The intimate connection between antisocial personality and substance abuse

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Clinical study of the relation of borderline personality disorder to Briquet's syndrome (hysteria), somatization disorder, antisocial personality disorder, and substance abuse disorders

OBJECTIVE: The criteria for borderline personality disorder seem to select patients with very high rates of Briquet's syndrome (hysteria), somatization disorder, antisocial personality disorder, and substance abuse disorders. This study was undertaken to determine whether systematic assessment of patients with borderline personality disorder would reveal characteristic features of that condition which would distinguish it from these other disorders. METHOD: Eighty-seven white female patients (75 in St. Louis and 12 in Milan, Italy) who had borderline personality disorder according to both the DSM-III-R criteria and the Revised Diagnostic Interview for Borderlines were further examined with the DSM-III-R Checklist and the Perley-Guze Hysteria Checklist to determine their patterns of psychiatric comorbidity. RESULTS: Every patient had at least one additional DSM diagnosis. Patients in St. Louis and Milan averaged five and four additional diagnoses, respectively. Eighty-four percent of the patients in St. Louis met criteria for either somatization disorder, Briquet's syndrome, antisocial personality disorder, or substance abuse disorders. Patterns of comorbidity for panic (51%), generalized anxiety disorder (55%), and major depression (87%) in St. Louis were consistent with those in other studies. CONCLUSIONS: The data indicate that the boundaries for the borderline condition are not specific and identify a high percentage of patients with these other disorders. Furthermore, the comorbidity profiles closely resemble the psychiatric profiles of patients with these disorders. If the borderline syndrome is meant to include all of these disorders, its usefulness as a diagnosis is limited. Until the fundamental features of borderline personality disorder that distinguish it from the others are identified, it is recommended that clinicians carefully assess patients for these other diagnoses. Efforts should be made to change the borderline personality disorder criteria by shifting away from overlap with the criteria for the other disorders.     

Antisocial personality disorder, conduct disorder, and substance abuse in schizophrenia.

The validity of subtypes based on antisocial personality disorder (APD) or childhood conduct disorder without adult APD (CD only) in patients with schizophrenia (or schizoaffective disorder) and a substance use disorder (abuse or dependence) was examined. APD patients scored lower on personality measures related to socialization and higher on antisocial bebavior, psychopathy, and aggression. APD patients also reported higher rates of aggression and legal problems. APD, and to a lesser extent CD only, was associated with more severe psychiatric symptoms, an earlier age of onset of substance abuse, more severe symptoms of substance abuse, and a stronger family history of substance abuse and psychiatric hospitalization. The findings suggest that schizophrenia patients with APD represent a high-risk subgroup vulnerable to more severe substance abuse, psychiatric impairment, aggression, and legal problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Diagnosing the DSM-III antisocial personality disorder.

The criteria for diagnosing the DSM-III antisocial personality disorder have become so broad as to include the vast majority rather than a small minority of criminals. The psychiatric diagnosis attributes to criminals a fundamental antisocial trait, which ignores low levels of cross-situational consistency and predictability of dangerous and criminal behavior. The diagnosis ignores individual differences regarding chronicity, degree of violence, situational determinants, and rehabilitation potential. Since required use of the diagnosis may often lead to prejudicial dispositional and therapeutic results that violate the ethical standards of psychologists, several responses to this dilemma are explored. (35 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

DSM—IV antisocial personality disorder field trial.

The development of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994 ) included 12 field trials to assess proposed revisions. This article provides results from the antisocial personality disorder (APD) field trial that was conducted to obtain data of relevance to the proposals for simplification and for the inclusion of more traditional traits of psychopathy. Provided herein are the results from 4 sites that had sampled from populations of particular relevance to the diagnosis of APD (i.e., prison inmates, psychiatric inpatients, outpatients with substance use disorders, and homeless persons). The results indicated that some items from the 3rd revised Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987) could be deleted without affecting the diagnosis. The field trial provided mixed support for the proposal to include more traditional traits of psychopathy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Child maltreatment moderates the association of MAOA with symptoms of depression and antisocial personality disorder.

