Anti-social Personality DisorderAPD: Objectives
ØHighlight signs and symptoms presenting in APD via case study ØDiscuss the problems in identifying APD’s etiological determinants
(w/r nomenclature, developmental schemas, and research methods) ØReview and discuss a study seeking to identify possible etiological
determinants of APD ØHighlight a study seeking to identify possible etiological determinant ØHighlight a study seeking to identify possible etiological determinant
of APD as it relates to culture/diversity ØProvide overview of DSM-V revisions of APD as proposed by the APA ØSuggest two possible exam questions pertinent to the diagnosis and
theoretical conceptualization of APD ØPresent an annotated bibliography of five studies seeking etiological
explanations of APD ØProvide references and resources for further familiarization with
APD/psychopathy
Nate’s misbehavior as a child took many forms including temper tantrums, lying, petty theft, setting fires, & bullying. At 12yrs old, he became, increasingly interested in drugs & was arrested for cocaine possession. While in juvenile detention he secretly cooked meth in his cell & sold samples to fellow inmates. When he was 14 he made crude sexual advances toward a younger girl, & when she threatened to tell her parents he locked her in a shed & proceeded to behead her cat. It was about 16 hrs before she was found. Nate was delighted that he
APD: Case StudyAPD: Case Study
It was about 16 hrs before she was found. Nate was delighted that he was never caught.
When he was 17, Nate forged his father’s name to a large check & spent a year traveling the around Caribbean and S. America making adult films. He lived well but continued to fabricate lies to avoid paying spa & hotel bills. His sexual experiences were frequent, casual, callous, & often under the influence of crystal meth. He had 3 marriages before he was 30; they all ended in divorce due to his repeated patronage of hookers, use of “roofies” on his wife & step kids, & hocking their family heirlooms on e-Bay.
Nate, now 30, was set to complete a 7-yr prison term for arson, bigamy, & assault with a chainsaw when, w/ less than 1 mo. left to serve, he faked illness & escaped from the prison hospital. During the 10 mo. escape, he lived off money he conned from nursing homes while impersonating a priest. When spotted by police, he stole an ice- cream truck at gun point & drove to Mexico. Reports say he ran 5 stop signs. Nate was captured at the airport set to board a flight to Costa
APD: Case Study cont’dAPD: Case Study cont’d
signs. Nate was captured at the airport set to board a flight to Costa Rica. When interviewed, he reflected stating he was only sorry that he wasn’t wearing his Gucci shades to block the flashing lights of the police cars and news cameras.
APD also abbreviated ASPD, associated with terms 1 psychopathy dissocial personality disorder (DPD), sociopathy moral insanity Varying nomenclature can be problematic Reflecting different theoretical orientations w/r
definition of APD, instruments used diagnose/assess APD, design of Tx interventions & review of Tx outcomes for APD,
APD: A Problem of NomenclatureAPD: A Problem of Nomenclature
design of Tx interventions & review of Tx outcomes for APD, BUT also differing views on the Etiology of APD
DSM-IV-TR sees all the above terms as ONE construct 2 ICD-10 does not see all terms as the same 3
DSM-IV-TR focal are overt Bx (aggress/delinquency/ criminality) ICD-10- focal are intra/interpersonal cognitive and affective traits Nomenclature reflects Operational definition → affect the factors considered valid/reliable → affect what we look for& offer as proof4
APD Does NOT EXIST before 18th birthday, but is this assertion a Legal standard? or one based on irrefutable empiricism? 4
If we agree APD does not appear randomly,… then do “roots” of APD exist before age 18yr? And if so what are they?
A “root” DSM recognized & proposed: Conduct Disorder (CD) 5
APD: A Problem of Developmental ReificationAPD: A Problem of Developmental Reification
Is CD a cause, a result, or bystander (correlate)? Cant be result, b/c developmentally CD comes before APD If cause, then unreliable b/c not all CD cases → APD 6 If correlate, then correlation is perfect and imperfect
r = 1 by DSM’s definition of APD where CD is a criterion (C) r≠1 by DSM’s definition of CD
Maybe CD is partial correlate ?
Even when we all agree on APD construct, we may differ on which method best identifies the etiology?
