A narcissistic defence, with the disorder’s typical over-valuation of the self, can appear at any stage of development.
Defence Sequences
The narcissist typically runs through a sequence of defences to discharge painful feelings until he or she finds one that works:
Unconscious repression.
Conscious denial.
Distortion (including exaggeration and minimisation), rationalisation and lies.
Psychological projection (blaming somebody else).
Enlisting the help of one or more of their co-dependent friends who will support their distorted view.
Freudians
Sigmund Freud did not focus specifically on narcissistic defences, but did note in On Narcissism how “even great criminals and humorists, as they are represented in literature, compel our interest by the narcissistic consistency with which they manage to keep away from their ego anything that would diminish it”. Freud saw narcissistic regression as a defensive answer to object loss – denying the loss of an important object by way of a substitutive identification with it.
Freud also considered social narcissism as a defence mechanism, apparent when communal identifications produce irrational panics at perceived threats to ‘Throne and Altar’ or ‘Free Markets’, or in English over-reaction to any questioning of the status and identity of William Shakespeare.
Fenichel
Otto Fenichel considered that “identification, performed by means of introjection, is the most primitive form of relationship to objects” a primitive mechanism only used “if the ego’s function of reality testing is severely damaged by a narcissistic regression.”
Fenichel also highlighted “eccentrics who have more or less succeeded in regaining the security of primary narcissism and who feel ‘Nothing can happen to me’….[failing] to give up the archaic stages of repudiating displeasure and to turn toward reality”.
Lacan
Jacques Lacan, following out Freud’s view of the ego as the result of identifications, came to consider the ego itself as a narcissistic defence, driven by what he called “the ‘narcissistic passion’ …in the coming-into-being (devenir) of the subject”.
Kleinians
Melanie Klein, emphasised projective identification in narcissism, and the manic defence against becoming aware of the damage done to objects in this way. For Kleinians, at the core of manic defences in narcissism stood what Hanna Segal called “a triad of feelings—control, triumph and contempt”.
Rosenfeld
Herbert Rosenfeld looked at the role of omnipotence, combined with projective identification, as a narcissistic means of defending against awareness of separation between ego and object.
Object Relations Theory
In the wake of Klein, object relations theory, including particularly the American schools of Otto Kernberg and Heinz Kohut has explored narcissistic defences through analysis of such mechanisms as denial, projective identification, and extreme idealisation.
Kernberg emphasised the role of the splitting apart introjections, and identifications of opposing qualities, as a cause of ego weakness. Kohut too stressed the fact in narcissism “vertical splits are between self-structures (among others)—’I am grand’ and ‘I am wretched’—with very little communication between them”.
Neville Symington however placed greater weight on the way “a person dominated by narcissistic currents…survives through being able to sense the emotional tone of the other…wearing the cloaks of others”; while for Spotnitz the key element is that the narcissist turns feelings in upon the self in narcissistic defence.
Positive Defences
Kernberg emphasised the positive side to narcissistic defences, while Kohut also stressed the necessity in early life for narcissistic positions to succeed each other in orderly maturational sequences.
Others like Symington would maintain that “it is a mistake to split narcissism into positive and negative…we do not get positive narcissism without self-hatred”.
Stigmatising Attitude to Psychiatric Illness
Arikan found that a stigmatising attitude to psychiatric patients is associated with narcissistic defences.
21st century
The twenty-first century has seen a distinction drawn between cerebral and somatic narcissists – the former building up their self-sense through intellectualism, the latter through an obsession with their bodies, as with the woman who, in bad faith, invests her sense of freedom only in being an object of beauty for others.
Literary Parallels
Sir Philip Sidney is said to have seen poetry in itself as a narcissistic defence.
Jean-Paul Sartre’s aloof, detached protagonists have been seen as crude narcissists who preserve their sense of self only by petrifying it into solid form.
Personality disorders (PD) are a class of mental disorders characterised by enduring maladaptive patterns of behaviour, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual’s culture.
These patterns develop early, are inflexible, and are associated with significant distress or disability. The definitions may vary somewhat, according to source, and remain a matter of controversy. Official criteria for diagnosing personality disorders are listed in the fifth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM).
Personality, defined psychologically, is the set of enduring behavioural and mental traits that distinguish individual humans. Hence, PDs are defined by experiences and behaviours that deviate from social norms and expectations. Those diagnosed with a PD may experience difficulties in cognition, emotiveness, interpersonal functioning, or impulse control. In general, PDs are diagnosed in 40-60% of psychiatric patients, making them the most frequent of psychiatric diagnoses.
PDs are characterised by an enduring collection of behavioural patterns often associated with considerable personal, social, and occupational disruption. PDs are also inflexible and pervasive across many situations, largely due to the fact that such behaviour may be ego-syntonic (i.e. the patterns are consistent with the ego integrity of the individual) and are therefore perceived to be appropriate by that individual. In addition, people with personality disorders often lack insight into their condition and so refrain from seeking treatment. This behaviour can result in maladaptive coping skills and may lead to personal problems that induce extreme anxiety, distress, or depression and result in impaired psychosocial functioning. These behaviour patterns are typically recognised by adolescence, the beginning of adulthood or sometimes even childhood and often have a pervasive negative impact on the quality of life.
While emerging treatments, such as dialectical behaviour therapy, have demonstrated efficacy in treating PDs, such as borderline personality disorder, PDs are associated with considerable stigma in popular and clinical discourse alike. Despite various methodological schemas designed to categorise PDs, many issues occur with classifying a personality disorder because the theory and diagnosis of such disorders occur within prevailing cultural expectations; thus, their validity is contested by some experts on the basis of inevitable subjectivity. They argue that the theory and diagnosis of PDs are based strictly on social, or even sociopolitical and economic considerations.
Personality disorder is a term with a distinctly modern meaning, owing in part to its clinical usage and the institutional character of modern psychiatry. The currently accepted meaning must be understood in the context of historical changing classification systems such as DSM-IV and its predecessors. Although highly anachronistic, and ignoring radical differences in the character of subjectivity and social relations, some have suggested similarities to other concepts going back to at least the ancient Greeks. For example, the Greek philosopher Theophrastus described 29 ‘character’ types that he saw as deviations from the norm, and similar views have been found in Asian, Arabic and Celtic cultures. A long-standing influence in the Western world was Galen’s concept of personality types, which he linked to the four humours proposed by Hippocrates.
Such views lasted into the eighteenth century, when experiments began to question the supposed biologically based humours and ‘temperaments’. Psychological concepts of character and ‘self’ became widespread. In the nineteenth century, ‘personality’ referred to a person’s conscious awareness of their behaviour, a disorder of which could be linked to altered states such as dissociation. This sense of the term has been compared to the use of the term ‘multiple personality disorder’ in the first versions of the DSM.
Physicians in the early nineteenth century started to diagnose forms of insanity involving disturbed emotions and behaviours but seemingly without significant intellectual impairment or delusions or hallucinations. Philippe Pinel referred to this as ‘ manie sans délire ‘ – mania without delusions – and described a number of cases mainly involving excessive or inexplicable anger or rage. James Cowles Prichard advanced a similar concept he called moral insanity, which would be used to diagnose patients for some decades. ‘Moral’ in this sense referred to affect (emotion or mood) rather than ethics, but it was arguably based in part on religious, social and moral beliefs, with a pessimism about medical intervention so social control should take precedence. These categories were much different and broader than later definitions of personality disorder, while also being developed by some into a more specific meaning of moral degeneracy akin to later ideas about ‘psychopaths’. Separately, Richard von Krafft-Ebing popularised the terms sadism and masochism, as well as homosexuality, as psychiatric issues.
The German psychiatrist Koch sought to make the moral insanity concept more scientific, and in 1891 suggested the phrase ‘psychopathic inferiority’, theorised to be a congenital disorder. This referred to continual and rigid patterns of misconduct or dysfunction in the absence of apparent mental retardation or illness, supposedly without a moral judgement. Described as deeply rooted in his Christian faith, his work established the concept of personality disorder as used today.
20th century
In the early 20th century, another German psychiatrist, Emil Kraepelin, included a chapter on psychopathic inferiority in his influential work on clinical psychiatry for students and physicians. He suggested six types:
Excitable;
Unstable;
Eccentric;
Liar;
Swindler; and
Quarrelsome.
The categories were essentially defined by the most disordered criminal offenders observed, distinguished between criminals by impulse, professional criminals, and morbid vagabonds who wandered through life. Kraepelin also described three paranoid (meaning then delusional) disorders, resembling later concepts of schizophrenia, delusional disorder and paranoid personality disorder. A diagnostic term for the latter concept would be included in the DSM from 1952, and from 1980 the DSM would also include schizoid, schizotypal; interpretations of earlier (1921) theories of Ernst Kretschmer led to a distinction between these and another type later included in the DSM, avoidant personality disorder.
In 1933 Russian psychiatrist Pyotr Borisovich Gannushkin published his book Manifestations of Psychopathies: Statics, Dynamics, Systematic Aspects, which was one of the first attempts to develop a detailed typology of psychopathies. Regarding maladaptation, ubiquity, and stability as the three main symptoms of behavioural pathology, he distinguished nine clusters of psychopaths: cycloids (including constitutionally depressive, constitutionally excitable, cyclothymics, and emotionally labile), asthenics (including psychasthenics), schizoids (including dreamers), paranoiacs (including fanatics), epileptoids, hysterical personalities (including pathological liars), unstable psychopaths, antisocial psychopaths, and constitutionally stupid. Some elements of Gannushkin’s typology were later incorporated into the theory developed by a Russian adolescent psychiatrist, Andrey Yevgenyevich Lichko, who was also interested in psychopathies along with their milder forms, the so-called accentuations of character.
In 1939, psychiatrist David Henderson published a theory of ‘psychopathic states’ that contributed to popularly linking the term to anti-social behaviour. Hervey M. Cleckley’s 1941 text, The Mask of Sanity, based on his personal categorisation of similarities he noted in some prisoners, marked the start of the modern clinical conception of psychopathy and its popularist usage.
Towards the mid 20th century, psychoanalytic theories were coming to the fore based on work from the turn of the century being popularized by Sigmund Freud and others. This included the concept of character disorders, which were seen as enduring problems linked not to specific symptoms but to pervasive internal conflicts or derailments of normal childhood development. These were often understood as weaknesses of character or wilful deviance, and were distinguished from neurosis or psychosis. The term ‘borderline’ stems from a belief some individuals were functioning on the edge of those two categories, and a number of the other personality disorder categories were also heavily influenced by this approach, including dependent, obsessive-compulsive and histrionic, the latter starting off as a conversion symptom of hysteria particularly associated with women, then a hysterical personality, then renamed histrionic personality disorder in later versions of the DSM. A passive aggressive style was defined clinically by Colonel William Menninger during World War II in the context of men’s reactions to military compliance, which would later be referenced as a personality disorder in the DSM. Otto Kernberg was influential with regard to the concepts of borderline and narcissistic personalities later incorporated in 1980 as disorders into the DSM.
Meanwhile, a more general personality psychology had been developing in academia and to some extent clinically. Gordon Allport published theories of personality traits from the 1920s – and Henry Murray advanced a theory called personology, which influenced a later key advocate of personality disorders, Theodore Millon. Tests were developing or being applied for personality evaluation, including projective tests such as the Rorshach, as well as questionnaires such as the Minnesota Multiphasic Personality Inventory. Around mid-century, Hans Eysenck was analysing traits and personality types, and psychiatrist Kurt Schneider was popularising a clinical use in place of the previously more usual terms ‘character’, ‘temperament’ or ‘constitution’.