There is a growing body of data indicating that Gene × Child Maltreatment interactions at monoamine oxidase A (MAOA) play a role in vulnerability to symptoms of antisocial personality disorder (ASPD) but not major depression (MD). Using a sample of 538 participants from the Iowa Adoption Studies, we introduce a conceptual model that highlights two distinct pathways from child maltreatment to symptoms of MD, suggesting that maltreatment has different effects depending on genotype and highlighting the importance of including the indirect pathway through ASPD. As predicted by the model, high activity alleles predispose to symptoms of MD in the context of child maltreatment whereas low activity alleles predispose to symptoms of ASPD. We conclude that the Gene × Environment interplay at this locus (MAOA) contributes to both symptoms of ASPD and MD and that careful specification of child maltreatment may be essential if genetic association research is to produce replicable results. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Gender differences in autonomic indicators of antisocial personality disorder features.

We investigated the autonomic indicators of antisocial personality disorder (APD) features in a mixed gender student sample. One hundred college students (50 men, 50 women) were administered an interview of APD and self-report measures of aggression and psychopathy. Participants completed a passive coping task and viewed emotionally valenced slideshows while their electrodermal activity (EDA), pre-ejection period (PEP), and respiratory sinus arrhythmia (RSA) were measured. Associations between APD features and autonomic reactivity were examined, controlling for aggression and psychopathy. APD features were associated with EDA hyporeactivity in men, but not women, during passive coping. While viewing threatening slides, APD features were associated with RSA hyperreactivity in women and with PEP hyperreactivity in men. APD features were associated with RSA hyperreactivity in women, but not men, while viewing slides of others in distress. These findings suggest that APD features are characterized by parasympathetic nervous system dysfunction in women but sympathetic nervous system dysfunction in men. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Correspondence between self-report and interview-based assessments of antisocial personality disorder.

Antisocial personality disorder (ASPD) is associated with suicide, violence, and risk-taking behavior and can slow response to first-line treatment for Axis I disorders. ASPD may be assessed infrequently because few efficient diagnostic tools are available. This study evaluated 2 promising self-report measures for assessing ASPD--the ASPD scale of the Personality Diagnostic Questionnaire-4 (PDQ-4; S. E. Hyler, 1994) and the Personality Assessment Inventory (PAI; L. Morey, 1991, 2007)--as well as the ASPD module of the Structured Clinical Interview for DSM-IV Axis II (SCID-II; M. B. First, R. L. Spitzer, M. Gibbon, J. B. W. Williams, & L. S. Benjamin, 1997). The measures were administered to 1,345 offenders in court-mandated residential substance abuse treatment programs and prisons. PDQ-4 and PAI scores related strongly to SCID-II symptom counts (rs = .67 and .51, respectively), indicating these measures convey useful clinical information about the severity of offenders' ASPD pathology. The dimensional association between the measures was relatively invariant across gender, race, and site, although differences in mean scores were observed. Levels of agreement of the SCID-II with the PDQ-4 (κ = .31) and PAI (κ = .32) in classifying participants as ASPD was limited. Alternative thresholds for both self-report measures were identified and cross-validated. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Validating female psychopathy subtypes: Differences in personality, antisocial and violent behavior, substance abuse, trauma, and mental health.

Recent empirical investigations utilizing male prisoners have begun to validate clinical conceptualizations of primary and secondary psychopathy subtypes. We extended this literature by identifying similar psychopathic subtypes in female prisoners on the basis of personality structure using model-based cluster analysis. Secondary psychopaths (n = 39) were characterized by personality traits of negative emotionality and low behavioral constraint, an early onset of antisocial and criminal behavior, greater substance use and abuse, more violent behavior and institutional misconduct, and more mental health problems, including symptoms of posttraumatic stress disorder and suicide attempts. Primary psychopaths (n = 31) exhibited few distinguishing personality features but were prolific criminals especially in regards to nonviolent crime, and exhibited relatively few mental health problems despite substantial exposure to traumatic events. The results support alternative etiological pathways to antisocial and criminal behavior that are evident in personality structure as well as gender similarities and differences in the manifestation of psychopathic personalities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Reliability of personality disorder symptoms and personality traits in substance-dependent inpatients.

The authors compared the internal consistency, 1-year temporal stability and self-informant agreement of ratings of personality trait (NEO Five-Factor Inventory; NEO-FFI; P. T. Costa & R. R. McCrae, 1992) and personality disorder symptom severity (Structured Clinical Interview for DSM-III-R personality Disorders Questionnaire; SCID-II-Q ; R. L. Spitzer, J. B. W. Williams, M. Gibbon, & M. First, 1990) in 131 substance-dependent inpatients. Internal consistency coefficients were acceptable to very good for most NEO-FFI and SCID-II-Q scales, and temporal stability correlations were significant for all measures. Agreement between patient and informant ratings was more modest. Substance abuse and depression symptom severity moderated the temporal stability and self-informant agreement of several personality trait and disorder ratings. The authors did not find that the five factors were more reliable than the Axis II symptoms. Issues related to the reliability of personality assessment in multiply diagnosed patients are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Unique roles of antisocial personality disorder and psychopathic traits in distress tolerance.

