Symptoms tend to peak in the late teens and early twenties and can improve through age 40. Researchers sometimes call the decline in impulsive and aggressive behavior "antisocial burnout", though manipulativeness and emotional detachment may persist. A study of 443 emerging adults found that low parental behavioral control and high impulsivity were significant predictors of antisocial personality problems. Past studies found remission in only 27-31 percent of patients, with "the most violent and dangerous features remitting". Because charm is part of the pattern, patients may appear "cured" simply to get out of treatment. In older adults, frontotemporal dementia can mimic or worsen antisocial behavior, which complicates assessment.

  A study of homeless youths in San Francisco and Chicago found that 84 percent and 48 percent respectively met the criteria for ASPD. Another study of homeless people found that 25 percent had it. Divorce, unemployment, and premature death by suicide are also more common, and suicide is a leading cause of death among youth who display antisocial behavior alongside delinquency. One study found aggressive tendencies in about 72 percent of male patients, with about 29 percent showing premeditated aggression. Researchers concluded that aggression in ASPD is mostly impulsive. Harvard Medical School notes that, for severe cases, time and resources may be better spent treating the victims, such as the patient's family.

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