Research methods: self reports, parent or teacher reports criminal records
APD: A Problem of Research MethodologyAPD: A Problem of Research Methodology
criminal records neuro-imaging, physiological reactivity behavior genetics, twin studies cross-sectional or longitudinal designs can influence results of an Etiological study of APD 4,7
Journal: Journal of Consulting & Clinical Psychology, 2007 Title: Development of antisocial personality disorder in detained youths: The predictive value of mental disorders. DOI: 10.1037/0022-006X.75.2.221 8
Authors: Washburn and colleagues
APD: A Study on EtiologyAPD: A Study on Etiology
Authors: Washburn and colleagues Affiliated institutions: Northwestern University’s Feinberg School of Medicine (IL), and Alexian Brothers Behavioral Health Hospital (IL)
Design: A prospective, longitudinal design (which was non- randomized, used convenient sample, & had no control group) Number of Literature citations: 14 published studies as of 2010 per PsycINFO (Nov, 2010) 9
Rationale: Pervasive Antisocial Bx is burden on community & systems 8 Identifying at risk youth is critical for prevention of APD 8
95,000 youths detained in U.S.A. on any given day 8 50%-66% detained youths have ≥ 1 mental D/O 8
APD: A Study on EtiologyAPD: A Study on Etiology
50%-66% detained youths have ≥ 1 mental D/O Lets specify factors believed to affect development of APD
How is study Unique? 1st prospective study examining development of APD among youths involved in juvenile justice system 8
Study of detained youth = DYS (the detained youth study)
Disruptive Bx risk: Dx CD means 17X → APD, compared to nL 10
Each CD Sx (up to 5 Sx ) ↑ risk for APD by 37% 11
Covert Sx of CD v. Overt Sx of CD ↑ risk for APD 11
ODD w/ comorbid ADHD ↑ risk for CD… which ↑risk for APD 10
CD w/ comorbid ADHD ↑↑ risk for APD 12
APD: Prior Scholarship on Risk for APD (DYS)APD: Prior Scholarship on Risk for APD (DYS)
Mood disorder risk: Anxiety D/O ↓risk for APD, Depressive D/O ↑risk 10
Substance-related disorder risk: Strong association between youth marijuana use and APD 13
Race/ethnicity risk: More Blacks than Whites in detention, but whites show more mental D/O and more substance related D/O 8
Mental D/O can co-vary and/or interact (CoVI) Roots of APD exist in before age 18 years Mental D/O existing before age 18 yr may CoVI to give APD
Hypothesis 1 CD will associate with APD As No. of CD Sx ↑, Risk of APD ↑
APD: Theory and Hypotheses (DYS)APD: Theory and Hypotheses (DYS)
As No. of CD Sx ↑, Risk of APD ↑ No. of covert, but not overt, CD Sx will associate more with APD Hypothesis 2 CD will mediate association betw. other Disruptive Bx D/O & APD ADHD wont ↑ risk of APD if CD is absent Hypothesis 3 Mental D/O (other than Non-Disruptive Bx) will associate with APD Depressive and substance-related D/O will ↑ risk of APD Anxiety D/O will ↓ risk of APD [Again, Hypotheses 1,2,3, all with respect to detained youth]
N= 1829 “Convenient sample” i.e., Youths arrested/detained at CCJTDC in Cook County, Chicago According to authors, sampling was wasn’t erroneous as • IL’s juvenile justice system typical
Informed consent/assent Age <15yr excluded •Initial interview w/n 2days
of intake •FU interview ~ 3.3 yrs later
in jails (29%), community (70%),
APD: Participants and Methods (DYS)APD: Participants and Methods (DYS)
• IL’s juvenile justice system typical to others
• Most detention centers in urban areas
• Racially/ethnically diverse • Gender, age, offense distributions
similar to detained juveniles nationwide
community (70%), Tx centers/home(1%)
• At FU new N= 1112 • M= 681 and F= 431 • W(186), B(605), H(319),
other(2) • Mean age at FU is 19yr • Median annual income at
FU was $1,700
Materials DISC Version 2.3 to assess w/n past 6mo a DSM-III-R Dx of CD, ODD, ADHD; MDD, dysthymia, OCD, GAD, panic D/O; Or Substance Use
DIS Version 4 to assess w/n past 12mo a DSM-IV Dx of APD w/o criterion C = M-APD (modified APD)
APD: Materials and Analyses (DYS)APD: Materials and Analyses (DYS)
APD w/o criterion C = M-APD (modified APD)
Statistical Analysis Data stratified on age, sex, race, legal status Sample Weights for descriptive stats Taylor series linearity/Logistic regression for association between mental D/O & M-APD, Pt. demographics & M-APD
At 3yr FU: 17.3% participants → APD, while 27.6% → M-APD More males than females → APD [p<.05]
Hypothesis 1 CD will associate with APD? True [p<.05] As No. of CD Sx ↑, Risk of APD ↑? True [p<.05] and discontinuity in linearity for No. of CD Sx ≥5 (suggesting Sx threshold) No. of covert, not overt, CD Sx associate more w/ APD? True [p<.05]
APD: Results (DYS)APD: Results (DYS)
No. of covert, not overt, CD Sx associate more w/ APD? True [p<.05]
Hypothesis 2 ADHD wont ↑risk APD if CD is absent? False. ADHD will ↑risk APD if CD is absent [p<.05] CD will mediate association betw. other Disruptive Bx D/O and APD?