Previous research indicates that individuals with antisocial personality disorder (ASPD) evidence low distress tolerance, which signifies impaired ability to persist in goal-directed behavior during an aversive situation, and is associated with a variety of poor interpersonal and drug use outcomes. Based on theory and research indicating that psychopathic traits are associated with hypo-reactivity in emotional responding, a unique hypothesis emerges where psychopathic traits should have the opposite effect of ASPD and be related to high levels of distress tolerance. In a sample of 107 substance-dependent patients in an inner-city substance use residential treatment facility, this hypothesis was supported. ASPD was related to lower distress tolerance, while psychopathic traits were related to higher distress tolerance, with each contributing unique variance. Findings are discussed in relation to different presentations of distress tolerance as a function of psychopathic traits among those with an ASPD diagnosis. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Psychopathy and the DSM-IV criteria for antisocial personality disorder.

The Axis II Work Group of the Task Force on Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) has expressed concern that antisocial personality disorder (APD) criteria are too long and cumbersome and that they focus on antisocial behaviors rather than personality traits central to traditional conceptions of psychopathy and to international criteria. R. D. Hare et al describe an alternative to the approach taken in the DSM-III—Revised (DSM-III—R; American Psychiatric Association, 1987), namely, the revised Psychopathy Checklist. The authors also discuss the multisite APD field trials designed to evaluate and compare 4 criteria sets: the DSM-III—R criteria, a shortened list of these criteria, the criteria for dyssocial personality disorder from the 10th edition of the International Classification of Diseases (World Health Organization, 1990), and a 10-item criteria set for psychopathic personality disorder derived from the revised Psychopathy Checklist. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Childhood abuse, personality disorder and chronic fatigue syndrome

In a recent article entitled, Requests "for inappropriate" treatment based on religious beliefs, Orr and Genesen claim that futile treatment should be provided to patients who request it if their request is based on a religious belief. I claim that this implies that we should also accede to requests for harmful or cost-ineffective treatments based on religious beliefs. This special treatment of religious requests is an example of special pleading on the part of theists and morally objectionable discrimination against atheists. It also provides an excellent illustration of how different the practices of religion and ethics are.     

The effect of systematic variation in retrospective conduct disorder reports on antisocial personality disorder diagnoses.

A diagnosis of antisocial personality disorder (ASPD) requires a conduct disorder (CD) diagnosis. A CD diagnosis is often obtained retrospectively. This study tested the influence of current behavior on CD recall and the association between recent behavior change and inconsistencies in contemporaneous and retrospective CD reports. Five hundred young adults reported ASPD; retrospective CD; current problem behavior; and, at ages 12 to 15 years, contemporaneous CD. True-positive, true-negative, false-positive, and false-negative CD and ASPD groups were identified. The results supported the hypotheses. Participants whose current behavior agreed with past behavior provided reliable retrospective CD reports. Inaccurate diagnoses occurred among participants whose current behavior was inconsistent with past behavior, either becoming more problematic (CD and ASPD false positives) or less problematic (CD and ASPD false negatives) over time. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Identifying persistently antisocial offenders using the Hare Psychopathy Checklist and DSM antisocial personality disorder criteria.

Early starting, lifetime criminal persistence has been called sociopathy, antisocial personality disorder, and psychopathy. There is, however, disagreement about its core features and which measure is best for identifying such individuals. In the 1st of 2 studies of male offenders (n = 74), we found a large association between scores on the Psychopathy Checklist-Revised (PCL-R; R. D. Hare, 1991) and the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV; American Psychiatric Association, 1994) antisocial personality disorder criteria scored as a scale. The second study (n = 684) replicated this finding and found that, as previously shown for PCL-R scores, a discrete class (or taxon) also underlies scores on items reflecting antisocial personality disorder. The high association among these sets of items and their similarity in predicting violence suggested that the same natural class underlies each. Results indicated that life-course-persistent antisociality can be assessed well by measures of psychopathy and antisocial personality disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A twin study of the association between pathological gambling and antisocial personality disorder.

