What are the factors that contribute to aggression in patients with co-occurring antisocial personality disorder and substance abuse?

The purpose of this study was to determine the extent of comorbid substance use disorders in patients referred for treatment of personality disorders. Two hundred inpatients and outpatients were assessed by semistructured interviews for substance use and personality disorders. Univariate odds ratios were calculated for groups of substance use disorders and each DSM-III-R axis II disorder; comorbidity among axis II disorders was controlled in multivariate models predicting current or lifetime substance use disorder groups. The impact of personality disorder on chronicity and overall impairment associated with substance use disorders was evaluated. Close to 60% of subjects with substance use disorders had personality disorders. Borderline personality disorder was significantly associated with current substance use disorders, excluding alcohol and cannabis, and with lifetime alcohol, stimulant, and other substance use disorders, excluding cannabis. Antisocial personality disorder was associated with lifetime substance use disorders other than alcohol, cannabis, and stimulants. These relationships remained significant after controlling for the presence of all other personality disorders. There was no evidence that personality disorders increased the chronicity of substance use disorders, but comorbid personality disorders were associated with greater global impairment. Borderline personality disorder may be associated with a wide variety of substance use disorders, especially among patients seeking treatment for personality problems.

Back to table of contents Previous article Next article Letter to the EditorFull AccessThe Difficulty of Making a Sole Diagnosis of Antisocial Personality DisorderScott A. Freeman, M.D.Scott A. FreemanSearch for more papers by this author, M.D.Published Online:1 Aug 2010https://doi.org/10.1176/appi.ajp.2010.10030394AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Several actions and recommendations made by Daniel Antonius, Ph.D., et al. (1) in their Clinical Case Conference, published in the March 2010 issue of the Journal, are laudable. Much of the case conference was focused on assessing and treating assaultive behavior in patients with antisocial personality disorder comorbid with an axis I major mental illness. The authors' assertion that "Mr. J" had a major mental illness, however, appears to be erroneous. They stated, "In the case of Mr. J, the presence of an axis I diagnosis of mental illness is relatively obvious (1, p. 255). This statement was confusing in light of the lack of substantiation for an axis I disorder in the clinical vignette. The symptoms Dr. Antonius et al. cited for an axis I disorder were self-injurious behavior, mood lability, "hopelessness about the future, and reported insomnia due to nightmares, which [the patient] attributed to a previously undisclosed sexual assault that occurred during a past incarceration" (1, p. 254). The patient was given the axis I diagnosis of mood disorder not otherwise specified in addition to antisocial personality disorder. However, DSM-IV-TR criteria for antisocial personality disorder include impulsivity, irritability, and disregard for the safety of self or others, which would explain the mood lability and self-injurious behavior (2). It is unclear why an additional diagnosis of mood disorder not otherwise specified was made.The authors appear to have been basing much of their diagnosis of an axis I disorder on the isolated symptoms of mood lability, self-injurious behavior (including suicide attempts), and hopelessness. To the extent that hopelessness may be related to a depressive affect, it has been shown in certain samples of youth with antisocial behavior that gang involvement is associated with negative affect but not major depressive disorder (3). The patient's history of suicidal behavior is consistent with studies that have shown an increased rate of suicidal behavior in individuals with antisocial personality disorder comorbid with substance abuse, and Mr. J had a history of cannabis and alcohol abuse (4). This leaves "insomnia due to nightmares," an isolated posttraumatic stress disorder symptom, as the only symptom not accounted for by antisocial personality disorder. This isolated symptom, however, would not qualify for an axis I psychiatric disorder, including anxiety disorder not otherwise specified, because of the lack of "prominent anxiety or phobic avoidance" that is a requirement for the diagnosis. (2).With the increased number of forensic psychiatric hospital admissions over the past several years, it is important that psychiatrists make accurate diagnoses in this population. Although quite difficult, being able to make the diagnosis of antisocial personality disorder in the absence of comorbid mental illness and then making an appropriate disposition that does not include psychiatric hospitalization is crucial in preventing the victimization of those with severe mental illnesses.Boston, Mass.The author reports no financial relationships with commercial interests.References1 Antonius D , Fuchs L , Herbert F , Kwon J , Fried JL , Burton PRS , Straka T , Levin Z : Psychiatric assessment of aggressive patients: a violent attack on a resident. Am J Psychiatry 2010; 167:253–259 Link, Google Scholar2 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV-TR). Washington, DC, American Psychiatric Publishing, 2000 Google Scholar3 Harper GW , Davidson J , Hosek SG : Influence of gang membership on negative affect, substance use, and antisocial behavior among homeless African-American male youths. Am J Mens Health 2008; 2:229–243 Crossref, Medline, Google Scholar4 Links PS , Gould B , Ratnayake R : Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder. Can J Psychiatry 2003; 48:301–310 Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited ByNone Volume 167Issue 8 August 2010Pages 997-997 Metrics PDF download History Accepted 1 June 2010 Published online 1 August 2010 Published in print 1 August 2010