False, w/r both ADHD & ODD… But note CD mediates ADHD association w/ APD [p<.05] only if
CD Sx ≥ 5 (post-hoc analysis)
Hypothesis 3 Mental D/O (other than Non-Disruptive Bx) will associate with APD? True w/r alcohol use [p<.05] True w/r dysthymia [p<.05] False w/r MDD
APD: Results (DYS)APD: Results (DYS)
Anxiety D/O will ↓risk of APD? True w/r GAD [p<.05] False w/r OCD, panic D/O
APD: Discussion of Findings (DYS)APD: Discussion of Findings (DYS) Similar to youths receiving mental health Tx, detained youths w/ CD later exhibit APD as adults
In detained youths, the presence of CD, ↑’d No. of covert CD Sx, ADHD, dysthymia, and alcohol use (before 18 age yrs) are factors that ↑ risk of developing APD in adulthoods (at after 18 age yrs)
Results provoke the following Questions: What’s so special ab/o CD? What’s so special ab/o Covert Sx in CD? What’s so special ab/o ADHD? What’s so special ab/o dysthymia? What’s so special ab/o alcohol use? What’s so special ab/o GAD w/r ↓ risk APD?
CD No explanation given (maybe b/c CD and APD viewed as one in same) Covert CD Sx Overt CD Bx draws immediate attention/risk for rejection/extinction. While covert Bx draw less immediate attention & thus ↓risk for rejection & ↑ likelihood of persistence
APD: Discussion of Findings (DYS)APD: Discussion of Findings (DYS)
& ↑ likelihood of persistence ADHD No explanation given (maybe ADHD risk for social discord) Dysthymia Low-levels irritability/self-esteem/pessimism ↑risk for social discord, impaired decision making & likelihood of irresponsible Bx Alcohol Alcohol leads to ↑ affective volatility and impulsivity
APD: Discussion of Findings (DYS)APD: Discussion of Findings (DYS)
GAD GAD’s excessive worrying is conceptually inconsistent w/ the fearlessness and Bx disinhibition found in persons with APD. Anxiety may ↑social isolation, ↑inhibition, & ↓ opportunities for engaging in antisocial Bx.
Clinical implications w/r the etiology of APD: CD not reliable predictor of APD (as APD seen w/o prior Dx of CD) But if assessing CD, covert Sx ≥ 5 in No. has greater prognostic value Assessing dysthymia may be of greater prognostic value
See Table 2: positive predictive value of CD, CD with Covert Sx ≥ 5, dysthymia, and combined CD with Covert Sx ≥ 5 with dysthymia were 35%, 49%, 48%, and 61%, respectively
Strengths: Large sample size Interviews done in-person Interviews were structured DISC-2.3 and DIS-IV show acceptable validity/reliability
Weaknesses: No control of variables experienced
between initial & FU interviews Results maybe generalizable only to detained youths
Dissimilar race/ethnicity rates
APD: Study Strengths and Limitations (DYS)APD: Study Strengths and Limitations (DYS)
acceptable validity/reliability w/r assessing DSM D/O
Similar gender rates
Acculturation Stress, Anxiety Disorders, and Alcohol Dependence in a Select Population of Young Adult Mexican-Americans by Ehlers et al. (2009) 14
Study sought to ascertain and quantify the association between
APD: Study of etiological determinant in Mexican-Americans (diversity)
Study sought to ascertain and quantify the association between acculturation stress and alcohol-related disorders in influencing the risk of mental health disorders (including CD and/or APD) within immigrant Mexican-American young adults. Results from studying a sample of 240 showed acculturation stressors are not associated with or increase the risk of APD (and/or CD) in immigrants with alcohol-related disorders and who self-identify as Mexican-American.