American psychiatrists officially recognised concepts of enduring personality disturbances in the first Diagnostic and Statistical Manual of Mental Disorders in the 1950s, which relied heavily on psychoanalytic concepts. Somewhat more neutral language was employed in the DSM-II in 1968, though the terms and descriptions had only a slight resemblance to current definitions. The DSM-III published in 1980 made some major changes, notably putting all personality disorders onto a second separate ‘axis’ along with mental retardation, intended to signify more enduring patterns, distinct from what were considered axis one mental disorders. ‘Inadequate’ and ‘asthenic’ personality disorder’ categories were deleted, and others were expanded into more types, or changed from being personality disorders to regular disorders. Sociopathic personality disorder, which had been the term for psychopathy, was renamed Antisocial Personality Disorder. Most categories were given more specific ‘operationalised’ definitions, with standard criteria psychiatrists could agree on to conduct research and diagnose patients. In the DSM-III revision, self-defeating personality disorder and sadistic personality disorder were included as provisional diagnoses requiring further study. They were dropped in the DSM-IV, though a proposed ‘depressive personality disorder’ was added; in addition, the official diagnosis of passive-aggressive personality disorder was dropped, tentatively renamed ‘negativistic personality disorder.’
International differences have been noted in how attitudes have developed towards the diagnosis of personality disorder. Kurt Schneider argued they were ‘abnormal varieties of psychic life’ and therefore not necessarily the domain of psychiatry, a view said to still have influence in Germany today. British psychiatrists have also been reluctant to address such disorders or consider them on par with other mental disorders, which has been attributed partly to resource pressures within the National Health Service, as well as to negative medical attitudes towards behaviours associated with personality disorders. In the US, the prevailing healthcare system and psychanalytic tradition has been said to provide a rationale for private therapists to diagnose some personality disorders more broadly and provide ongoing treatment for them.
Epidemiology
The prevalence of personality disorder in the general community was largely unknown until surveys starting from the 1990s. In 2008 the median rate of diagnosable PD was estimated at 10.6%, based on six major studies across three nations. This rate of around one in ten, especially as associated with high use of services, is described as a major public health concern requiring attention by researchers and clinicians.
The prevalence of individual personality disorders ranges from about 2% to 3% for the more common varieties, such as schizotypal, antisocial, borderline, and histrionic, to 0.5-1% for the least common, such as narcissistic and avoidant.
A screening survey across 13 countries by the WHO using DSM-IV criteria, reported in 2009 a prevalence estimate of around 6% for personality disorders. The rate sometimes varied with demographic and socioeconomic factors, and functional impairment was partly explained by co-occurring mental disorders. In the US, screening data from the National Comorbidity Survey Replication between 2001 and 2003, combined with interviews of a subset of respondents, indicated a population prevalence of around 9% for personality disorders in total. Functional disability associated with the diagnoses appeared to be largely due to co-occurring mental disorders (Axis I in the DSM).
A UK national epidemiological study (based on DSM-IV screening criteria), reclassified into levels of severity rather than just diagnosis, reported in 2010 that the majority of people show some personality difficulties in one way or another (short of threshold for diagnosis), while the prevalence of the most complex and severe cases (including meeting criteria for multiple diagnoses in different clusters) was estimated at 1.3%. Even low levels of personality symptoms were associated with functional problems, but the most severely in need of services was a much smaller group.
Personality disorders (especially Cluster A) are also very common among homeless people.
There are some sex differences in the frequency of personality disorders which are shown below (type of PD/predominant gender):
Paranoid personality disorder: Male.
Schizoid personality disorder: Male.
Schizotypal personality disorder: Male.
Antisocial personality disorder: Male.
Borderline personality disorder: Female.
Histrionic personality disorder: Female.
Narcissistic personality disorder: Male.
Avoidant personality disorder: Male.
Dependent personality disorder: Female.
Depressive personality disorder: Female.
Passive–aggressive personality disorder: Male.
Obsessive-compulsive personality disorder: Male.
Self-defeating personality disorder: Female.
Sadistic personality disorder: Male.
Classification
The two relevant major systems of classification are:
The ICD system is a collection of numerical codes that have been assigned to all known clinical disease states, which provides uniform terminology for medical records, billing, and research purposes. The DSM defines psychiatric diagnoses based on research and expert consensus, and its content informs the ICD-10 classifications. Both have deliberately merged their diagnoses to some extent, but some differences remain. For example, ICD-10 does not include narcissistic personality disorder as a distinct category, while DSM-5 does not include enduring personality change after catastrophic experience or after psychiatric illness. ICD-10 classifies the DSM-5 schizotypal personality disorder as a form of schizophrenia rather than as a personality disorder. There are accepted diagnostic issues and controversies with regard to distinguishing particular personality disorder categories from each other.
General Criteria
Both diagnostic systems provide a definition and six criteria for a general personality disorder. These criteria should be met by all personality disorder cases before a more specific diagnosis can be made.
The ICD-10 lists these general guideline criteria:
Markedly disharmonious attitudes and behaviour, generally involving several areas of functioning, e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;
The abnormal behaviour pattern is enduring, of long standing, and not limited to episodes of mental illness;
The abnormal behaviour pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;
The above manifestations always appear during childhood or adolescence and continue into adulthood;
The disorder leads to considerable personal distress but this may only become apparent late in its course;
The disorder is usually, but not invariably, associated with significant problems in occupational and social performance.
The ICD adds: “For different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations.”
In DSM-5, any personality disorder diagnosis must meet the following criteria:
An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
Cognition (i.e. ways of perceiving and interpreting self, other people, and events).
Affectivity (i.e. the range, intensity, lability, and appropriateness of emotional response).
Interpersonal functioning.
Impulse control.
The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
The enduring pattern is not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition (e.g. head trauma).
In ICD-10
Chapter V in the ICD-10 contains the mental and behavioural disorders and includes categories of personality disorder and enduring personality changes. They are defined as ingrained patterns indicated by inflexible and disabling responses that significantly differ from how the average person in the culture perceives, thinks, and feels, particularly in relating to others.
The specific personality disorders are: paranoid, schizoid, dissocial, emotionally unstable (borderline type and impulsive type), histrionic, anankastic, anxious (avoidant) and dependent.
Besides the ten specific PD, there are the following categories:
Other specific personality disorders (involves PD characterised as eccentric, haltlose, immature, narcissistic, passive-aggressive, or psychoneurotic).
Personality disorder, unspecified (includes “character neurosis” and “pathological personality”).
Mixed and other personality disorders (defined as conditions that are often troublesome but do not demonstrate the specific pattern of symptoms in the named disorders).
Enduring personality changes, not attributable to brain damage and disease (this is for conditions that seem to arise in adults without a diagnosis of personality disorder, following catastrophic or prolonged stress or other psychiatric illness).
In ICD-11
In the proposed revision of ICD-11, all discrete personality disorder diagnoses will be removed and replaced by the single diagnosis “personality disorder”. Instead, there will be specifiers called “prominent personality traits” and the possibility to classify degrees of severity ranging from “mild”, “moderate”, and “severe” based on the dysfunction in interpersonal relationships and everyday life of the patient.
There are six prominent personality traits/patterns categorised by the ICD-11:
Negative affectivity (“tendency to experience a broad range of negative emotions.”).
Detachment (“tendency to maintain interpersonal distance (social detachment) and emotional distance (emotional detachment).”).
Dissociality (“disregard for the rights and feelings of others, encompassing both self-centredness and lack of empathy.” Equivalent to the DSM-5 classification of antisocial personality disorder.).
Disinhibition (“tendency to act rashly based on immediate external or internal stimuli (i.e., sensations, emotions, thoughts), without consideration of potential negative consequences.”).
Anankastia (“narrow focus on one’s rigid standard of perfection and of right and wrong, and on controlling one’s own and others’ behaviour and controlling situations to ensure conformity to these standards.” Equivalent to the DSM-5 classification of obsessive-compulsive personality disorder.),
Borderline pattern (“pattern of personality disturbance is characterised by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity”. Equivalent to the DSM-5 classification of borderline personality disorder.),
In DSM-5
The most recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders stresses that a personality disorder is an enduring and inflexible pattern of long duration leading to significant distress or impairment and is not due to use of substances or another medical condition. The DSM-5 lists personality disorders in the same way as other mental disorders, rather than on a separate ‘axis’, as previously.
DSM-5 lists ten specific personality disorders: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent and obsessive-compulsive personality disorder.
The DSM-5 also contains three diagnoses for personality patterns not matching these ten disorders, but nevertheless exhibit characteristics of a personality disorder:
Personality change due to another medical condition – personality disturbance due to the direct effects of a medical condition.
Other specified personality disorder – general criteria for a personality disorder are met but fails to meet the criteria for a specific disorder, with the reason given.
Unspecified personality disorder – general criteria for a personality disorder are met but the personality disorder is not included in the DSM-5 classification.
Personality Clusters
The specific personality disorders are grouped into the following three clusters based on descriptive similarities:
Cluster A (Odd or Eccentric Disorders)
Cluster A personality disorders are often associated with schizophrenia: in particular, schizotypal personality disorder shares some of its hallmark symptoms with schizophrenia, e.g., acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behaviour. However, people diagnosed with odd-eccentric personality disorders tend to have a greater grasp on reality than those with schizophrenia. Patients suffering from these disorders can be paranoid and have difficulty being understood by others, as they often have odd or eccentric modes of speaking and an unwillingness and inability to form and maintain close relationships. Though their perceptions may be unusual, these anomalies are distinguished from delusions or hallucinations as people suffering from these would be diagnosed with other conditions. Significant evidence suggests a small proportion of people with Cluster A personality disorders, especially schizotypal personality disorder, have the potential to develop schizophrenia and other psychotic disorders. These disorders also have a higher probability of occurring among individuals whose first-degree relatives have either schizophrenia or a Cluster A personality disorder.
Paranoid personality disorder: characterised by a pattern of irrational suspicion and mistrust of others, interpreting motivations as malevolent.
Schizoid personality disorder: lack of interest and detachment from social relationships, apathy, and restricted emotional expression.
Cluster B (Dramatic, Emotional or Erratic Disorders)
Antisocial personality disorder: pervasive pattern of disregard for and violation of the rights of others, lack of empathy, bloated self-image, manipulative and impulsive behaviour.
Borderline personality disorder: pervasive pattern of abrupt emotional outbursts, altered empathy, instability in relationships, self-image, identity, behaviour and affect, often leading to self-harm and impulsivity.
Narcissistic personality disorder: pervasive pattern of superior grandiosity, need for admiration, and a perceived or real lack of empathy. In a more severe expression, narcissistic personality disorder may show evidence of paranoia, aggression, psychopathy, and sadistic personality disorder, which is known as malignant narcissism.
Cluster C (Anxious or Fearful Disorders)
Avoidant personality disorder: pervasive feelings of social inhibition and inadequacy, extreme sensitivity to negative evaluation.
Obsessive-compulsive personality disorder: characterised by rigid conformity to rules, perfectionism, and control to the point of satisfaction and exclusion of leisurely activities and friendships (distinct from obsessive-compulsive disorder).
