Description

Antisocial personality disorder (APD) is a consistent and pervasive pattern of disregard for, and violation of, the rights of others (1).

• Manipulativeness, antagonism, and dishonesty are central features.
• Failure to conform to the law
• Derive self-esteem from personal gain and power
• Callous and lack remorse
• Directed toward dominance
• Incapacity for empathy and intimacy; exploitative
• Fearlessness and impulsivity
• Irresponsibility at work or financially
• Patterns become evident in childhood or adolescence with some symptoms of conduct disorder seen before age 15 years.

Geriatric Considerations
Although APD tends to diminish by the 4th decade of life, it is certainly possible that disregard for others can continue until the end of life.

Pediatric Considerations
The APD diagnosis cannot be made before age 18 years. Conduct and other externalizing or impulse control disorders may be considered instead.

Epidemiology

• Predominant age: onset no later than adolescence or early adulthood (may go undiagnosed for years)
• Much more common in males than females. It may be underdiagnosed in females given the emphasis on aggression in making the diagnosis.

Prevalence

• General population: 3.3% of population in Western countries (2)
• Males in prisons or with severe substance abuse disorders: 70%

Etiology and Pathophysiology

Undetermined but generally accepted that APD is due to a combination of the following:

• Hereditary temperamental traits
• A two-factor model has been demonstrated with imaging studies and factor analyses: Factors are fearlessness dominance and impulsivity (3)[C].
• Neurobiologic research of APD continues to increase the understanding of the etiology:
  • Abnormalities of the frontolimbic circuitry in relation to impulsivity and poor emotional stability
  • Diminished autonomic response to social stressors

Genetics

• First-degree relatives are at greater risk for this disorder.
• Rate is higher in biologic relatives of females with APD.

Risk Factors

• Genetic factors contribute; however, no specific genes have yet been identified (3).
• Adoption studies demonstrate strong role of genetics, yet also the significant role of environmental influences via
  • Poor parenting
  • Role modeling
  • Poverty and population migration increase risk.
  • Physical abuse is risk factor for later aggressive behavior.

General Prevention

• Tends to be a multigenerational problem
• Reduce the roots that are common to criminal behaviors.
• For clinically referred severely antisocial children, early intervention in the form of group parenting training may prevent the development of antisocial outcomes in adolescence and may improve academic performance (4)[B].
• Parenting interventions decreasing harsh discipline predict lower conduct disorder symptoms; increased parental warmth predicts callousness.

Commonly Associated Conditions

• Substance-related disorders
• Somatic symptom disorders and malingering
• Associated with increased risk of violence