DSM-V Proposed Revisions of APD APD (301.82) will be one of ONLY 5 Personality Disorders (PD) 15
Each PD will be rated by clinicians w/r severity of level of personality functioning dimensions of personality traits (domains and facets)
Unclear if name of Dx will be “APD” or “Antisocial/Psychopathic PD” Focal will be two general components of the personality
disinhibition-externalizing component disinhibition-externalizing component (traits commonly seen w/ adult features of DSM-IV-APD)
Rationale: research suggests each component differs in neurobiology correlates and etiological determinants Unclear if consensus reached on recognizing different Types of APD
Why are Anxiety D/Os (such as GAD) believed to be less likely comorbid with APD? Anxiety promotes behavioral inhibition which is incompatible with actively searching for and creating moral turpitude as seen in APD.
APD: Exam Questions (DYS)APD: Exam Questions (DYS)
In the DSM-IV-TR, what is Criterion C of APD? DSM Dx/Sx of Conduct Disorder by age 15yrs.
Emotional, cognitive and physiological correlates of abuse-related Stress in borderline and antisocial personality disorder by Lobbestael & Arntz (2010). 16
Study sought to ascertain degree to which cognitive-affective dysregulation in APD with past medical history of child maltreatment is as a function of exposure to external reminders of child maltreatment. From a sample of 21 it was shown that reminders of child maltreatment is associated with cognitive-affective dysregulation in APD suggesting emotion regulation strategies as opposed to lack of emotion
APD: Annotated Bibliography
APD suggesting emotion regulation strategies as opposed to lack of emotion (such as empathy) may maintain APD.
Early temperamental and psychological precursors of adult psychopathic personality by Glenn et al. (2007). 17
Study sought to ascertain degree to which psychopathy is a function of low fear and inhibition in childhood. From a longitudinal sample of 335 it was shown that persons scoring high on the PCL-R exhibited less fear and less inhibition in infancy compared persons scoring low on the PCL-R. Findings suggest precursors of psychopathy exist as early as age 3 and are seen in the form of temperament.
Serotonin transporter polymorphism and borderline or antisocial traits among low-income young adults by Lyons-Ruth et al. (2007). 18
Study sought to ascertain the degree to which APD in young adults from lower socioeconomic status (SES) is a function of possessing the short allele for the serotonin transporter (5HTTLPR). From a sample of 96 it was shown that the number of short 5HTTLPR is associated with APD in young adults from low SES. Findings suggest gene-environment interaction as an etiological determinant of
APD: Annotated Bibliography cont’d
Findings suggest gene-environment interaction as an etiological determinant of APD.
Child maltreatment moderates the association of MAOA with symptoms of depression and antisocial personality disorder by Beach et al. (2010). 19
Researcher sought to construct of model detailing how depression and APD can represent a multi-finality stemming from abnormal activity of the enzyme (monoamine oxidase type A, MAOA) and experience of child maltreatment. From a sample of 538 it was shown that low MAOA activity coupled with child maltreatment shows strong correlation with later APD, while high MAOA activity coupled with child maltreatment shows strong correlation with depression.
Acculturation Stress, Anxiety Disorders, and Alcohol Dependence in a Select Population of Young Adult Mexican-Americans by Ehlers et al. (2009) 14
Study sought to ascertain and quantify the association between acculturation stress and alcohol-related disorders in influencing the risk of mental health disorders (including CD and/or APD) within
APD: Annotated Bibliography cont’d
the risk of mental health disorders (including CD and/or APD) within immigrant Mexican-American young adults. Results from studying a sample of 240 showed acculturation stressors are not associated with or increase the risk of APD (and/or CD) in immigrants with alcohol-related disorders and who self-identify as Mexican-American.
APD: Additional Resources (recommended readings)
Patrick, C.J. (2006). The handbook of psychopathy. Guildford Press: NY, NY.
Hare, R. D. (1993). Without conscience: The disturbing world of the psychopaths among us. Guildford Press: NY, NY
Fersch, E. L. (2006). Thinking about psychopaths and psychopathy: Answers to Questions with case examples. Universe Publishing: Lincoln, NE
1. Ogloff, J. Psychopathy/antisocial personality disorder conundrum. (2006). Australian and New Zealand Journal of Psychiatry, 40(6-7), 519-528
2. The American Psychiatric Association. (2004). Diagnostic and Statistical Manual of Mental Disorders. (4th ed-Text Revision). Washington, DC: Author.
