Transcript Gender Identity Disorder in Children & Adolescents

Antisocial personality disorder
(APD)
J.J. Deogracias
University of Toronto at Mississauga
DSM-IV Criteria for APD
•
Part of the Cluster B (i.e., dramatic/erratic cluster) of
personality disorders
1.
There is a pervasive pattern of disregard for and violation of
the rights of others occurring since age 15 years, as indicated
by three (or more) of the following
a.
failure to conform to social norms with respect to lawful
behaviors as indicated by repeatedly performing acts that
are grounds for arrest
b. deceitfulness, as indicated by repeated lying, use of aliases,
or conning others for personal profit or pleasure
c. impulsivity or failure to plan ahead
DSM-IV Criteria for APD
(cont’d)
d. irritability and aggressiveness, as indicated by
repeated physical fights or assaults
e. reckless disregard for safety of self or others
f. consistent irresponsibility, as indicated by repeated
failure to sustain consistent work behaviour or
honour financial obligations
g. lack of remorse, as indicated by being indifferent to
or rationalizing having hurt, mistreated, or stolen
from another
DSM-IV Criteria for APD
(cont’d)
2. The individual is at least 18 years old
(under 18, see Conduct Disorder )
3. There is evidence of Conduct
Disorder with onset before age 15 years.
4. The occurrence of antisocial behaviour is
not exclusively during the course of
Schizophrenia or a Manic Episode
(APA, 1994)
Psychopathy
• “a clinical construct characterized by a
cluster of interpersonal, affective, and
lifestyle features, including egocentricity,
grandiosity, deceptiveness, shallow
emotions, lack of empathy, guilt, or
remorse, impulsivity, irresponsibility, and
the ready violation of social and legal norms
and expectations” (Hare, 1996, p.25)
Psychopathy Checklist – Revised
(PCL-R)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Glibness / Superficial Charm
Grandiose Sense of Self Worth
Need for Stimulation/Prone to Boredom
Pathological Lying
Conning/Manipulative
Lack of Remorse or Guilt
Shallow Affect
Callous/Lack of Emotion
Parasitic Lifestyle
Poor Behavioural Controls
PCL-R (cont’d)
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Promiscuous Sexual Behaviour
Early Behavioural Problems
Lack of Realistic, Long-term goals
Impulsivity
Irresponsibility
Failure to Accept Responsibility for Actions
Many Short-term Marital Relationships
Juvenile Delinquency
Revocation of Conditional Release
Criminal Versatility
Psychopathy in DSM-IV
definition
• Addition note for prison or forensic
settings:
– Features common in psychopathy (i.e., lack of
empathy, inflated self-appraisal and superficial
charm) may distinguish individuals with APD
in prison or forensic settings (p. 647).
Difference between APD &
Psychopathy
• DSM-IV only identifies people with antisocial
behaviour, who are not necessarily psychopath
– 20% of people with APD scored high on PCL-R
• DSM-IV stated that features common in psychopathy
(i.e., lack of empathy, inflated self-appraisal and
superficial charm) may distinguish individuals with
APD in prison or forensic settings (p. 647).
– Person diagnosed with APD outside forensic settings may not
be diagnosed with APD within forensic settings unless they
exhibits traits of psychopathy
• For this presentation, terms will be interchangeable
Epidemiology
• Prevalence
–
–
–
–
General population: ~1.0% - 3.5%
Drug / alcohol abusers: 18 - 53%
Prison inmates: 20%
Gender: 3% in men, 1% in women (US)
• Other interesting statistics
– responsible for more than 50% of serious crimes
– 44% of offenders who killed a law enforcement
officer had APD
COMORBIDITY
Alcohol and Drug Abuse
• 80% of individuals with APD abuse drugs
• Review by Mulder (2002)
– Cross-sectional: alcoholics have high scores on
measures of impulsivity and novelty seeking, as well
as high rates of APD
– Longitudinal studies: Antisocial behaviour related
to later alcoholism, including antisocial activity,
aggressive and sadistic behaviour, and rebellion and
hostility
– Genetic epidemiology: In women, the strongest
association with alcohol dependence was childhood
conduct disorder; in men, this association was
weaker
Major Depression (MD)
• History of APD predicted fourfold increase in
probability of reporting a history of MD
• 38% of total genetic variance in risk of MD was
associated with APD
• APD -- major determinant of genetic risk between
MD and alcohol dependence, and between MD and
marijuana dependence
(Fu et al., 2002)
• in the absence of anxiety disorders, major depression
is no longer significantly associated with APD
(Goodwin & Hamilton, 2003)
Anxiety Disorders
• 54.3% of adults with APD met criteria for an
anxiety disorder during their lifetime
• any anxiety disorder (especially social phobia
and PTSD) increases likelihood of APD
• Anxiety disorder important in the link between
major depression and APD
– In the absence of anxiety disorders, major
depression is no longer significantly associated with
APD
(Goodwin & Hamilton, 2003)
Attention Deficit Hyperactivity
Disorder (ADHD)
• 21% of hyperactive probands qualified for
ASPD, a fivefold increase in risk over control
group
• risk for APD among ADHD children is
substantially influenced by severity of childhood
conduct problems, and by severity of teen
conduct disorder (CD)
(Fischer et al., 2000)
Conduct Disorder (CD)
• boys with ADHD+CD showed a decrease in
autonomic responses (e.g., skin conductance
response) compared with ADHD matched
children and controls
• this group showed a pattern similar to that
reported from studies with psychopathic
antisocial personalities
(Herpertz et al., 2001)