Aggression is one of the leading clinical characteristics of antisocial personality disorder (APD). Studies aiming to clarify and control the biological basis of aggression are ongoing. Thyroid hormones have been indicated to play a role in the development of aggression. The aim of this study was to examine the level of aggression and serum thyroid hormone in a sample of APD and to make contributions to this field with the current findings. The sample consisted of 96 subjects with a diagnosis of APD and 97 subjects as a control group. Structured Clinical Interview for DSM-IV Axis (SCID) 1 and 2 were used for the diagnosis, and the Buss-Perry Aggression Questionnaire was administered. Based on criminal patterns, the APD group was then divided into two subgroups: "criminal" and "noncriminal" APD groups. The day after the interview, after one night of fasting, blood was collected from the subjects between 7:00 a.m. and 9:00 a.m.. Thyroid function tests and other biochemical analyses related to the confounding variables were also administered. The study group and the control group were compared in terms of their aggression scores and thyroid hormone levels. The mean score of free T3 level in the criminal APD group was found to be significantly higher than that in the noncriminal APD group. APD subjects with higher free T3 levels also had higher aggression scores. In the noncriminal APD group, as serum free T3 and T4 levels increased, there was also an increment in the aggression scores. However, in the criminal APD group, there was no significant correlation between thyroid hormone levels and aggression. The findings of this study indicated that criminal and noncriminal APD groups actually show different properties.

There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour. Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported. The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.

Relationship of substance use disorder to aggression in male subjects with antisocial personality disorder

The current study examined how antisocial personality disorder (APD) and substance use disorder contributed to partners’ reports of physical partner violence among single and dual substance-abusing couples. Participants were 69 heterosexual couples entering treatment in which one or both partners met criteria for substance use disorder. APD diagnosis of the male partner was linked to significantly higher male-to-female and female-to-male perpetration of physical partner violence and victimization. Female partner’s APD diagnosis was associated with women’s reports of victimization by their male partners. Dual substance use diagnosis emerged as a moderator, in which the effect of men’s APD diagnosis on men’s perpetration of physical partner violence and victimization was significantly reduced if both partners had substance use disorder. Findings underscore the importance of both partners’ APD diagnosis and substance use status for understanding physical partner violence among single and dual substance-abusing couples.

Psychopathy has traditionally been characterised as a disorder primarily of personality (particularly affective deficits) and, to a lesser extent, behaviour. Although often used interchangeably, the diagnostic constructs of psychopathy, antisocial personality disorder, and dissocial personality disorder are distinct. In this article, the relevant historical and contemporary literature concerning psychopathy is briefly reviewed. The diagnostic criteria for psychopathy, antisocial personality disorder, and dissocial personality disorder are compared. Consideration is given to the assessment, prevalence, and implications of psychopathy for violence risk and treatment efficacy. The DSM-IV-TR criteria for antisocial personality disorder, in particular, are largely behaviourally based. The ICD criteria for dissocial personality disorder, while paying more attention to affective deficits, also do not represent the broad personality and behavioural components of psychopathy. Since 1980, a great deal of research on these disorders has been conducted, using the Hare Psychopathy Checklist, Revised (PCL-R). The PCL-R assesses both personality (interpersonal and affective) and behavioural (lifestyle and antisocial) deficits. As such, the research and clinical implications of psychopathy, as operationalised by the PCL-R, cannot be readily extrapolated to the diagnoses of antisocial personality disorder and dissocial personality disorder. As currently construed, the diagnosis of antisocial personality disorder grossly over-identifies people, particularly those with offence histories, as meeting the criteria for the diagnosis. For example, research shows that between 50% and 80% of prisoners meet the criteria for a diagnosis of antisocial personality disorder, yet only approximately 15% of prisoners would be expected to be psychopathic, as assessed by the PCL-R. As such, the characteristics and research findings drawn from the psychopathy research may not be relevant for those with antisocial or dissocial personality disorder.

