1. Antisocial Personality Disorder Karin Neufeld, MD MPH Addiction Treatment Services Department of Psychiatry Johns Hopkins University School of Medicine

2. Copyright Alcohol Medical Scholars Program2 http://indice.elpais.es/2004/11/13/ Who was Gary Gilmore?

3. Copyright Alcohol Medical Scholars Program3 History of Identification  1835 Moral insanity  1900 Psychopathic character  1930 Sociopathic personality  1980 Antisocial personality disorder (ASPD)

4. Copyright Alcohol Medical Scholars Program4 Validity and Reliability  Empirical data  Childhood precursor – Conduct disorder (CD)  Good reliability

5. Copyright Alcohol Medical Scholars Program5 Societal Impacts of ASPD   Risk of death –  6x teens/young adults   Psychiatric comorbidity –80% substance use disorder (SUD)  High legal cost –40% of prisoners –$41 billion/yr for US prison system

6. Copyright Alcohol Medical Scholars Program6 Objectives Review diagnosis Review diagnosis Describe epidemiology Describe epidemiology Review risk factors Review risk factors Describe the course Describe the course Review treatment Review treatment

7. Copyright Alcohol Medical Scholars Program7 Key Points  Very common in SUD patients  Genes and environment involved  Associated with great suffering  Treatment is helpful

8. Copyright Alcohol Medical Scholars Program8 Objectives Review diagnosis Review diagnosis Describe epidemiology Review risk factors Describe the course Review treatment

9. Copyright Alcohol Medical Scholars Program9 DSM-IV Diagnosis 1  Persistent violation of others’ rights with 3+ of: -Disobey the law -Lying or conning -Impulsivity -Irritability, aggressiveness, physical fights -Disregard for safety -No sustained work history -Lack of remorse

10. Copyright Alcohol Medical Scholars Program10 DSM-IV Diagnosis 2  18 y/o  >18 y/o  Early CD < 15yrs –Aggression to people or animals –Destruction of property –Deceitfulness or theft –Serious violation of rules  R/O other major mental illness

11. Copyright Alcohol Medical Scholars Program11 Objectives Review diagnosis Review diagnosis Describe epidemiology Describe epidemiology Review risk factors Describe the course Review treatment

12. Copyright Alcohol Medical Scholars Program12 ASPD Prevalence  General population ~ 3% –M ~ 6%; F ~ 1%  General medical clinics ~ 8%  Mental health settings ~ 10%  SUD treatment ~ at least 25%  Prisoners ~ 40% –M ~ 50%; F ~ 20%

13. Copyright Alcohol Medical Scholars Program13 Associated Demographics  M:F = 6:1  Young (25 – 44) > Older (45 +)  Race: no difference  School drop-out: 5x by 11 yrs  Abuse/neglect in childhood –50%  risk of adult criminal behavior

14. Copyright Alcohol Medical Scholars Program14 Objectives Review diagnosis Review diagnosis Describe epidemiology Describe epidemiology Review risk factors Review risk factors Describe the course Review treatment

15. Copyright Alcohol Medical Scholars Program15 Genetics  Family studies:  ASPD  Twin studies: ~ 70% heritability –Vulnerability  CD, ASPD, SUD  Adoption studies: (Cadoret) –  CD, ASPD, SUD

16. Copyright Alcohol Medical Scholars Program16 Genetic and Environmental Impact ASPD Biological Parent ChildhoodAggression ASPDSUD 4x 9x 7x Adverse Adoptive Home 8x (Cadoret 1995, 1997)

17. Copyright Alcohol Medical Scholars Program17 EEG Studies  Event related potential ERP   Amplitude (P300)  Not specific  Attentional problems 300 msec Standard Target

18. Copyright Alcohol Medical Scholars Program18 Neuroimaging  MRI:  Prefrontal volume  PET & SPECT:  Prefrontal function  Poor executive function www.brainexplorer.org

19. Copyright Alcohol Medical Scholars Program19 ASPD Biologic Markers  Increased aggression: –  synaptic serotonin (5HT)  Serotonin transporter protein (STP) –  STP activity ~  aggression Cadoret ’03 – Opposite findings exist  Monoamine oxidase (MAO) –Neuronal 5HT metabolism

20. Copyright Alcohol Medical Scholars Program20 www.drugabuse.gov Intrasynaptic Serotonin MAO Transporter

21. Copyright Alcohol Medical Scholars Program21 MAO A Genotype and Environmental Interaction Caspi et al, 2002 Science, 297, p851-4.

22. Copyright Alcohol Medical Scholars Program22 MAO A Genotype and Environmental Interaction Caspi et al, 2002 Science, 297, p851-4.

23. Copyright Alcohol Medical Scholars Program23 Objectives Review diagnosis Review diagnosis Describe epidemiology Describe epidemiology Review risk factors Review risk factors Describe the course Describe the course Review treatment

24. Copyright Alcohol Medical Scholars Program24 Childhood  Irritable/impulsive temperament 3 y/o –ASPD 3 X’s more likely  Conduct disorder (CD) –25% develop ASPD –  educational difficulties –Earlier the CD:  ASPD

25. Copyright Alcohol Medical Scholars Program25 Adulthood  Data limited (Black et al 1995)  29 yr follow-up of hospitalized ASPD  24% of sample died  Of remainder alive: –27% remission –31% improved –42% no change

26. Copyright Alcohol Medical Scholars Program26 Psychiatric Comorbidity  Lifetime prevalence in ASPD: –70% alcohol use disorder –50 % drug use disorder  80% of ASPD in tx: multiple SUD   Severity of SUD  4x SUD treatment episodes

27. Copyright Alcohol Medical Scholars Program27 Morbidity and Mortality  Morbidity –  HIV and high risk behaviors –  Medical problems –  Injuries  Mortality –  Risk of violent death (6x in youth) –  Risk of suicide

28. Copyright Alcohol Medical Scholars Program28 Objectives Review diagnosis Review diagnosis Describe epidemiology Describe epidemiology Review risk factors Review risk factors Describe the course Describe the course Review treatment Review treatment

29. Copyright Alcohol Medical Scholars Program29 Treatment of ASPD  Effectiveness?  Clinical fatalism  Patients rarely ask for ASPD tx –Poor insight –Lifelong disturbance  Often come for tx of SUD

30. Copyright Alcohol Medical Scholars Program30 Treatment Elements  Thorough history and exam  Therapeutic relationship –Firm behavioral limits –Professional boundaries –Maintain your empathy –Negotiate behavioral goals in advance

31. Copyright Alcohol Medical Scholars Program31 Treatment Expectations  Not curative  Focus on improved function  Decrease problem behaviors –  Impulsive actions – Anticipate novelty seeking –  Empathy in patient

32. Copyright Alcohol Medical Scholars Program32 Treatment Outcomes  SUD literature = best impact data  ASPD and opioid dependence –Same retention in methadone tx –  Drug use –  High risk behaviors  Psychotherapy response mixed  Good response to behavioral tx

33. Copyright Alcohol Medical Scholars Program33 Pharmacotherapy  Poor to no data  Mood stabilizers ~  impulsive aggression  SSRI’s ~ maybe  aggression  Antipsychotics not effective  Avoid habit forming drugs – i.e. benzodiazepines

34. Copyright Alcohol Medical Scholars Program34 Summary  Very common in SUD patients  Genes and environment involved  Associated with great suffering  Treatment is helpful