Other Personality Types
Some types of personality disorder were in previous versions of the diagnostic manuals but have been deleted. Examples include sadistic personality disorder (pervasive pattern of cruel, demeaning, and aggressive behaviour) and self-defeating personality disorder or masochistic personality disorder (characterised by behaviour consequently undermining the person’s pleasure and goals). They were listed in the DSM-III-R appendix as “Proposed diagnostic categories needing further study” without specific criteria. The psychologist Theodore Millon and others consider some relegated diagnoses to be equally valid disorders, and may also propose other personality disorders or subtypes, including mixtures of aspects of different categories of the officially accepted diagnoses.
Millon’s Description
Psychologist Theodore Millon, who has written numerous popular works on personality, proposed the following description of personality disorders:
Type of Personality Disorder
Description
Paranoid
Guarded, defensive, distrustful and suspicious. Hypervigilant to the motives of others to undermine or do harm. Always seeking confirmatory evidence of hidden schemes. Feel righteous, but persecuted. Experience a pattern of pervasive distrust and suspicion of others that lasts a long time. They are generally difficult to work with and are very hard to form relationships with. They are also known to be somewhat short-tempered.
Schizoid
Apathetic, indifferent, remote, solitary, distant, humourless, contempt, odd fantasies. Neither desire nor need human attachments. Withdrawn from relationships and prefer to be alone. Little interest in others, often seen as a loner. Minimal awareness of the feelings of themselves or others. Few drives or ambitions, if any. Is an uncommon condition in which people avoid social activities and consistently shy away from interaction with others. It affects more males than females. To others, they may appear somewhat dull or humourless. Because they don’t tend to show emotion, they may appear as though they don’t care about what’s going on around them.
Schizotypal
Eccentric, self-estranged, bizarre, absent. Exhibit peculiar mannerisms and behaviours. Think they can read thoughts of others. Preoccupied with odd daydreams and beliefs. Blur line between reality and fantasy. Magical thinking and strange beliefs. People with schizotypal personality disorder are often described as odd or eccentric and usually have few, if any, close relationships. They think others think negatively of them.
Antisocial
Impulsive, irresponsible, deviant, unruly. Act without due consideration. Meet social obligations only when self-serving. Disrespect societal customs, rules, and standards. See themselves as free and independent. People with antisocial personality disorder depict a long pattern of disregard for other people’s rights. They often cross the line and violate these rights.
Borderline
Unpredictable, egocentric, emotionally unstable. Frantically fears abandonment and isolation. Experience rapidly fluctuating moods. Shift rapidly between loving and hating. See themselves and others alternatively as all-good and all-bad. Unstable and frequently changing moods. People with borderline personality disorder have a pervasive pattern of instability in interpersonal relationships.
Histrionic
Hysteria, dramatic, seductive, shallow, egocentric, attention-seeking, vain. Overreact to minor events. Exhibitionistic as a means of securing attention and favours. See themselves as attractive and charming. Constantly seeking others’ attention. Disorder is characterised by constant attention-seeking, emotional overreaction, and suggestibility. Their tendency to over-dramatise may impair relationships and lead to depression, but they are often high-functioning.
Narcissistic
Egotistical, arrogant, grandiose, insouciant. Preoccupied with fantasies of success, beauty, or achievement. See themselves as admirable and superior, and therefore entitled to special treatment. Is a mental disorder in which people have an inflated sense of their own importance and a deep need for admiration. Those with narcissistic personality disorder believe that they are superior to others and have little regard for other people’s feelings.
Avoidant
Hesitant, self-conscious, embarrassed, anxious. Tense in social situations due to fear of rejection. Plagued by constant performance anxiety. See themselves as inept, inferior, or unappealing. They experience long-standing feelings of inadequacy and are very sensitive of what others think about them.
Dependent
Helpless, incompetent, submissive, immature. Withdrawn from adult responsibilities. See themselves as weak or fragile. Seek constant reassurance from stronger figures. They have the need to be taken care of by a person. They fear being abandoned or separated from important people in their life.
Obsessive-Compulsive
Restrained, conscientious, respectful, rigid. Maintain a rule-bound lifestyle. Adhere closely to social conventions. See the world in terms of regulations and hierarchies. See themselves as devoted, reliable, efficient, and productive.
Depressive
Sombre, discouraged, pessimistic, brooding, fatalistic. Present themselves as vulnerable and abandoned. Feel valueless, guilty, and impotent. Judge themselves as worthy only of criticism and contempt. Hopeless, suicidal, restless. This disorder can lead to aggressive acts and hallucinations.
Passive-Aggressive (Negativistic)
Resentful, contrary, sceptical, discontented. Resist fulfilling others’ expectations. Deliberately inefficient. Vent anger indirectly by undermining others’ goals. Alternately moody and irritable, then sullen and withdrawn. Withhold emotions. Will not communicate when there is something problematic to discuss.
Sadistic
Explosively hostile, abrasive, cruel, dogmatic. Liable to sudden outbursts of rage. Gain satisfaction through dominating, intimidating and humiliating others. They are opinionated and closed-minded. Enjoy performing brutal acts on others. Find pleasure in abusing others. Would likely engage in a sadomasochist relationship, but will not play the role of a masochist.
Self-Defeating (Masochistic)
Deferential, pleasure-phobic, servile, blameful, self-effacing. Encourage others to take advantage of them. Deliberately defeat own achievements. Seek condemning or mistreatful partners. They are suspicious of people who treat them well. Would likely engage in a sadomasochist relationship.
Additional Factors
In addition to classifying by category and cluster, it is possible to classify personality disorders using additional factors such as severity, impact on social functioning, and attribution.
Severity
This involves both the notion of personality difficulty as a measure of subthreshold scores for personality disorder using standard interviews and the evidence that those with the most severe personality disorders demonstrate a “ripple effect” of personality disturbance across the whole range of mental disorders. In addition to subthreshold (personality difficulty) and single cluster (simple personality disorder), this also derives complex or diffuse personality disorder (two or more clusters of personality disorder present) and can also derive severe personality disorder for those of greatest risk.
Dimensional System of Classifying Personality Disorders
Level of Severity
Description
Definition by Categorical System
0
No personality disorder
Does not meet actual or subthreshold criteria for any personality disorder.
1
Personality difficulty
Meets sub-threshold criteria for one or several personality disorders.
2
Simple personality disorder
Meets actual criteria for one or more personality disorders within the same cluster.
3
Complex (diffuse) personality disorder
Meets actual criteria for one or more personality disorders within more than one cluster.
4
Severe personality disorder
Meets criteria for creation of severe disruption to both individual and to many in society.
There are several advantages to classifying personality disorder by severity:
It not only allows for but also takes advantage of the tendency for personality disorders to be comorbid with each other.
It represents the influence of personality disorder on clinical outcome more satisfactorily than the simple dichotomous system of no personality disorder versus personality disorder.
This system accommodates the new diagnosis of severe personality disorder, particularly “dangerous and severe personality disorder” (DSPD).
Effect on Social Functioning
Social function is affected by many other aspects of mental functioning apart from that of personality. However, whenever there is persistently impaired social functioning in conditions in which it would normally not be expected, the evidence suggests that this is more likely to be created by personality abnormality than by other clinical variables. The Personality Assessment Schedule gives social function priority in creating a hierarchy in which the personality disorder creating the greater social dysfunction is given primacy over others in a subsequent description of personality disorder.
Attribution
Many who have a personality disorder do not recognise any abnormality and defend valiantly their continued occupancy of their personality role. This group have been termed the Type R, or treatment-resisting personality disorders, as opposed to the Type S or treatment-seeking ones, who are keen on altering their personality disorders and sometimes clamour for treatment. The classification of 68 personality disordered patients on the caseload of an assertive community team using a simple scale showed a 3 to 1 ratio between Type R and Type S personality disorders with Cluster C personality disorders being significantly more likely to be Type S, and paranoid and schizoid (Cluster A) personality disorders significantly more likely to be Type R than others.
Presentation
Comorbidity
There is a considerable personality disorder diagnostic co-occurrence. Patients who meet the DSM-IV-TR diagnostic criteria for one personality disorder are likely to meet the diagnostic criteria for another. Diagnostic categories provide clear, vivid descriptions of discrete personality types but the personality structure of actual patients might be more accurately described by a constellation of maladaptive personality traits.
Impact on Functioning
It is generally assumed that all personality disorders are linked to impaired functioning and a reduced quality of life (QoL) because that is a basic diagnostic requirement. But research shows that this may be true only for some types of personality disorder.
In several studies, higher disability and lower QoL were predicted by avoidant, dependent, schizoid, paranoid, schizotypal and antisocial personality disorder. This link is particularly strong for avoidant, schizotypal and borderline PD. However, obsessive-compulsive PD was not related to a compromised QoL or dysfunction. A prospective study reported that all PD were associated with significant impairment 15 years later, except for obsessive compulsive and narcissistic personality disorder.
One study investigated some aspects of “life success” (status, wealth and successful intimate relationships). It showed somewhat poor functioning for schizotypal, antisocial, borderline and dependent PD, schizoid PD had the lowest scores regarding these variables. Paranoid, histrionic and avoidant PD were average. Narcissistic and obsessive-compulsive PD, however, had high functioning and appeared to contribute rather positively to these aspects of life success.
There is also a direct relationship between the number of diagnostic criteria and quality of life. For each additional personality disorder criterion that a person meets there is an even reduction in quality of life.
Issues
In the Workplace
Depending on the diagnosis, severity and individual, and the job itself, personality disorders can be associated with difficulty coping with work or the workplace – potentially leading to problems with others by interfering with interpersonal relationships. Indirect effects also play a role; for example, impaired educational progress or complications outside of work, such as substance abuse and co-morbid mental disorders, can plague sufferers. However, personality disorders can also bring about above-average work abilities by increasing competitive drive or causing the sufferer to exploit his or her co-workers.
In 2005 and again in 2009, psychologists Belinda Board and Katarina Fritzon at the University of Surrey, UK, interviewed and gave personality tests to high-level British executives and compared their profiles with those of criminal psychiatric patients at Broadmoor Hospital in the UK. They found that three out of eleven personality disorders were actually more common in executives than in the disturbed criminals:
Histrionic personality disorder: including superficial charm, insincerity, egocentricity and manipulation
Narcissistic personality disorder: including grandiosity, self-focused lack of empathy for others, exploitativeness and independence.
Obsessive-compulsive personality disorder: including perfectionism, excessive devotion to work, rigidity, stubbornness and dictatorial tendencies.
According to leadership academic Manfred F.R. Kets de Vries, it seems almost inevitable that some personality disorders will be present in a senior management team.
In Children
Early stages and preliminary forms of personality disorders need a multi-dimensional and early treatment approach. Personality development disorder is considered to be a childhood risk factor or early stage of a later personality disorder in adulthood. In addition, in Robert F. Krueger’s review of their research indicates that some children and adolescents do suffer from clinically significant syndromes that resemble adult personality disorders, and that these syndromes have meaningful correlates and are consequential. Much of this research has been framed by the adult personality disorder constructs from Axis II of the Diagnostic and Statistical Manual. Hence, they are less likely to encounter the first risk they described at the outset of their review: clinicians and researchers are not simply avoiding use of the PD construct in youth. However, they may encounter the second risk they described: under-appreciation of the developmental context in which these syndromes occur. That is, although PD constructs show continuity over time, they are probabilistic predictors; not all youths who exhibit PD symptomatology become adult PD cases.
Versus Mental Disorders
The disorders in each of the three clusters may share with each other underlying common vulnerability factors involving cognition, affect and impulse control, and behavioural maintenance or inhibition, respectively. But they may also have a spectrum relationship to certain syndromal mental disorders:
Paranoid, schizoid or schizotypal personality disorders may be observed to be premorbid antecedents of delusional disorders or schizophrenia.
