Alcohol Medical Scholars Lecture

Antisocial Personality Disorder

Karin Neufeld MD MPH

I.

SLIDE 1

Introduction

SLIDE 2

Who was Gary Gilmore?

Example of severe ASPD (see appended biography)

A. History and importance:

1.

SLIDE 3

Long history of identification.

a) “Moral insanity” by Pritchard¹: repeated immoral behaviors from psychological deficits.

b) Psychopathic character:

(i) Late 1800’s: socially unacceptable personality characteristics.

(ii) Cleckley² influenced DSM I and II³.

c) Sociopathy⁴:

(i) Coined in 1930;

(ii) “Anything deviated or pathological in social relations”.

d) Antisocial Personality Disorder (ASPD):

(i) Robins⁵ studied adults 40 yrs after involvement in juvenile court system.

(ii) Antisocial Personality Disorder (ASPD) adopted in 1980 (DSM III): largely based on Robins’ work⁶.

2.

SLIDE 4

Most valid and reliable of the personality diagnoses.

a) Only personality diagnosis derived from empirical data⁵.

b) Includes the childhood precursor of Conduct Disorder (CD) in diagnosis^6.

c) Inter-rater reliability of diagnosis is average to good (.75)^7,8..

3.

SLIDE 5

Great public impact.

a) 6 X hrisk of death in adolescence and young adults with antisocial behavior⁹.

b) High psychiatric comorbidity: 80% of ASPD have substance use disorder (SUD)¹⁰.

c) High cost of incarceration and law enforcement:

(i) 50% male prisoners with ASPD¹¹.

(ii) 41 billion $/yr (US) for prison system.

B.

SLIDE 6

Purpose of this lecture:

1. Review diagnosis.

2. Describe epidemiology.

3. Review possible etiologic mechanisms (risk factors).

4. Describe the course.

5.

SLIDE 7

Review treatment of the disorder.

C. Key points about ASPD:

1. Very common among those with SUD.

2. Caused by interplay between genetic and environmental factors.

3. Associated with great morbidity and mortality.

4. Difficult to cure but possible to help.

SLIDE 8

II. Diagnosis according to DSM IV¹²

A.

SLIDE 9

Pervasive pattern of behavior:

1. Persistent disregard and violation of the rights of others since age 15.

2. Presence of 3 + of:

a) Repeatedly failing to obey the law.

b) Repeated lying, aliases, conning for profit or pleasure.

c) Impulsivity or failure to plan ahead.

d) Irritability, aggressiveness, repeated physical fights or assaults.

e) Reckless disregard for safety of self or others.

f) Enduring irresponsibility: no sustained work or meeting $ obligations.

g) Lack of remorse for hurting/mistreating others.

B.

SLIDE 10

Age criterion: At least 18 years of age.

C. Childhood precursors:

1. Meets criteria for conduct disorder (CD): onset < 15 years.

2. Conduct problems cause impairment.

3. Behaviors repeated over 12 + mo period.