Antisocial personality disorder and psychopathy - summary of chapter 26 of Oxford Textbook of Psychopathology

Oxford Textbook of Psychopathology
Chapter 26
Antisocial personality disorder and psychopathy

Antisocial personality disorder: current conceptions and empirical findings

ASPD in DSM-5

The categorical diagnostic criteria for ASPD in DSM-5 are polythetic, only a proportion need to be met.

Child criteria for ASPD include: 1) aggressive and destructive behaviours 2) deceitfulness/theft 3) non-aggressive rule-breaking acts.

The adult criteria for ASPD include: 1) one aggression-specific criterion, irritability/aggressiveness 2) three clearly nonaggressive criteria, deceitfulness, impulsivity, irresponsibility 3) three nonspecific criteria, failure to conform to norms with respect to lawful behaviours, reckless disregard for safety of self or others, lacks remorse.

Disinhibition entails tendencies toward impulsivity, irresponsibility, and deceitfulness. Aggressive disregard entails irritability or aggressiveness and behaviours indicative of recklessness and lack of concern for self and others.

The characterisation of personality pathology according to the alternative dimensional-trait approach (not used in DSM-5) entails two steps 1) assessment of the presence of personality disturbance, as indicated by dysfunction of areas of self and social relations 2) designation of the specific nature of personality pathology, in terms of elevations on PD-relevant traits with five thematic domains.

Prevalence

The estimated prevalence of ASPD in the general community is 2% (for men 3% and for women 1%).

The prevalence of ASPD in clinical (forensic) settings has a 50-80% rate.

Accounting for comorbidity with other DSM disorders and common personality correlates: the externalizing spectrum model

ASPD sows patterns of comorbidity, in particular with substance use disorders. They show common personality correlates, namely: impulsiveness and aggressiveness.

There might be an heritable basis to a general externalizing factor. This may be different expressions of a general factor.

Neurobiological correlates

Antisocial individuals show evidence of reduced levels of serotonin. Reduced serotonergic modulation of appetitive urges and negative emotional reactions may account in part for the lack of inhibitory control.

Autonomic hypoarousal has been interpreted as reflecting dispositional sensation-seeking tendencies.

Reduced P300 response (a positive cortical potential), has been observed in relation to various specific impulse control problems. It is an indication of an general externalizing factor.

Psychopathy: current conceptions and empirical findings

The Psychopathy Checklist-Revised (PCL-R) was developed to identify psychopathy. This conception is more purely pathological. PCL-R total scores correlates highly with overall symptoms of ASPD.

PLC-R factors

Structural analysis have revealed distinctive subdimensions: 1) Interpersonal-affective factor, marked by items indexing superficial charm, grandiosity, conning/deceptiveness, absence of remorse or empathy, shallow affect, and externalization of blame 2) impulsive-antisocial factor, early behaviour problems, impulsivity, irresponsibility, boredom proneness, lack of long-term goals, and hot-tempered aggressiveness.

Adaptations of the PCL-R used with young clinical samples

This questionnaire has two distinguishable factors 1) Callous-unemotional factor, reflects emotional insensitivity and exploitative disregard for others 2) impulsive/conduct problems, encompasses impulsive tendencies, reckless or delinquent behaviour, and inflated sense of self-importance.

Prevalence of PCL-R defined psychopathy

In male forensic populations, this prevalence is 15-25%. It is estimated that the prevalence in the general population is around 1% for men and .3-.7% for women.

Comorbidity with DSM disorders

The DSM disorder associated most closely with PCL-R defined psychopathy is ASPD. This relationship is asymmetric. Most individuals who meet the criteria for psychopathy also meet the criteria for ASPD, but not the other way around. The behaviourally based criteria for ASPD overlap with the impulsive-antisocial features of psychopathy.

The impulsive/conduct problems shows associations with measures of substance abuse and borderline personality disorder.

Scores on the callous-unemotional factor relate to measures of narcissistic and histrionic personality disorder.