Borderline personality disorder is seen in association with mood and anxiety disorders, with impulse-control disorders, eating disorders, ADHD, or a substance use disorder.
Avoidant personality disorder is seen with social anxiety disorder.
Versus Normal Personality
The issue of the relationship between normal personality and personality disorders is one of the important issues in personality and clinical psychology. The personality disorders classification (DSM-5 and ICD-10) follows a categorical approach that views personality disorders as discrete entities that are distinct from each other and from normal personality. In contrast, the dimensional approach is an alternative approach that personality disorders represent maladaptive extensions of the same traits that describe normal personality.
Thomas Widiger and his collaborators have contributed to this debate significantly. He discussed the constraints of the categorical approach and argued for the dimensional approach to the personality disorders. Specifically, he proposed the Five Factor Model of personality as an alternative to the classification of personality disorders. For example, this view specifies that Borderline Personality Disorder can be understood as a combination of emotional lability (i.e. high neuroticism), impulsivity (i.e. low conscientiousness), and hostility (i.e. low agreeableness). Many studies across cultures have explored the relationship between personality disorders and the Five Factor Model. This research has demonstrated that personality disorders largely correlate in expected ways with measures of the Five Factor Model and has set the stage for including the Five Factor Model within DSM-5.
In clinical practice, individuals are generally diagnosed by an interview with a psychiatrist based on a mental status examination, which may take into account observations by relatives and others. One tool of diagnosing personality disorders is a process involving interviews with scoring systems. The patient is asked to answer questions, and depending on their answers, the trained interviewer tries to code what their responses were. This process is fairly time-consuming.
As of 2002, there were over fifty published studies relating the five factor model (FFM) to personality disorders. Since that time, quite a number of additional studies have expanded on this research base and provided further empirical support for understanding the DSM personality disorders in terms of the FFM domains. In her seminal review of the personality disorder literature published in 2007, Lee Anna Clark asserted that “the five-factor model of personality is widely accepted as representing the higher-order structure of both normal and abnormal personality traits”.
The five factor model has been shown to significantly predict all 10 personality disorder symptoms and outperform the Minnesota Multiphasic Personality Inventory (MMPI) in the prediction of borderline, avoidant, and dependent personality disorder symptoms.
Research results examining the relationships between the FFM and each of the ten DSM personality disorder diagnostic categories are widely available. For example, in a study published in 2003 titled “The five-factor model and personality disorder empirical literature: A meta-analytic review”, the authors analysed data from 15 other studies to determine how personality disorders are different and similar, respectively, with regard to underlying personality traits. In terms of how personality disorders differ, the results showed that each disorder displays a FFM profile that is meaningful and predictable given its unique diagnostic criteria. With regard to their similarities, the findings revealed that the most prominent and consistent personality dimensions underlying a large number of the personality disorders are positive associations with neuroticism and negative associations with agreeableness.
Openness to Experience
At least three aspects of openness to experience are relevant to understanding personality disorders: cognitive distortions, lack of insight (means the ability to recognise one’s own mental illness here) and impulsivity. Problems related to high openness that can cause problems with social or professional functioning are excessive fantasising, peculiar thinking, diffuse identity, unstable goals and nonconformity with the demands of the society.
High openness is characteristic to schizotypal personality disorder (odd and fragmented thinking), narcissistic personality disorder (excessive self-valuation) and paranoid personality disorder (sensitivity to external hostility). Lack of insight (shows low openness) is characteristic to all personality disorders and could help explain the persistence of maladaptive behavioural patterns.
The problems associated with low openness are difficulties adapting to change, low tolerance for different worldviews or lifestyles, emotional flattening, alexithymia and a narrow range of interests. Rigidity is the most obvious aspect of (low) openness among personality disorders and that shows lack of knowledge of one’s emotional experiences. It is most characteristic of obsessive-compulsive personality disorder; the opposite of it known as impulsivity (here: an aspect of openness that shows a tendency to behave unusually or autistically) is characteristic of schizotypal and borderline personality disorders.
Causes
Currently, there are no definitive proven causes for personality disorders. However, there are numerous possible causes and known risk factors supported by scientific research that vary depending on the disorder, the individual, and the circumstance. Overall, findings show that genetic disposition and life experiences, such as trauma and abuse, play a key role in the development of personality disorders.
Child Abuse
Child abuse and neglect consistently show up as risk factors to the development of personality disorders in adulthood. A study looked at retrospective reports of abuse of participants that had demonstrated psychopathology throughout their life and were later found to have past experience with abuse. In a study of 793 mothers and children, researchers asked mothers if they had screamed at their children, and told them that they did not love them or threatened to send them away. Children who had experienced such verbal abuse were three times as likely as other children (who did not experience such verbal abuse) to have borderline, narcissistic, obsessive-compulsive or paranoid personality disorders in adulthood. The sexually abused group demonstrated the most consistently elevated patterns of psychopathology. Officially verified physical abuse showed an extremely strong correlation with the development of antisocial and impulsive behaviour. On the other hand, cases of abuse of the neglectful type that created childhood pathology were found to be subject to partial remission in adulthood.
Socioeconomic Status
Socioeconomic status has also been looked at as a potential cause for personality disorders. There is a strong association with low parental/neighbourhood socioeconomic status and personality disorder symptoms. In a 2015 publication from Bonn, Germany, which compared parental socioeconomic status and a child’s personality, it was seen that children who were from higher socioeconomic backgrounds were more altruistic, less risk seeking, and had overall higher IQs. These traits correlate with a low risk of developing personality disorders later on in life. In a study looking at female children who were detained for disciplinary actions found that psychological problems were most negatively associated with socioeconomic problems. Furthermore, social disorganisation was found to be inversely correlated with personality disorder symptoms.
Parenting
Evidence shows personality disorders may begin with parental personality issues. These cause the child to have their own difficulties in adulthood, such as difficulties reaching higher education, obtaining jobs, and securing dependable relationships. By either genetic or modelling mechanisms, children can pick up these traits. Additionally, poor parenting appears to have symptom elevating effects on personality disorders. More specifically, lack of maternal bonding has also been correlated with personality disorders. In a study comparing 100 healthy individuals to 100 borderline personality disorder patients, analysis showed that BPD patients were significantly more likely not to have been breastfed as a baby (42.4% in BPD vs. 9.2% in healthy controls). These researchers suggested this act may be essential in fostering maternal relationships. Additionally, findings suggest personality disorders show a negative correlation with two attachment variables: maternal availability and dependability. When left unfostered, other attachment and interpersonal problems occur later in life ultimately leading to development of personality disorders.
Genetics
Currently, genetic research for the understanding of the development of personality disorders is severely lacking. However, there are a few possible risk factors currently in discovery. Researchers are currently looking into genetic mechanisms for traits such as aggression, fear and anxiety, which are associated with diagnosed individuals. More research is being conducted into disorder specific mechanisms.
Research shows a malfunctioning inner brain: hippocampus up to 18% smaller, a smaller amygdala, malfunctions in the striatum-nucleus accumbens and the cingulum neural pathways connecting them and taking care of the feedback loops on what to do with all the incoming information from the multiple senses; so what comes out is anti-social – not according to what is the social norm, socially acceptable and appropriate.
Management
Specific Approaches
There are many different forms (modalities) of treatment used for personality disorders:
Individual psychotherapy has been a mainstay of treatment. There are long-term and short-term (brief) forms.
Family therapy, including couples therapy.
Group therapy for personality dysfunction is probably the second most used.
Psychological-education may be used as an addition.
Self-help groups may provide resources for personality disorders.
Psychiatric medications for treating symptoms of personality dysfunction or co-occurring conditions.
Milieu therapy, a kind of group-based residential approach, has a history of use in treating personality disorders, including therapeutic communities.
The practice of mindfulness that includes developing the ability to be non-judgementally aware of unpleasant emotions appears to be a promising clinical tool for managing different types of personality disorders.
There are different specific theories or schools of therapy within many of these modalities. They may, for example, emphasize psychodynamic techniques, or cognitive or behavioural techniques. In clinical practice, many therapists use an ‘eclectic’ approach, taking elements of different schools as and when they seem to fit to an individual client. There is also often a focus on common themes that seem to be beneficial regardless of techniques, including attributes of the therapist (e.g. trustworthiness, competence, caring), processes afforded to the client (e.g. ability to express and confide difficulties and emotions), and the match between the two (e.g. aiming for mutual respect, trust and boundaries).
Response of Patients with Personality Disorders to Biological and Psychosocial Treatments
Cluster
Evidence for Brain Dysfunction
Response to Biological Treatments
Response to Psychosocial Treatments
A
Evidence for relationship to schizophrenia; otherwise none known.
Schizotypal patients may improve on antipsychotic medication; otherwise not indicated.
Poor. Supportive psychotherapy may help.
B
Evidence for relationship to bipolar disorder; otherwise none known.
Antidepressants, antipsychotics, or mood stabilizers may help for borderline personality; otherwise not indicated.
Poor in antisocial personality. Variable in borderline, narcissistic, and histrionic personalities.
C
Evidence for relationship to generalized anxiety disorder; otherwise none known.
No direct response. Medications may help with comorbid anxiety and depression.
Most common treatment for these disorders. Response variable.
Challenges
The management and treatment of personality disorders can be a challenging and controversial area, for by definition the difficulties have been enduring and affect multiple areas of functioning. This often involves interpersonal issues, and there can be difficulties in seeking and obtaining help from organisations in the first place, as well as with establishing and maintaining a specific therapeutic relationship. On the one hand, an individual may not consider themselves to have a mental health problem, while on the other, community mental health services may view individuals with personality disorders as too complex or difficult, and may directly or indirectly exclude individuals with such diagnoses or associated behaviours. The disruptiveness that people with personality disorders can create in an organisation makes these, arguably, the most challenging conditions to manage.
Apart from all these issues, an individual may not consider their personality to be disordered or the cause of problems. This perspective may be caused by the patient’s ignorance or lack of insight into their own condition, an ego-syntonic perception of the problems with their personality that prevents them from experiencing it as being in conflict with their goals and self-image, or by the simple fact that there is no distinct or objective boundary between ‘normal’ and ‘abnormal’ personalities. There is substantial social stigma and discrimination related to the diagnosis.
The term ‘personality disorder’ encompasses a wide range of issues, each with a different level of severity or disability; thus, personality disorders can require fundamentally different approaches and understandings. To illustrate the scope of the matter, consider that while some disorders or individuals are characterised by continual social withdrawal and the shunning of relationships, others may cause fluctuations in forwardness. The extremes are worse still: at one extreme lie self-harm and self-neglect, while at another extreme some individuals may commit violence and crime. There can be other factors such as problematic substance use or dependency or behavioural addictions. A person may meet the criteria for dissociative identity disorder (formerly “multiple personality disorder”) diagnoses and/or other mental disorders, either at particular times or continually, thus making coordinated input from multiple services a potential requirement.