NEUROTRANSMITTERS
Serotonin (5-HT)
• mediating impulsive and aggressive behaviours
– Association between low 5-HT function and aggressive
behaviour
– inverse relationship between 5-HT metabolite 5-hydroxy
indoleacetic (5-HIAA) and impulsivity, irritability, hostility
and aggression
• tryptophan depletion
– men with higher basal levels of hostility or antisocial traits
experience increased hostility
• patients diagnosed with APD, alcohol dependence, or
drug dependence
– chronic ethanol administration decreases 5-HT levels, leading
to behavioural disinhibition, including impulsive aggression
– antisocial alcoholics with lower basal CSF 5-HIAA levels
than controls
5-HT (cont’d)
• Possible genetic connection: genes
encoding 5-HT receptors (especially
HTR1B) are likely candidates for both
substance dependence and APD
– Inconsistent results
Dopamine (DA)
• Significant associations with D2 & D4 receptor
gene polymorphism and sensation seeking
– D2 & D4 combined contribute more to this behaviour
than separately
• May also be related due to comorbid drug abuse:
Abused drugs (e.g., cocaine) release DA in
nucleus accumbens (NA) and ventral tegmental
area (VTA) for reinforcement
– 5-HT plays role by modulating DA activity and its
effect on neurons of the VTA
– No empirical data to support this to my knowledge
NEUROANATOMY
Review by Martens (2001)
• Neurological dysfunctions, such as brain
injuries and cerebrovascular disorders
• Frontal lobe lesions
• Reduction in prefrontal grey matter volume
• EEG abnormalities
• Reduced cortical arousal
• Frontal-limbic neural circuit (not mentioned in
review)
Frontal Lobe Lesions
• Orbitofrontal and/or ventromedial frontal cortex
– implicated in cognitive, linguistic behavioural, and
affective processes of psychopaths
– Implicated in aggression and violence
– “acquired sociopathic” syndrome following
ventromedial frontal lobe lesions; may contribute to
poor impulse control in APD
– activation in posterior orbitofrontal cortex during
response inhibition (Horn et al., 2003)
Prefrontal Cortex
• MRI: people with APD showed significant
reduction in volume of prefrontal gray matter
• However, may not be the whole story
– 13-year-old boy with history of conduct disorder,
and co-morbid ADHD sustained a self-inflicted
gunshot wound to medial PFC
– conduct disorder did not change much after injury
– No distinct neuropsychological impairment on tests
thought to be sensitive to frontal function after
injury
Prefrontal-limbic circuit
• including the amygdala, anterior cingulate,
and orbitofrontal cortex
• anticipating aversive stimuli, and mediating
anticipatory planning & emotion regulation
• Lesions of this circuit result in so-called
‘acquired sociopathy’
• Psychopaths show hypoactive frontolimbic
circuitry during aversive conditioning
(Veit et al., 2002)
Reduced Cortical Arousal
• leading to excessive need for stimulation (i.e.,
sensation seeking)
– low heart rate associated with aggressive forms of antisocial
behaviour
– low heart rate and low skin conductance with fearlessness
and stimulation & sensation seeking in antisocial behaviour
or APD
• persons with APD who had prefrontal gray matter
volume reductions had lower skin conductance activity
during stressor than those without reduced prefrontal
gray volume (Raine et al., 2000)
• psychopaths failed to show anticipatory skin
conductance response in aversive stimuli (Veit et al.,
2002)
PHARMACOTHERAPY
Treatment Problems
• Few treatments, or little research on treatments
for individuals with APD
– rarely treated in hospitals because of their
troublesome behaviours
– patient trying to manipulate the mental health
professional or physician (e.g., get doctor to
prescribe medication they abused in past)
– APD was found to be negative predictor for success
of psychotherapy in opiate addicts
– May attempt to manipulate Will reject medications
that do not produce euphoria, especially if have
unpleasant adverse effects
Risperidone
• Antipsychotic -- combined dopamine D2 and
serotonin 5-HT2 receptor antagonism
• Placebo-controlled trials of risperidone reported
significant decreased in aggression in adults
with dementia in adults with autism, and in
children with CD
• Also reported effectiveness against impulsivity
in borderline personality disorder
• However, no official study on treating APD
Risperidone (cont’d)
• Case study for APD:
– 32-year old male fulfilling DSM-IV diagnosis for
APD
– major problems: severe aggression and impulsive
violence
– started on risperidone (6 mg/day)
– abatement of aggression and impulsivity rapid
following risperidone 4 days later
– Side effects: antipsychotic-induced akathisia
(restless and fidgety)
• lower dosage of risperidone, and adding other antiakathisia agents (biperidon, propranolol and diazepam) to
control it
Quetiapine
• Atypical antipsychotic agent to treat impulsivity,
irritability and aggression
• From four case studies (30-60 day treatment),
– effective dosage: 600 to 800 mg once daily
– patients attribute treatment compliance to its
effectiveness and its favourable adverse-effect
profile
– successfully used in combination with mood
stabilizers, particularly gabapentin, in patients with
affective instability
– because of treatment cost, it has been discontinued
leading to reoccurrence of aggression and other
dangerous manifestations
Conclusion
• Contradictions behind the neurobiology of
APD
– Methodological improvements (i.e., larger sample
sizes in MRI/fMRI studies)
– More studies needed
• Lack of research in pharmacological
treatments
– Only efficacious “studies” lacked larger sample
size, control groups, etc.
– More studies needed