Gerwyn Makai, Pharm.D. PP7501-Adult Psychopathology Argosy
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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