Therapists in this area can become disheartened by lack of initial progress, or by apparent progress that then leads to setbacks. Clients may be perceived as negative, rejecting, demanding, aggressive or manipulative. This has been looked at in terms of both therapist and client; in terms of social skills, coping efforts, defence mechanisms, or deliberate strategies; and in terms of moral judgments or the need to consider underlying motivations for specific behaviours or conflicts. The vulnerabilities of a client, and indeed a therapist, may become lost behind actual or apparent strength and resilience. It is commonly stated that there is always a need to maintain appropriate professional personal boundaries, while allowing for emotional expression and therapeutic relationships. However, there can be difficulty acknowledging the different worlds and views that both the client and therapist may live with. A therapist may assume that the kinds of relationships and ways of interacting that make them feel safe and comfortable have the same effect on clients. As an example of one extreme, people who may have been exposed to hostility, deceptiveness, rejection, aggression or abuse in their lives, may in some cases be made confused, intimidated or suspicious by presentations of warmth, intimacy or positivity. On the other hand, reassurance, openness and clear communication are usually helpful and needed. It can take several months of sessions, and perhaps several stops and starts, to begin to develop a trusting relationship that can meaningfully address a client’s issues.
Conduct disorder (CD) is a mental disorder diagnosed in childhood or adolescence that presents itself through a repetitive and persistent pattern of behaviour that includes theft, lies, physical violence that may lead to destruction and wanton breaking of rules, in which the basic rights of others or major age-appropriate norms are violated.
These behaviours are often referred to as “antisocial behaviours.” It is often seen as the precursor to antisocial personality disorder, which is per definition not diagnosed until the individual is 18 years old. Conduct disorder may result from parental rejection and neglect and can be treated with family therapy, as well as behavioural modifications and pharmacotherapy. Conduct disorder is estimated to affect 51.1 million people globally as of 2013.
Signs and Symptoms
One of the symptoms of conduct disorder is a lower level of fear. Research performed on the impact of toddlers exposed to fear and distress shows that negative emotionality (fear) predicts toddlers’ empathy-related response to distress. The findings support that if a caregiver is able to respond to infant cues, the toddler has a better ability to respond to fear and distress. If a child does not learn how to handle fear or distress the child will be more likely to lash out at other children. If the caregiver is able to provide therapeutic intervention teaching children at risk better empathy skills, the child will have a lower incident level of conduct disorder.
Increased instances of violent and antisocial behaviour are also associated with the condition; examples may range from pushing, hitting and biting when the child is young, progressing towards beating and inflicted cruelty as the child becomes older.
Conduct disorder can present with limited prosocial emotions, lack of remorse or guilt, lack of empathy, lack of concern for performance, and shallow or deficient affect. Symptoms vary by individual, but the four main groups of symptoms are described below.
Aggression to People and Animals
Often bullies, threatens or intimidates others.
Often initiates physical fights.
Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).
Has been physically cruel to people.
Has been physically cruel to animals.
Has stolen while confronting a victim (e.g. mugging, purse snatching, extortion, armed robbery).
Has forced someone into sexual activity (rape or molestation).
Feels no remorse or empathy towards the harm, fear, or pain they may have inflicted on others.
Destruction of Property
Has deliberately engaged in fire setting with the intention of causing serious damage.
Has deliberately destroyed others’ property (other than by fire setting).
Deceitfulness or Theft
Has broken into someone else’s house, building, or car.
Often lies to obtain goods or favours or to avoid obligations (i.e. “cons” others).
Has stolen items of nontrivial value without confronting a victim (e.g. shoplifting, but without breaking and entering; forgery).
Serious Violations of Rules
Often stays out at night despite parental prohibitions, beginning before age 13 years.
Has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period).
Is often truant from school, beginning before age 13 years.
The lack of empathy these individuals have and the aggression that accompanies this carelessness for the consequences is dangerous – not only for the individual but for those around them.
Developmental Course
Currently, two possible developmental courses are thought to lead to conduct disorder. The first is known as the “childhood-onset type” and occurs when conduct disorder symptoms are present before the age of 10 years. This course is often linked to a more persistent life course and more pervasive behaviours. Specifically, children in this group have greater levels of ADHD symptoms, neuropsychological deficits, more academic problems, increased family dysfunction and higher likelihood of aggression and violence.
There is debate among professionals regarding the validity and appropriateness of diagnosing young children with conduct disorder. The characteristics of the diagnosis are commonly seen in young children who are referred to mental health professionals. A premature diagnosis made in young children, and thus labelling and stigmatising an individual, may be inappropriate. It is also argued that some children may not in fact have conduct disorder, but are engaging in developmentally appropriate disruptive behaviour.
The second developmental course is known as the “adolescent-onset type” and occurs when conduct disorder symptoms are present after the age of 10 years. Individuals with adolescent-onset conduct disorder exhibit less impairment than those with the childhood-onset type and are not characterised by similar psychopathology. At times, these individuals will remit in their deviant patterns before adulthood. Research has shown that there is a greater number of children with adolescent-onset conduct disorder than those with childhood-onset, suggesting that adolescent-onset conduct disorder is an exaggeration of developmental behaviours that are typically seen in adolescence, such as rebellion against authority figures and rejection of conventional values. However, this argument is not established and empirical research suggests that these subgroups are not as valid as once thought.
In addition to these two courses that are recognised by the DSM, there appears to be a relationship among oppositional defiant disorder, conduct disorder, and antisocial personality disorder. Specifically, research has demonstrated continuity in the disorders such that conduct disorder is often diagnosed in children who have been previously diagnosed with oppositional defiant disorder, and most adults with antisocial personality disorder were previously diagnosed with conduct disorder. For example, some research has shown that 90% of children diagnosed with conduct disorder had a previous diagnosis of oppositional defiant disorder. Moreover, both disorders share relevant risk factors and disruptive behaviours, suggesting that oppositional defiant disorder (ODD) is a developmental precursor and milder variant of conduct disorder. However, this is not to say that this trajectory occurs in all individuals. In fact, only about 25% of children with oppositional defiant disorder will receive a later diagnosis of conduct disorder. Correspondingly, there is an established link between conduct disorder and the diagnosis of antisocial personality disorder as an adult. In fact, the current diagnostic criteria for antisocial personality disorder require a conduct disorder diagnosis before the age of 15. However, again, only 25-40% of youths with conduct disorder will develop an antisocial personality disorder. Nonetheless, many of the individuals who do not meet full criteria for antisocial personality disorder still exhibit a pattern of social and personal impairments or antisocial behaviours. These developmental trajectories suggest the existence of antisocial pathways in certain individuals, which have important implications for both research and treatment.
Associated Conditions
Children with conduct disorder have a high risk of developing other adjustment problems. Specifically, risk factors associated with conduct disorder and the effects of conduct disorder symptomatology on a child’s psychosocial context have been linked to overlapping with other psychological disorders. In this way, there seems to be reciprocal effects of comorbidity with certain disorders, leading to increased overall risk for these youth.
Attention Deficit Hyperactivity Disorder
ADHD is the condition most commonly associated with conduct disorders, with approximately 25-30% of boys and 50-55% of girls with conduct disorder having a comorbid ADHD diagnosis. While it is unlikely that ADHD alone is a risk factor for developing conduct disorder, children who exhibit hyperactivity and impulsivity along with aggression is associated with the early onset of conduct problems. Moreover, children with comorbid conduct disorder and ADHD show more severe aggression.
Substance Use Disorders
Conduct disorder is also highly associated with both substance use and abuse. Children with conduct disorder have an earlier onset of substance use, as compared to their peers, and also tend to use multiple substances. However, substance use disorders themselves can directly or indirectly cause conduct disorder like traits in about half of adolescents who have a substance use disorder. As mentioned above, it seems that there is a transactional relationship between substance use and conduct problems, such that aggressive behaviours increase substance use, which leads to increased aggressive behaviour.
Substance use in conduct disorder can lead to antisocial behaviour in adulthood.
Schizophrenia
Conduct disorder is a precursor to schizophrenia in a minority of cases, with about 40% of men and 31% of women with schizophrenia meeting criteria for childhood conduct disorder.
Cause
While the cause of conduct disorder is complicated by an intricate interplay of biological and environmental factors, identifying underlying mechanisms is crucial for obtaining accurate assessment and implementing effective treatment. These mechanisms serve as the fundamental building blocks on which evidence-based treatments are developed. Despite the complexities, several domains have been implicated in the development of conduct disorder including cognitive variables, neurological factors, intraindividual factors, familial and peer influences, and wider contextual factors. These factors may also vary based on the age of onset, with different variables related to early (e.g. neurodevelopmental basis) and adolescent (e.g. social/peer relationships) onset.
Risks
The development of conduct disorder is not immutable or predetermined. A number of interactive risk and protective factors exist that can influence and change outcomes, and in most cases conduct disorder develops due to an interaction and gradual accumulation of risk factors. In addition to the risk factors identified under cause, several other variables place youth at increased risk for developing the disorder, including child physical abuse, in-utero alcohol exposure, and maternal smoking during pregnancy. Protective factors have also been identified, and most notably include high IQ, being female, positive social orientations, good coping skills, and supportive family and community relationships.
However, a correlation between a particular risk factor and a later developmental outcome (such as conduct disorder) cannot be taken as definitive evidence for a causal link. Co-variation between two variables can arise, for instance, if they represent age-specific expressions of similar underlying genetic factors. For example, the tendency to smoke during pregnancy (SDP) is subject to substantial genetic influence, as is conduct disorder. Thus, the genes that dispose the mother to SDP may also dispose the child to CD following mitotic transmission. Indeed, Rice et al. (2009) found that in mother-fetus pairs that were not genetically related (by virtue of in-vitro fertilisation), no link between SDP and later conduct problems arose. Thus, the distinction between causality and correlation is an important consideration.
Learning Disabilities
While language impairments are most common, approximately 20-25% of youth with conduct disorder have some type of learning disability. Although the relationship between the disorders is complex, it seems as if learning disabilities result from a combination of ADHD, a history of academic difficulty and failure, and long-standing socialisation difficulties with family and peers. However, confounding variables, such as language deficits, SES disadvantage, or neurodevelopmental delay also need to be considered in this relationship, as they could help explain some of the association between conduct disorder and learning problems.
Cognitive Factors
In terms of cognitive function, intelligence and cognitive deficits are common amongst youths with conduct disorder, particularly those with early-onset and have intelligence quotients (IQ) one standard deviation below the mean and severe deficits in verbal reasoning and executive function. Executive function difficulties may manifest in terms of one’s ability to shift between tasks, plan as well as organise, and also inhibit a prepotent response. These findings hold true even after taking into account other variables such as socioeconomic status (SES), and education. However, IQ and executive function deficits are only one piece of the puzzle, and the magnitude of their influence is increased during transactional processes with environmental factors.
Brain Differences
Beyond difficulties in executive function, neurological research on youth with conduct disorder also demonstrate differences in brain anatomy and function that reflect the behaviours and mental anomalies associated in conduct disorder. Compared to normal controls, youths with early and adolescent onset of conduct disorder displayed reduced responses in brain regions associated with social behaviour (i.e. amygdala, ventromedial prefrontal cortex, insula, and orbitofrontal cortex). In addition, youths with conduct disorder also demonstrated less responsiveness in the orbitofrontal regions of the brain during a stimulus-reinforcement and reward task. This provides a neural explanation for why youths with conduct disorder may be more likely to repeat poor decision making patterns. Lastly, youths with conduct disorder display a reduction in grey matter volume in the amygdala, which may account for the fear conditioning deficits. This reduction has been linked to difficulty processing social emotional stimuli, regardless of the age of onset. Aside from the differences in neuroanatomy and activation patterns between youth with conduct disorder and controls, neurochemical profiles also vary between groups. Individuals with conduct disorder are characterised as having reduced serotonin and cortisol levels (e.g. reduced hypothalamic-pituitary-adrenal (HPA) axis), as well as reduced autonomic nervous system (ANS) functioning. These reductions are associated with the inability to regulate mood and impulsive behaviours, weakened signals of anxiety and fear, and decreased self-esteem. Taken together, these findings may account for some of the variance in the psychological and behavioural patterns of youth with conduct disorder.