Psychopathy has traditionally been characterised as a disorder primarily of personality (particularly affective deficits) and, to a lesser extent, behaviour. Although often used interchangeably, the diagnostic constructs of psychopathy, antisocial personality disorder, and dissocial personality disorder are distinct. In this article, the relevant historical and contemporary literature concerning psychopathy is briefly reviewed. The diagnostic criteria for psychopathy, antisocial personality disorder, and dissocial personality disorder are compared. Consideration is given to the assessment, prevalence, and implications of psychopathy for violence risk and treatment efficacy. The DSM-IV-TR criteria for antisocial personality disorder, in particular, are largely behaviourally based. The ICD criteria for dissocial personality disorder, while paying more attention to affective deficits, also do not represent the broad personality and behavioural components of psychopathy. Since 1980, a great deal of research on these disorders has been conducted, using the Hare Psychopathy Checklist, Revised (PCL-R). The PCL-R assesses both personality (interpersonal and affective) and behavioural (lifestyle and antisocial) deficits. As such, the research and clinical implications of psychopathy, as operationalised by the PCL-R, cannot be readily extrapolated to the diagnoses of antisocial personality disorder and dissocial personality disorder. As currently construed, the diagnosis of antisocial personality disorder grossly over-identifies people, particularly those with offence histories, as meeting the criteria for the diagnosis. For example, research shows that between 50% and 80% of prisoners meet the criteria for a diagnosis of antisocial personality disorder, yet only approximately 15% of prisoners would be expected to be psychopathic, as assessed by the PCL-R. As such, the characteristics and research findings drawn from the psychopathy research may not be relevant for those with antisocial or dissocial personality disorder.

This study examined the associations among posttraumatic stress disorder (PTSD) symptom severity, antisocial personality disorder (ASPD) diagnosis, and intimate partner violence (IPV) in a sample of 145 substance abuse treatment-seeking men and women with positive trauma histories; sex was examined as a moderator. ASPD diagnosis significantly predicted both verbal and physical aggression; sex moderated the association between ASPD diagnosis and physical violence. PTSD symptom severity significantly predicted engaging in verbal, but not physical, aggression. Overall, these results suggest that an ASPD diagnosis may be an important risk factor for engaging in IPV among women seeking treatment for a substance use disorder.

Despite the number of studies investigating co-occurring disorders, and more recently, co-occurring disorders and criminal offending, few studies have considered samples from forensic mental health services. The present study was conducted to investigate the relationship between mental illness, substance use disorders, antisocial personality disorder, and offending. The prevalence of co-occurring disorders was investigated in 130 male offenders who had contact with the statewide forensic mental health service in Victoria, Australia. Offense histories and severity of offending were compared among participants diagnosed with a single mental illness (or no mental illness), co-occurring mental illness and substance use, and co-occurring disorders plus antisocial personality disorder. The majority of participants had co-occurring mental and substance use disorders; a significant minority met the criteria for antisocial personality disorder. Participants with co-occurring mental illness and substance use disorders, and those who had an additional diagnosis of antisocial personality disorder, were responsible for more serious and frequent offending than those with mental illness alone. Forensic mental health services must take into account the effect that co-occurring disorders have on clients' functioning and offending. Those who work with people with psychiatric disabilities and co-occurring substance use disorders must ensure that the substance disorders are addressed to help ensure recovery from the mental illness and to reduce the likelihood of offending. (PsycINFO Database Record

Modestly prevalent in the general population (~ 4%), but highly prevalent in prison populations (> 40%), the diagnosis of antisocial personality disorder (ASPD) involves aggression as one of several possible criteria. Using multiple informants, we aimed to determine if general aggression, as well as direct and indirect subtypes, assessed in early adolescence (ages 12, 14) predict young adulthood ASPD in a population-based sample. Using data from a Finnish population-based longitudinal twin cohort study with psychiatric interviews available at age 22 (N = 1347), we obtained DSM-IV-based ASPD diagnoses. Aggression measures from ages 12 (parental and teacher ratings) and 14 (teacher, self, and co-twin ratings) were used to calculate odds ratios (OR) of ASPD from logistic regression models and the area under the curve (AUC) from receiver operating characteristic curve analysis. Analyses were adjusted for sex, age, and family structure. All informants’ aggression ratings were significant (p < 0.05) predictors of ASPD (OR range 1.3–1.8; AUC range 0.65–0.72). Correlations between informants ranged from 0.13 to 0.33. Models including two or more aggression ratings, particularly age 14 teacher and self ratings, more accurately predicted ASPD (AUC: 0.80; 95% confidence interval 0.73–0.87). Direct aggression rated by all informants significantly predicted ASPD (OR range 1.4–1.9), whereas only self-rated indirect aggression was significantly associated with ASPD (OR = 1.4). Across different informants, general and direct aggression at ages 12 and 14 predicted ASPD in a population-based sample. Psychiatric, social, and parenting interventions for ASPD prevention should focus on children and adolescents with high aggression levels, with an aim to gather information from multiple informants.