3. World Health Organization. 1990. International classification of diseases and related health problems , 10th revision. Geneva: World Health Organization.
4. Patrick, C.J. (2006). The handbook of psychopathy. Guildford Press: NY, NY. 5. Abramowitz, C. S., Kosson, D. S. & Seidenberg, M. (2004). The relationship
References
5. Abramowitz, C. S., Kosson, D. S. & Seidenberg, M. (2004). The relationship between childhood attention deficit hyperactivity disorder and conduct problems and adult psychopathy in male inmates. Personality & Individual Differences, 36, 1031-1047.
6. Maughan, B., & Rutter, M. (2001). Antisocial children grown up. In J. Hill & B. Maughan (Eds.), Conduct disorders in childhood and adolescence (p. 507–552). New York: Cambridge University Press.
7. McCartney, K. , Harris, M. J., & Bernieri, F. (1990). Growing up and growing apart: A developmental meta-analysis of twin studies. Psychological Bulletin, 107, 226-237.
8. Washburn, J. J., Romero, E. G., Welty, L. J., Abram, K. M., Teplin, L. A., McClelland, G.M., & Paskar, L.D. (2007). Development of antisocial personality disorder in detained youths: The predictive value of mental disorders. Journal of Consulting and Clinical Psychology. 75(2), 221-231
9. Proquest © 2010. Washburn, J. J., Romero, E. G., Welty, L. J., Abram, K. M., Teplin, L. A., McClelland, G.M., & Paskar, L.D. (2007). Development of antisocial personality disorder in detained youths: The predictive value of mental disorders. Journal of Consulting and Clinical Psychology. 75(2), 221-231. DOI: 10.1037/0022-006X.75.2.221. Retrieved from PsycINFO database.
References cont’d
PsycINFO database. http://csaweb115v.csa.com/ids70/results.php?SID=i8q9enojjqi2sll2eta0u0hi02&id=5
10. Loeber, R., Green, S. M., & Lahey, B. B. (2003). Risk factors for adult antisocial personality. In D. P. Farrington, & J. W. Coid (Eds.), Early prevention of adult antisocial behaviour (p. 79-108). Cambridge, England: Cambridge University Press.
11. Lahey, B. B., Loeber, R., Burke, J. D., & Applegate, B. (2005). Predicting future antisocial personality disorder in males from a clinical assessment in childhood. Journal of Consulting and Clinical Psychology, 73, 389-399 10.1037/0022-006X .73.3.389.
12. Lynam, D. R. (1996). Early identification of chronic offenders: Who is the fledgling psychopath. Psychological Bulletin, 120, 209-234. DOI:10.1037/0033-2909 .120.2.209.
13. Loeber, R., Burke, J. D., & Lahey, B. B. (2002). What are adolescent antecedents to antisocial personality disorder. Criminal Behaviour & Mental Health, 12, 24-36.
14. Ehlers, C.E., Gilder, D.A., Criado, J.R. & Caetano, R. (2009). Acculturation Stress, Anxiety Disorders, and Alcohol Dependence in a Select Population of Young Adult Mexican-Americans. Journal of Addiction Medicine, 3(4), 227-233
15. American Psychiatric Association. (2010). DSM-5 development: Personality and personality disorders. Retrieved on December 1, 2010 from http://www.dsm5.org/ProposedRevisions/Pages/PersonalityandPersonalityDisorders.aspx
16. Lobbestael, J. & Arntz, A. (2010). Emotional, cognitive and physiological correlates of abuse-related stress in borderline and antisocial personality disorder. Journal of Behavior Research and Therapy, 48, 116-124
References cont’d
Research and Therapy, 48, 116-124 17. Glenn, A.L., Raine, A., Venables, P.H., & Mednick, S. A. (2007). Early temperamental
and psychological precursors of adult psychopathic personality. Journal of Abnormal Psychology, 116 (3), 508-518.
18. Lyons-Rith, K., Holmes, B., Sasvari-Szekely, & Ronai, Z. (2007). Serotonin transporter polymorphism and borderline or antisocial traits among low-income young adults. Journal of Psychiatric Genetics, 17, 339-343