Intra-Individual Factors
Aside from findings related to neurological and neurochemical profiles of youth with conduct disorder, intraindividual factors such as genetics may also be relevant. Having a sibling or parent with conduct disorder increases the likelihood of having the disorder, with a heritability rate of .53. There also tends to be a stronger genetic link for individuals with childhood-onset compared to adolescent onset. In addition, youth with conduct disorder also exhibit polymorphism in the monoamine oxidase A gene, low resting heart rates, and increased testosterone.
Family and Peer Influences
Elements of the family and social environment may also play a role in the development and maintenance of conduct disorder. For instance, antisocial behaviour suggestive of conduct disorder is associated with single parent status, parental divorce, large family size, and the young age of mothers. However, these factors are difficult to tease apart from other demographic variables that are known to be linked with conduct disorder, including poverty and low socioeconomic status. Family functioning and parent-child interactions also play a substantial role in childhood aggression and conduct disorder, with low levels of parental involvement, inadequate supervision, and unpredictable discipline practices reinforcing youth’s defiant behaviours. Peer influences have also been related to the development of antisocial behaviour in youth, particularly peer rejection in childhood and association with deviant peers. Peer rejection is not only a marker of a number of externalizing disorders, but also a contributing factor for the continuity of the disorders over time. Hinshaw and Lee (2003) also explain that association with deviant peers has been thought to influence the development of conduct disorder in two ways: 1) a “selection” process whereby youth with aggressive characteristics choose deviant friends, and 2) a “facilitation” process whereby deviant peer networks bolster patterns of antisocial behaviour. In a separate study by Bonin and colleagues, parenting programmes were shown to positively affect child behaviour and reduce costs to the public sector.
Wider Contextual Factors
In addition to the individual and social factors associated with conduct disorder, research has highlighted the importance of environment and context in youth with antisocial behaviour. However, it is important to note that these are not static factors, but rather transactional in nature (e.g. individuals are influenced by and also influence their environment). For instance, neighbourhood safety and exposure to violence have been studied in conjunction with conduct disorder, but it is not simply the case that youth with aggressive tendencies reside in violent neighbourhoods. Transactional models propose that youth may resort to violence more often as a result of exposure to community violence, but their predisposition towards violence also contributes to neighbourhood climate.
Diagnosis
Conduct disorder is classified in the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM). It is diagnosed based on a prolonged pattern of antisocial behaviour such as serious violation of laws and social norms and rules in people younger than the age of 18. Similar criteria are used in those over the age of 18 for the diagnosis of antisocial personality disorder. No proposed revisions for the main criteria of conduct disorder exist in the DSM-5; there is a recommendation by the work group to add an additional specifier for callous and unemotional traits. According to DSM-5 criteria for conduct disorder, there are four categories that could be present in the child’s behaviour: aggression to people and animals, destruction of property, deceitfulness or theft, and serious violation of rules.
Almost all adolescents who have a substance use disorder have conduct disorder-like traits, but after successful treatment of the substance use disorder, about half of these adolescents no longer display conduct disorder-like symptoms. Therefore, it is important to exclude a substance-induced cause and instead address the substance use disorder prior to making a psychiatric diagnosis of conduct disorder.
Treatment
First-line treatment is psychotherapy based on behaviour modification and problem-solving skills. This treatment seeks to integrate individual, school, and family settings. Parent-management training can also be helpful. No medications have been FDA approved for Conduct Disorder, but Risperidone (a second-generation antipsychotic) has the most evidence to support its use for aggression in children who have not responded to behavioural and psychosocial interventions. Selective Serotonin Reuptake Inhibitors (SSRIs) are also sometimes used to treat irritability in these patients.
Prognosis
About 25-40% of youths diagnosed with conduct disorder qualify for a diagnosis of antisocial personality disorder when they reach adulthood. For those that do not develop ASPD, most still exhibit social dysfunction in adult life.
Epidemiology
Conduct disorder is estimated to affect 51.1 million people globally as of 2013. The percentage of children affected by conduct disorder is estimated to range from 1-10%. However, among incarcerated youth or youth in juvenile detention facilities, rates of conduct disorder are between 23% and 87%.
Sex Differences
The majority of research on conduct disorder suggests that there are a significantly greater number of males than females with the diagnosis, with some reports demonstrating a threefold to fourfold difference in prevalence. However, this difference may be somewhat biased by the diagnostic criteria which focus on more overt behaviours, such as aggression and fighting, which are more often exhibited by males. Females are more likely to be characterised by covert behaviours, such as stealing or running away. Moreover, conduct disorder in females is linked to several negative outcomes, such as antisocial personality disorder and early pregnancy, suggesting that sex differences in disruptive behaviours need to be more fully understood.
Females are more responsive to peer pressure including feelings of guilt than males.
Racial Differences
Research on racial or cultural differences on the prevalence or presentation of conduct disorder is limited. However, according to studies on American youth, it appears that African-American youth are more often diagnosed with conduct disorder, while Asian-American youth are about one-third as likely to develop conduct disorder when compared to White American youth. It has been widely theorised for decades that this disparity is due to unconscious bias in those who give the diagnosis.
Antisocial personality disorder (ASPD or infrequently APD) is a personality disorder characterised by a long-term pattern of disregard for, or violation of, the rights of others. A weak or non-existent conscience is often apparent, as well as a history of legal problems or impulsive and aggressive behaviour.
Antisocial personality disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), while the equivalent concept of dissocial personality disorder (DPD) is defined in the International Statistical Classification of Diseases and Related Health Problems (ICD); the primary theoretical distinction between the two is that antisocial personality disorder focuses on observable behaviours, while dissocial personality disorder focuses on affective deficits. Otherwise, both manuals provide similar criteria for diagnosing the disorder. Both have also stated that their diagnoses have been referred to, or include what is referred to, as psychopathy or sociopathy. However, some researchers have drawn distinctions between the concepts of antisocial personality disorder and psychopathy, with many researchers arguing that psychopathy is a disorder that overlaps with but is distinguishable from ASPD.
Brief History
The first version of the DSM in 1952 listed sociopathic personality disturbance. This category was for individuals who were considered “…ill primarily in terms of society and of conformity with the prevailing milieu, and not only in terms of personal discomfort and relations with other individuals”. There were four subtypes, referred to as “reactions”: antisocial, dyssocial, sexual, and addiction. The antisocial reaction was said to include people who were “always in trouble” and not learning from it, maintaining “no loyalties”, frequently callous and lacking responsibility, with an ability to “rationalise” their behaviour. The category was described as more specific and limited than the existing concepts of “constitutional psychopathic state” or “psychopathic personality” which had had a very broad meaning; the narrower definition was in line with criteria advanced by Hervey M. Cleckley from 1941, while the term sociopathic had been advanced by George Partridge in 1928 when studying the early environmental influence on psychopaths. Partridge discovered the correlation between antisocial psychopathic disorder and parental rejection experienced in early childhood.
The DSM-II in 1968 rearranged the categories and “antisocial personality” was now listed as one of ten personality disorders but still described similarly, to be applied to individuals who are: “basically unsocialised”, in repeated conflicts with society, incapable of significant loyalty, selfish, irresponsible, unable to feel guilt or learn from prior experiences, and who tend to blame others and rationalise. The manual preface contains “special instructions” including “Antisocial personality should always be specified as mild, moderate, or severe.” The DSM-II warned that a history of legal or social offenses was not by itself enough to justify the diagnosis, and that a “group delinquent reaction” of childhood or adolescence or “social maladjustment without manifest psychiatric disorder” should be ruled out first. The dyssocial personality type was relegated in the DSM-II to “dyssocial behaviour” for individuals who are predatory and follow more or less criminal pursuits, such as racketeers, dishonest gamblers, prostitutes, and dope peddlers. (DSM-I classified this condition as sociopathic personality disorder, dyssocial type). It would later resurface as the name of a diagnosis in the ICD manual produced by the WHO, later spelled dissocial personality disorder and considered approximately equivalent to the ASPD diagnosis.
The DSM-III in 1980 included the full term antisocial personality disorder and, as with other disorders, there was now a full checklist of symptoms focused on observable behaviours to enhance consistency in diagnosis between different psychiatrists (‘inter-rater reliability’). The ASPD symptom list was based on the Research Diagnostic Criteria developed from the so-called Feighner Criteria from 1972, and in turn largely credited to influential research by sociologist Lee Robins published in 1966 as “Deviant Children Grown Up”. However, Robins has previously clarified that while the new criteria of prior childhood conduct problems came from her work, she and co-researcher psychiatrist Patricia O’Neal got the diagnostic criteria they used from Lee’s husband the psychiatrist Eli Robins, one of the authors of the Feighner criteria who had been using them as part of diagnostic interviews.
The DSM-IV maintained the trend for behavioural antisocial symptoms while noting “This pattern has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder” and re-including in the ‘Associated Features’ text summary some of the underlying personality traits from the older diagnoses. The DSM-5 has the same diagnosis of antisocial personality disorder. The Pocket Guide to the DSM-5 Diagnostic Exam suggests that a person with ASPD may present “with psychopathic features” if he or she exhibits “a lack of anxiety or fear and a bold, efficacious interpersonal style”.
Epidemiology
As seen in two North American studies and two European studies, ASPD is more commonly seen in men than in women, with men three to five times more likely to be diagnosed with ASPD than women. The prevalence of ASPD is even higher in selected populations, like prisons, where there is a preponderance of violent offenders. It has been found that the prevalence of ASPD among prisoners is just under 50%. Similarly, the prevalence of ASPD is higher among patients in alcohol or other drug (AOD) use treatment programmes than in the general population, suggesting a link between ASPD and AOD use and dependence. As part of the Epidemiological Catchment Area (ECA) study, men with ASPD were found to be three to five times more likely to excessively use alcohol and illicit substances than those men without ASPD. While ASPD occurs more often in men than women, there was found to be increased severity of this substance use in women with ASPD. In a study conducted with both men and women with ASPD, women were more likely to misuse substances compared to their male counterparts.
Individuals with ASPD are at an elevated risk for suicide. Some studies suggest this increase in suicidality is in part due to the association between suicide and symptoms or trends within ASPD, such as criminality and substance use. Offspring of ASPD victims are also at risk. Some research suggests that negative or traumatic experiences in childhood, perhaps as a result of the choices a parent with ASPD might make, can be a predictor of delinquency later on in the child’s life. Additionally, with variability between situations, children of a parent with ASPD may suffer consequences of delinquency if they’re raised in an environment in which crime and violence is common. Suicide is a leading cause of death among youth who display antisocial behaviour, especially when mixed with delinquency. Incarceration, which could come as a consequence of actions from a victim of ASPD, is a predictor for suicide ideation in youth.
Signs and Symptoms
Antisocial personality disorder is defined by a pervasive and persistent disregard for morals, social norms, and the rights and feelings of others. Individuals with this personality disorder will typically have no compunction in exploiting others in harmful ways for their own gain or pleasure and frequently manipulate and deceive other people. While some do so through a façade of superficial charm, others do so through intimidation and violence. They may display arrogance, think lowly and negatively of others, and lack remorse for their harmful actions and have a callous attitude to those they have harmed. Irresponsibility is a core characteristic of this disorder; most have significant difficulties in maintaining stable employment as well as fulfilling their social and financial obligations, and people with this disorder often lead exploitative, unlawful, or parasitic lifestyles.