Many individuals with a history of pathological gambling (PG) also have a history of engaging in antisocial behaviors, and this has often been interpreted as a result of the former causing the latter. In a sample of 7,869 men in 4,497 twin pairs form the Vietnam Era Twin Registry, the authors examined (a) the association between PG and antisocial personality disorder (ASPD), (b) the extent to which PG might be differentially associated with childhood conduct disorder (CD) and adult antisocial behavior (AAB), and (c) the contribution of genetic and environmental factors to the association of PG with ASPD, CD, and AAB. PG was significantly associated with all 3 antisocial behavior disorders, and the association of PG with ASPD, CD, and AAB was predominantly explained by genetic factors. The results of this study suggest that the greater-than-chance co-occurrence of PG and antisocial behavior disorders is partially due to their sharing a common genetic vulnerability. The antisocial behavior observed among many individuals with PG probably cannot be interpreted as being simply a consequence of the PG. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment outcome for substance misuse patients with personality disorder

Treatment outcome was compared for three groups of patients in a chemical dependency unit--14 patients with personality disorder, 16 patients with traits of personality disorder, and 34 patients with no personality disorder. Patients with personality disorder were as likely as other patients to complete the 4-month aftercare program and to maintain abstinence while in the aftercare program.     

Temporal stability of antisocial personality disorder: blind follow-up study at 8 years

We studied the relation between Helicobacter pylori and residual gastritis in 28 patients with gastric cancer on whom distal partial gastrectomy with Billroth I reconstruction was performed over a 13-month period. They were subjected to serologic testing along with endoscopic and histologic examinations before operation and at 3, 6, and 12 months after operation. Anti-H. pylori immunoglobulin G (IgG) and serum gastrin levels were measured by serologic tests. The presence or absence of gastritis was determined endoscopically, and gastric mucosal hexosamine levels were determined. Gastritis was measured quantitatively by histologic examination in specimens taken from the gastric mucosa using Rauws' score. After the initial histologic evaluation we divided the H. pylori-positive patients into two groups: those with a Rauws' score of 0 to 3 ("weak" gastritis group), and those with a Rauws' score of 4 to 10 ("strong" gastritis group), allowing us to compare the results of our three postoperative histologic examinations of the two groups for possible significant differences. Our endoscopic examinations showed gastric mucosal inflammatory changes in both H. pylori-positive and H. pylori-negative patients at 3, 6, and 12 months after operation, but there was no significant difference between these two groups at any point. During the histologic examinations, however, anti-H. pylori IgG assay had become negative in several patients in the "weak" gastritis group at 3 months after operation and was found to have become negative in 78% of all patients in that group 12 months after operation. In contrast, in the "strong" gastritis group H. pylori infection was still evident in the patients 12 months after operation, suggesting that "strong" histologic gastritis may have some connection to H. pylori infection, whereas "weak" histologic gastritis has no such connection. The gastric mucosal hexosamine level was higher in the "weak" gastritis group than in the "strong" gastritis group both before operation and at 6 and 12 months, indicating some relation between gastric inflammatory changes and hexosamine levels in gastric mucosa. It further suggested the possibility that H. pylori plays a role in destroying gastric mucosa by depleting mucin, thus acting as one (though not the only) cause of residual gastritis after distal partial gastrectomy. In conclusion, we found evidence that there is a relation between residual gastritis and H. pylori infection, but H. pylori is not the sole cause of residual gastritis after gastric surgery. A causal relation is difficult to detect by simple analysis of histologic findings or by endoscopic observation or clinical symptoms alone.     

Conduct disorder: Parsing the confounded relation to parental divorce and antisocial personality.

Previous research has shown an association between parental divorce and child conduct problems. This relation is confounded, however, because antisocial personality disorder (APD) is common among the parents of children with conduct disorder (CD) and divorce is very frequent for adults with this disorder. Twenty-eight clinic-referred boys who received a Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980) diagnosis of conduct disorder and 34 who received any other diagnosis served as subjects. A 2 (APD vs. not APD)?×? 2 (divorced vs. not divorced) log-linear analysis revealed a significant main effect for APD with the number of sons given the diagnosis of conduct disorder as the dependent variable, but the main effect for divorce and the interaction were not significant. Among boys with divorced parents, more than twice as many boys with a parent with APD received a diagnosis of CD than boys without a parent with APD, but there was no significant association between divorce and CD in the absence of parental APD. A similar 2?×?2 analysis of variance of the number of 13 specific DSM-III symptoms of conduct disorder resulted in essentially identical findings. These results suggest the hypothesis that parental APD is directly linked to both parental divorce and child CD, but the divorce and CD are not directly related. Methodological limitations of the present dataset are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)