Neurobiological correlates

Individuals high on overall psychopathy show reduced skin conductance reactivity to stressors of various types, in particular cues signalling an upcoming aversive event. This suggests a weakness in reactivity at a basic subcortical level among individuals exhibiting the core interpersonal-affective feature of psychopathy. There is amygdala dysfunction (reduced activity).

There are brain abnormalities in individuals with psychopathy. There are no impairments in frontal lobe function or in P300 response.

Psychopathy in community samples: self-report based operationalizations

The psychopathic personality inventory

The PPI’s items are organized into eight scales that tap distinct dispositional constructs of relevance to psychopathy: 1) Stress immunity 2) Social potency scale 3) Carefree, nonplanfulness 4) rebellious nonconformity 5) blame externalization 6) Machiavellian egocentricity 7) cold-heartedness 8) fearlessness

Higher orders of these scales are: fearless dominance and impulsive antisociality

Psychological and neurobiological correlates of the PPI factors

Scores on the fearless dominance factor are associated with social efficacy and emotional stability, as well as with narcissism, thrill seeking, and reduced emotional empathy. They have deviant pattern of startle reactivity.

Scores on the impulsive antisociality are associated with maladaptive tendencies, including impulsivity and aggressiveness, child and adult antisocial behaviour, substance problems, high negative affect, and suicidal ideation and acts. They show reduced electrodermal reactivity to picture stimuli, and increased amygdala activation when processing affective faces.

Reconciling contrasting conceptions of psychopathy; the triarchic model

The triarchic model proposes that contrasting perspective s and apparent contradictions in the literature can be reconciled by conceiving of psychopathy as encompassing three distinct phenotypic tendencies: 1) disinhibition 2) boldness 3) meanness.

Disinhibition

Disinhibition is a general proneness toward impulse control problems. This entails: 1) a lack of planfulness 2) a focus on immediate versus delayed gratification 3) difficulty in controlling emotions and urges 4) weak behavioural restraint.

Disihibition represents the nexus of impulsivity of impulsivity and negative emotionality. It is manifested by impatience, impulsive action leading to adverse consequences, irresponsibility, distrust and alienation, aggressive behaviour, repetitive illegal and/or rule-breaking acts, and proclivities toward substances.

Psychopathy is marked by emotional detachment. The triarchic model proposes that this distinguishing feature of psychopathy reflects the presence of boldness or meanness, or both.

Boldness

Boldness is a tendency toward social assurance and self-confidence, calmness, and poise in the face of stress or anger, rapid recovery from aversive experiences, and tolerance or preference for uncertainty and risk. It reflects stress immunity, thrill seeking and dominance. Behavioural expression include: social assertiveness,persuasiveness, imperturbability, venturesomeness, and courageous action.

It is not identical to fearlessness. Fearlessness is viewed as a biologically based disposition. Boldness is one way in which fearlessness can be exhibited.

Meanness

Meanness encompasses tendencies including deficient empathy, inability to bond with others, uncooperativeenss, exploitativeness, and empowerment through cruelty and destructive acts. It entails high dominance in conjunction with low affiliation and nurturance.

Meanness can be viewed as disaffiliated agency, an orientation involving active pursuit of goals and resources without concern for and at the expense of others. It involves active exploitation. Behavioural expressions include: disdain toward others, arrogance, rebellious defiance, lack of close relationships, harsh competitiveness, exploitation of others for personal gain, proactive aggression, cruelty toward people or animals and engagement in destructive acts for excitement.

Psychopathy in DSM-5

At the youth level, a ‘limited prosocial emotions’ specifier for the diagnosis of conduct disorder is included.

At the adult level, innovations along two lines have been made to provide for more effective representation of psychopathy tendencies 1) the trait-based system for PDs characterizes ASPD in terms of traits from the domain of antagonism along with traits form disinhibition 2) the inclusion of a psychopathic features specifier for the diagnosis of ASPD.