Those with antisocial personality disorder are often impulsive and reckless, failing to consider or disregarding the consequences of their actions. They may repeatedly disregard and jeopardise their own safety and the safety of others, which can place both themselves and other people in danger. They are often aggressive and hostile, with poorly regulated tempers, and can lash out violently with provocation or frustration. Individuals are prone to substance use disorders and addiction, and the non-medical use of various psychoactive substances is common in this population. These behaviours lead such individuals into frequent conflict with the law, and many people with ASPD have extensive histories of antisocial behaviour and criminal infractions stemming back to adolescence or childhood.
Serious problems with interpersonal relationships are often seen in those with the disorder. People with antisocial personality disorder usually form poor attachments and emotional bonds, and interpersonal relationships often revolve around the exploitation and abuse of others. They may have difficulties in sustaining and maintaining relationships, and some have difficulty entering them.
Conduct Disorder
While antisocial personality disorder is a mental disorder diagnosed in adulthood, it has its precedent in childhood. The DSM-5’s criteria for ASPD require that the individual have conduct problems evident by the age of 15. Persistent antisocial behaviour, as well as a lack of regard for others in childhood and adolescence, is known as conduct disorder and is the precursor of ASPD. About 25-40% of youths with conduct disorder will be diagnosed with ASPD in adulthood.
Conduct disorder (CD) is a disorder diagnosed in childhood that parallels the characteristics found in ASPD and is characterised by a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate norms are violated. Children with the disorder often display impulsive and aggressive behaviour, may be callous and deceitful, and may repeatedly engage in petty crime such as stealing or vandalism or get into fights with other children and adults. This behaviour is typically persistent and may be difficult to deter with threat or punishment. Attention deficit hyperactivity disorder (ADHD) is common in this population, and children with the disorder may also engage in substance use. CD is differentiated from oppositional defiant disorder (ODD) in that children with ODD do not commit aggressive or antisocial acts against other people, animals, and property, though many children diagnosed with ODD are subsequently re-diagnosed with CD.
Two developmental courses for CD have been identified based on the age at which the symptoms become present. The first is known as the “childhood-onset type” and occurs when conduct disorder symptoms are present before the age of 10 years. This course is often linked to a more persistent life course and more pervasive behaviours, and children in this group express greater levels of ADHD symptoms, neuropsychological deficits, more academic problems, increased family dysfunction, and higher likelihood of aggression and violence. The second is known as the “adolescent-onset type” and occurs when conduct disorder develops after the age of 10 years. Compared to the childhood-onset type, less impairment in various cognitive and emotional functions are present, and the adolescent-onset variety may remit by adulthood. In addition to this differentiation, the DSM-5 provides a specifier for a callous and unemotional interpersonal style, which reflects characteristics seen in psychopathy and are believed to be a childhood precursor to this disorder. Compared to the adolescent-onset subtype, the childhood-onset subtype, especially if callous and unemotional traits are present, tends to have a worse treatment outcome.
Comorbidity
ASPD commonly coexists with the following conditions:
Anxiety disorders.
Depressive disorder.
Impulse control disorders.
Substance-related disorders.
Somatization disorder.
Attention deficit hyperactivity disorder.
Bipolar disorder.
Borderline personality disorder.
Histrionic personality disorder.
Narcissistic personality disorder.
Sadistic personality disorder.
When combined with alcoholism, people may show frontal function deficits on neuropsychological tests greater than those associated with each condition. Alcohol Use Disorder is likely caused by lack of impulse and behavioural control exhibited by Antisocial Personality Disorder patients. The rates of ASPD tends to be around 40-50% in male alcohol and opiate addicts. However, it is important to remember this is not a causal relationship, but rather a plausible consequence of cognitive deficits as a result of ASPD.
Causes
Personality disorders are seen to be caused by a combination and interaction of genetic and environmental influences. Genetically, it is the intrinsic temperamental tendencies as determined by their genetically influenced physiology, and environmentally, it is the social and cultural experiences of a person in childhood and adolescence encompassing their family dynamics, peer influences, and social values. People with an antisocial or alcoholic parent are considered to be at higher risk. Fire-setting and cruelty to animals during childhood are also linked to the development of antisocial personality. The condition is more common in males than in females, and among people who are in prison.
Genetic
Research into genetic associations in antisocial personality disorder suggests that ASPD has some or even a strong genetic basis. Prevalence of ASPD is higher in people related to someone afflicted by the disorder. Twin studies, which are designed to discern between genetic and environmental effects, have reported significant genetic influences on antisocial behaviour and conduct disorder.
In the specific genes that may be involved, one gene that has seen particular interest in its correlation with antisocial behaviour is the gene that encodes for Monoamine oxidase A (MAO-A), an enzyme that breaks down monoamine neurotransmitters such as serotonin and norephinephrine. Various studies examining the genes’ relationship to behaviour have suggested that variants of the gene that results in less MAO-A being produced, such as the 2R and 3R alleles of the promoter region, have associations with aggressive behaviour in men. The association is also influenced by negative experience in early life, with children possessing a low-activity variant (MAOA-L) who experience such maltreatment being more likely to develop antisocial behaviour than those with the high-activity variant (MAOA-H). Even when environmental interactions (e.g. emotional abuse) are controlled for, a small association between MAOA-L and aggressive and antisocial behaviour remains.
The gene that encodes for the serotonin transporter (SCL6A4), a gene that is heavily researched for its associations with other mental disorders, is another gene of interest in antisocial behaviour and personality traits. Genetic associations studies have suggested that the short “S” allele is associated with impulsive antisocial behaviour and ASPD in the inmate population. However, research into psychopathy find that the long “L” allele is associated with the Factor 1 traits of psychopathy, which describes its core affective (e.g. lack of empathy, fearlessness) and interpersonal (e.g. grandiosity, manipulativeness) personality disturbances. This is suggestive of two different forms, one associated more with impulsive behaviour and emotional dysregulation, and the other with predatory aggression and affective disturbance, of the disorder.
Various other gene candidates for ASPD have been identified by a genome-wide association study published in 2016. Several of these gene candidates are shared with attention-deficit hyperactivity disorder, with which ASPD is comorbid. Furthermore, the study found that those who carry 4 mutations on chromosome 6 are 1.5 times more likely to develop antisocial personality disorder than those who do not.
Physiological
Hormones and Neurotransmitters
Traumatic events can lead to a disruption of the standard development of the central nervous system, which can generate a release of hormones that can change normal patterns of development. Aggressiveness and impulsivity are among the possible symptoms of ASPD. Testosterone is a hormone that plays an important role in aggressiveness in the brain. For instance, criminals who have committed violent crimes tend to have higher levels of testosterone than the average person. The effect of testosterone is counteracted by cortisol which facilitates the cognitive control of impulsive tendencies.
One of the neurotransmitters that has been discussed in individuals with ASPD is serotonin, also known as 5HT.[41] A meta-analysis of 20 studies found significantly lower 5-HIAA levels (indicating lower serotonin levels), especially in those who are younger than 30 years of age.
While it has been shown that lower levels of serotonin may be associated with ASPD, there has also been evidence that decreased serotonin function is highly correlated with impulsiveness and aggression across a number of different experimental paradigms. Impulsivity is not only linked with irregularities in 5HT metabolism, but may be the most essential psychopathological aspect linked with such dysfunction. Correspondingly, the DSM classifies “impulsivity or failure to plan ahead” and “irritability and aggressiveness” as two of seven sub-criteria in category A of the diagnostic criteria of ASPD.
Some studies have found a relationship between monoamine oxidase A and antisocial behaviour, including conduct disorder and symptoms of adult ASPD, in maltreated children.
Neurological
Antisocial behaviour may be related to head trauma. Antisocial behaviour is associated with decreased grey matter in the right lentiform nucleus, left insula, and frontopolar cortex. Increased volumes have been observed in the right fusiform gyrus, inferior parietal cortex, right cingulate gyrus, and post central cortex.
Intellectual and cognitive ability is consistently found to be impaired or reduced in the ASPD population. Contrary to stereotypes in popular culture of the “psychopathic genius”, antisocial personality disorder is associated with both reduced overall intelligence and specific reductions in individual aspects of cognitive ability. These deficits also occur in general-population samples of people with antisocial traits and in children with the precursors to antisocial personality disorder.
People that exhibit antisocial behaviour demonstrate decreased activity in the prefrontal cortex. The association is more apparent in functional neuroimaging as opposed to structural neuroimaging. The prefrontal cortex is involved in many executive functions, including behaviour inhibitions, planning ahead, determining consequences of action, and differentiating between right and wrong. However, some investigators have questioned whether the reduced volume in prefrontal regions is associated with antisocial personality disorder, or whether they result from co-morbid disorders, such as substance use disorder or childhood maltreatment. Moreover, it remains an open question whether the relationship is causal, i.e. whether the anatomical abnormality causes the psychological and behavioural abnormality, or vice versa.
Cavum septi pellucidi (CSP) is a marker for limbic neural maldevelopment, and its presence has been loosely associated with certain mental disorders, such as schizophrenia and post-traumatic stress disorder. One study found that those with CSP had significantly higher levels of antisocial personality, psychopathy, arrests and convictions compared with controls.
Environmental
Family Environment
Some studies suggest that the social and home environment has contributed to the development of antisocial behaviour. The parents of these children have been shown to display antisocial behaviour, which could be adopted by their children. A lack of parental stimulation and affection during early development leads to sensitization of the child’s stress response systems, which is thought to lead to underdevelopment of the child’s brain that deals with emotion, empathy and ability to connect to other humans on an emotional level. According to Dr. Bruce Perry in his book The Boy Who Was Raised as a Dog, “the [infant’s developing] brain needs patterned, repetitive stimuli to develop properly. Spastic, unpredictable relief from fear, loneliness, discomfort, and hunger keeps a baby’s stress system on high alert. An environment of intermittent care punctuated by total abandonment may be the worst of all worlds for a child.”
Cultural Influences
The sociocultural perspective of clinical psychology views disorders as influenced by cultural aspects; since cultural norms differ significantly, mental disorders such as ASPD are viewed differently. Robert D. Hare has suggested that the rise in ASPD that has been reported in the United States may be linked to changes in cultural mores, the latter serving to validate the behavioural tendencies of many individuals with ASPD. While the rise reported may be in part merely a byproduct of the widening use (and abuse) of diagnostic techniques, given Eric Berne’s division between individuals with active and latent ASPD – the latter keeping themselves in check by attachment to an external source of control like the law, traditional standards, or religion – it has been suggested that the erosion of collective standards may indeed serve to release the individual with latent ASPD from their previously prosocial behaviour.
There is also a continuous debate as to the extent to which the legal system should be involved in the identification and admittance of patients with preliminary symptoms of ASPD. Controversial clinical psychiatrist Pierre-Édouard Carbonneau suggested that the problem with legal forced admittance is the rate of failure when diagnosing ASPD. He states that the possibility of diagnosing and coercing a patient into prescribing medication to someone without ASPD, but is diagnosed with it could be potentially disastrous, but the possibility of not diagnosing it and seeing a patient go untreated because of a lack of sufficient evidence of cultural or environmental influences is something a psychiatrist must ignore, and in his words, “play it safe”.