Antisocial personality disorder (APD) is mainly based on social irresponsibility that leads to delinquent, criminal, and exploitative behavior toward others, as well as difficulty in adapting to social norms. This disorder predominates in the male gender, and therefore, most of the research to date has been conducted in men. In the following study, we aimed to describe the main sociodemographic variables and psychiatric comorbidities presented in women with a diagnosis of APD. We assessed 54 women with a diagnosis of APD, of whom sociodemographic characteristics were collected, and the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-IV Axis II Disorders (SCID-II) and the Mini-International Neuropsychiatric Interview (M.I.N.I.) 5.0.0 were applied. We found a weak positive correlation with the obsessive (rs = 0.28, p = 0.039), passive-aggressive (rs = 0.29, p = 0.034), paranoid (rs = 0.39, p = 0.004), narcissistic (rs = 0.36, p = 0.008), and borderline (rs = 0.35, p = 0.010) personality domains, with a median age of 24.00 (IQR = 11.50) years, and the majority mainly being single and unemployed. We also found high rates of suicidal risk, depression, anxiety, and substance abuse, which was consistent with what has been reported elsewhere. Research on APD and its comorbidities in women is limited, especially in Mexico, where women with APD show similar patterns to those in developed countries. This suggests the need for gender-specific interventions and a dimensional approach to improve the diagnosis and treatment of APD.

The evidence summarised in this review is insufficient to draw any conclusion about the use of pharmacological interventions in the treatment of antisocial personality disorder. The evidence comes from single, unreplicated studies of mostly older medications. The studies also have methodological issues that severely limit the confidence we can draw from their results. Future studies should recruit participants on the basis of having AsPD, and use relevant outcome measures, including reconviction.

Back to table of contents Previous article Next article Letters to the EditorFull AccessDr. Mills RepliesKATHERINE L. MILLS Ph.D.,KATHERINE L. MILLS Ph.D.Search for more papers by this author,Published Online:1 Oct 2006AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: We thank Drs. Sule and Kelly for their comments on our article and appreciate the opportunity to respond to their letter. A number of studies have found an association between antisocial personality disorder, substance use disorders, and PTSD. Nonetheless, we believe that our findings are unlikely to be confounded by antisocial personality disorder. First, antisocial personality disorder is an unreliable diagnosis, particularly among people with substance use disorders (1 , 2) . A diagnosis of antisocial personality disorder is based on behaviors often associated with drug use (e.g., criminality and social deviance) (3) . As such, it is difficult to distinguish “true psychopaths” (whose behaviors are driven by psychopathology) from “symptomatic psychopaths” (whose behaviors are driven by their drug use) (2 , 4) . Second, although it is true that antisocial personality disorder has been associated with considerable harm, when borderline personality disorder is controlled, the harms attributable to antisocial personality disorder disappear (1) . Finally, not one single respondent to the Australian National Survey of Mental Health and Well-Being screened positive for dissocial personality disorder (5) ; hence, it could not be controlled for in our study. This is unlikely because of the absence of the disorder in the Australian general population, but rather because of methodological limitations (5 , 6) and/or problems inherent in the operationalization of the disorder. We hope that our article, as well as the letter by Drs. Sule and Kelly, will contribute to future research in this area. Randwick, Australia

Back to table of contents Previous article Next article Letters to the EditorFull AccessDr. Mills RepliesKATHERINE L. MILLS Ph.D.,KATHERINE L. MILLS Ph.D.Search for more papers by this author,Published Online:1 Oct 2006AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: We thank Drs. Sule and Kelly for their comments on our article and appreciate the opportunity to respond to their letter. A number of studies have found an association between antisocial personality disorder, substance use disorders, and PTSD. Nonetheless, we believe that our findings are unlikely to be confounded by antisocial personality disorder. First, antisocial personality disorder is an unreliable diagnosis, particularly among people with substance use disorders (1 , 2) . A diagnosis of antisocial personality disorder is based on behaviors often associated with drug use (e.g., criminality and social deviance) (3) . As such, it is difficult to distinguish “true psychopaths” (whose behaviors are driven by psychopathology) from “symptomatic psychopaths” (whose behaviors are driven by their drug use) (2 , 4) . Second, although it is true that antisocial personality disorder has been associated with considerable harm, when borderline personality disorder is controlled, the harms attributable to antisocial personality disorder disappear (1) . Finally, not one single respondent to the Australian National Survey of Mental Health and Well-Being screened positive for dissocial personality disorder (5) ; hence, it could not be controlled for in our study. This is unlikely because of the absence of the disorder in the Australian general population, but rather because of methodological limitations (5 , 6) and/or problems inherent in the operationalization of the disorder. We hope that our article, as well as the letter by Drs. Sule and Kelly, will contribute to future research in this area. Randwick, Australia