It is characterised by at least 3 of the following:
Callous unconcern for the feelings of others;
Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations;
Incapacity to maintain enduring relationships, though having no difficulty in establishing them;
Very low tolerance to frustration and a low threshold for discharge of aggression, including violence;
Incapacity to experience guilt or to profit from experience, particularly punishment; and/or
Marked readiness to blame others or to offer plausible rationalisations for the behaviour that has brought the person into conflict with society.
The ICD states that this diagnosis includes “amoral, antisocial, asocial, psychopathic, and sociopathic personality”. Although the disorder is not synonymous with conduct disorder, presence of conduct disorder during childhood or adolescence may further support the diagnosis of dissocial personality disorder. There may also be persistent irritability as an associated feature.
It is a requirement of the ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
Psychopathy
Psychopathy is commonly defined as a personality disorder characterised partly by antisocial behaviour, a diminished capacity for empathy and remorse, and poor behavioural controls. Psychopathic traits are assessed using various measurement tools, including Canadian researcher Robert D. Hare’s Psychopathy Checklist, Revised (PCL-R). “Psychopathy” is not the official title of any diagnosis in the DSM or ICD; nor is it an official title used by other major psychiatric organisations. The DSM and ICD, however, state that their antisocial diagnoses are at times referred to (or include what is referred to) as psychopathy or sociopathy.
American psychiatrist Hervey Cleckley’s work on psychopathy formed the basis of the diagnostic criteria for ASPD, and the DSM states ASPD is often referred to as psychopathy. However, critics argue ASPD is not synonymous with psychopathy as the diagnostic criteria are not the same, since criteria relating to personality traits are emphasized relatively less in the former. These differences exist in part because it was believed such traits were difficult to measure reliably and it was “easier to agree on the behaviours that typify a disorder than on the reasons why they occur”.
Although the diagnosis of ASPD covers two to three times as many prisoners than the diagnosis of psychopathy, Robert Hare believes the PCL-R is better able to predict future criminality, violence, and recidivism than a diagnosis of ASPD. He suggests there are differences between PCL-R-diagnosed psychopaths and non-psychopaths on “processing and use of linguistic and emotional information”, while such differences are potentially smaller between those diagnosed with ASPD and without. Additionally, Hare argued confusion regarding how to diagnose ASPD, confusion regarding the difference between ASPD and psychopathy, as well as the differing future prognoses regarding recidivism and treatability, may have serious consequences in settings such as court cases where psychopathy is often seen as aggravating the crime.
Nonetheless, psychopathy has been proposed as a specifier under an alternative model for ASPD. In the DSM-5, under “Alternative DSM-5 Model for Personality Disorders”, ASPD with psychopathic features is described as characterised by “a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviours (e.g. fraudulence).” Low levels of withdrawal and high levels of attention-seeking combined with low anxiety are associated with “social potency” and “stress immunity” in psychopathy. Under the specifier, affective and interpersonal characteristics are comparatively emphasized over behavioural components.
Treatment
ASPD is considered to be among the most difficult personality disorders to treat. Rendering an effective treatment for ASPD is further complicated due to the inability to look at comparative studies between psychopathy and ASPD due to differing diagnostic criteria, differences in defining and measuring outcomes and a focus on treating incarcerated patients rather than those in the community. Because of their very low or absent capacity for remorse, individuals with ASPD often lack sufficient motivation and fail to see the costs associated with antisocial acts. They may only simulate remorse rather than truly commit to change: they can be seductively charming and dishonest, and may manipulate staff and fellow patients during treatment. Studies have shown that outpatient therapy is not likely to be successful, but the extent to which persons with ASPD are entirely unresponsive to treatment may have been exaggerated.
Most treatment done is for those in the criminal justice system to whom the treatment regimes are given as part of their imprisonment. Those with ASPD may stay in treatment only as required by an external source, such as parole conditions. Residential programmes that provide a carefully controlled environment of structure and supervision along with peer confrontation have been recommended. There has been some research on the treatment of ASPD that indicated positive results for therapeutic interventions. Psychotherapy also known as talk therapy is found to help treat patients with ASPD. Schema therapy is also being investigated as a treatment for ASPD. A review by Charles M. Borduin features the strong influence of Multisystemic therapy (MST) that could potentially improve this imperative issue. However, this treatment requires complete cooperation and participation of all family members. Some studies have found that the presence of ASPD does not significantly interfere with treatment for other disorders, such as substance use, although others have reported contradictory findings.
Therapists working with individuals with ASPD may have considerable negative feelings toward patients with extensive histories of aggressive, exploitative, and abusive behaviours. Rather than attempt to develop a sense of conscience in these individuals, which is extremely difficult considering the nature of the disorder, therapeutic techniques are focused on rational and utilitarian arguments against repeating past mistakes. These approaches would focus on the tangible, material value of prosocial behaviour and abstaining from antisocial behaviour. However, the impulsive and aggressive nature of those with this disorder may limit the effectiveness of even this form of therapy.
The use of medications in treating antisocial personality disorder is still poorly explored, and no medications have been approved by the FDA to specifically treat ASPD. A 2020 Cochrane review of studies that explored the use of pharmaceuticals in ASPD patients, of which 8 studies met the selection criteria for review, concluded that the current body of evidence was inconclusive for recommendations concerning the use of pharmaceuticals in treating the various issues of ASPD. Nonetheless, psychiatric medications such as antipsychotics, antidepressants, and mood stabilizers can be used to control symptoms such as aggression and impulsivity, as well as treat disorders that may co-occur with ASPD for which medications are indicated.
Prognosis
According to Professor Emily Simonoff of the Institute of Psychiatry, Psychology and Neuroscience there are many variables that are consistently connected to ASPD, such as: childhood hyperactivity and conduct disorder, criminality in adulthood, lower IQ scores and reading problems. The strongest relationship between these variables and ASPD are childhood hyperactivity and conduct disorder. Additionally, children who grow up with a predisposition of ASPD and interact with other delinquent children are likely to later be diagnosed with ASPD. Like many disorders, genetics play a role in this disorder but the environment holds an undeniable role in its development.
Boys are twice as likely to meet all of the diagnostic criteria for ASPD than girls (40% versus 25%) and they will often start showing symptoms of the disorder much earlier in life. Children that do not show symptoms of the disease through age 15 will not develop ASPD later in life. If adults exhibit milder symptoms of ASPD, it is likely that they never met the criteria for the disorder in their childhood and were consequently never diagnosed. Overall, symptoms of ASPD tend to peak in late-teens and early twenties, but can often reduce or improve through age 40.
ASPD is ultimately a lifelong disorder that has chronic consequences, though some of these can be moderated over time. There may be a high variability of the long-term outlook of antisocial personality disorder. The treatment of this disorder can be successful, but it entails unique difficulties. It is unlikely to see rapid change especially when the condition is severe. In fact, past studies revealed that remission rates were small, with up to only 31% rates of improvement instead of remittance. As a result of the characteristics of ASPD (e.g. displaying charm in effort of personal gain, manipulation), patients seeking treatment (mandated or otherwise) may appear to be “cured” in order to get out of treatment. According to definitions found in the DSM-5, people with ASPD can be deceitful and intimidating in their relationships. When they are caught doing something wrong, they often appear to be unaffected and unemotional about the consequences. Over time, continual behaviour that lacks empathy and concern may lead to someone with ASPD taking advantage of the kindness of others, including his or her therapist.
Without proper treatment, individuals suffering with ASPD could lead a life that brings about harm to themselves or others. This can be detrimental to their families and careers. ASPD victims suffer from lack of interpersonal skills (e.g. lack of remorse, lack of empathy, lack of emotional-processing skills). As a result of the inability to create and maintain healthy relationships due to the lack of interpersonal skills, individuals with ASPD may find themselves in predicaments such as divorce, unemployment, homelessness and even premature death by suicide. They also see higher rates of committed crime, reaching peaks in their late teens and often committing higher-severity crimes in their younger ages of diagnoses. Comorbidity of other mental illnesses such as Depression or substance use disorder is prevalent among ASPD victims. People with ASPD are also more likely to commit homicides and other crimes. Those who are imprisoned longer often see higher rates of improvement with symptoms of ASPD than others who have been imprisoned for a shorter amount of time.
According to one study, aggressive tendencies show in about 72% of all male patients diagnosed with ASPD. About 29% of the men studied with ASPD also showed a prevalence of pre-meditated aggression. Based on the evidence in the study, the researchers concluded that aggression in patients with ASPD is mostly impulsive, though there are some long-term evidences of pre-meditated aggressions. It often occurs that those with higher psychopathic traits will exhibit the pre-meditated aggressions to those around them. Over the course of a patient’s life with ASPD, he or she can exhibit this aggressive behaviour and harm those close to him or her.
Additionally, many people (especially adults) who have been diagnosed with ASPD become burdens to their close relatives, peers, and caretakers. Harvard Medical School recommends that time and resources be spent treating victims who have been affected by someone with ASPD, because the patient with ASPD may not respond to the administered therapies. In fact, a patient with ASPD may only accept treatment when ordered by a court, which will make their course of treatment difficult and severe. Because of the challenges in treatment, the patient’s family and close friends must take an active role in decisions about therapies that are offered to the patient. Ultimately, there must be a group effort to aid the long-term effects of the disorder.
Psychological interventions for antisocial personality disorder.
Background
Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties.
This review updates Gibbon 2010 (previous version of the review).
To evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD.
Methods
The researchers searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. They also searched reference lists and contacted study authors to identify studies.
Randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment.
The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events.
The researchers used standard methodological procedures expected by Cochrane.
Results
This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called ‘standard Maintenance'(SM) in some studies).
Eight of the 18 psychological interventions reported data on the primary outcomes.
Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD.
Data were available from only 10 studies involving 605 participants.
Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands.
Study duration ranged from 4 to 156 weeks (median = 26 weeks).
Most participants (75%) were male; the mean age was 35.5 years.
Eleven studies (58%) were funded by research councils.
Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%.
Cognitive behaviour therapy (CBT) + TAU versus TAU One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention.
One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) -1.60 points, 95% CI -5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention.
Impulsive lifestyle counselling (ILC) + TAU versus TAU One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI -0.35 to 0.49; very low-certainty evidence).
One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up.
Contingency management (CM) + SM versus SM One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD -0.08, 95% CI -0.14 to -0.02; low-certainty evidence) for outpatients at six months. ‘Driving whilst intoxicated’ programme (DWI) + incarceration versus incarceration.
One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI -0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months.
Schema therapy (ST) versus TAU One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years.
The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD -137.33, 95% CI -271.31 to -3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19).
The certainty of the evidence for all outcomes was very low.
Social problem-solving (SPS) + psychoeducation (PE) versus TAU One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants’ level of social functioning (MD -1.60 points, 95% CI -5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention.
Dialectical behaviour therapy versus TAU One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU.
Psychosocial risk management (PSRM; ‘Resettle’) versus TAU One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison.
It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence).
Conclusions
There is very limited evidence available on psychological interventions for adults with AsPD.
Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition.
No intervention reported compelling evidence of change in antisocial behaviour.
Overall, the certainty of the evidence was low or very low, meaning that the researchers have little confidence in the effect estimates reported.
The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies.
This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.
Reference
Gibbon, S., Khalifa, N.R., Cheung, N.H-Y., Vollm, B.A. & McCarthy, L. (2020) Psychological interventions for antisocial personality disorder. The Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.CD007668.pub3.
Mental Health Matters 