Antisocial Personality Disorder Karin Neufeld, MD MPH Addiction Treatment Services Department of Psychiatry Johns Hopkins University School of Medicine.
Download ReportTranscript Antisocial Personality Disorder Karin Neufeld, MD MPH Addiction Treatment Services Department of Psychiatry Johns Hopkins University School of Medicine.
Antisocial Personality Disorder
Karin Neufeld, MD MPH Addiction Treatment Services Department of Psychiatry Johns Hopkins University School of Medicine
http://indice.elpais.es/2004/11/13/ Copyright Alcohol Medical Scholars Program
Who was Gary Gilmore?
2
History of Identification
1835 Moral insanity 1900 Psychopathic character 1930 Sociopathic personality 1980 Antisocial personality disorder (ASPD) Copyright Alcohol Medical Scholars Program 3
Validity and Reliability
Empirical data Childhood precursor – Conduct disorder (CD) Good reliability Copyright Alcohol Medical Scholars Program 4
Societal Impacts of ASPD
h – h Risk of death h 6x teens/young adults Psychiatric comorbidity –80% substance use disorder (SUD) High legal cost –40% of prisoners –$41 billion/yr for US prison system Copyright Alcohol Medical Scholars Program 5
Objectives
Review diagnosis Describe epidemiology Review risk factors Describe the course Review treatment Copyright Alcohol Medical Scholars Program 6
Key Points
Very common in SUD patients Genes and environment involved Associated with great suffering Treatment is helpful Copyright Alcohol Medical Scholars Program 7
Objectives
Review diagnosis Describe epidemiology Review risk factors Describe the course Review treatment Copyright Alcohol Medical Scholars Program 8
DSM-IV Diagnosis 1
Persistent violation of others’ rights with 3+ of: - Disobey the law - Lying or conning - Impulsivity - Irritability, aggressiveness, physical fights - Disregard for safety - No sustained work history - Lack of remorse Copyright Alcohol Medical Scholars Program 9
DSM-IV Diagnosis 2
>18 y/o Early CD < 15yrs – Aggression to people or animals – Destruction of property – Deceitfulness or theft – Serious violation of rules R/O other major mental illness Copyright Alcohol Medical Scholars Program 10
Objectives
Review diagnosis Describe epidemiology Review risk factors Describe the course Review treatment Copyright Alcohol Medical Scholars Program 11
ASPD Prevalence
General population ~ 3% – M ~ 6%; F ~ 1% General medical clinics ~ 8% Mental health settings ~ 10% SUD treatment ~ at least 25% Prisoners ~ 40% – M ~ 50%; F ~ 20% Copyright Alcohol Medical Scholars Program 12
Associated Demographics
M:F = 6:1 Young (25 – 44) > Older (45 +) Race: no difference School drop-out: 5x by 11 yrs Abuse/neglect in childhood – 50% h risk of adult criminal behavior Copyright Alcohol Medical Scholars Program 13
Objectives
Review diagnosis Describe epidemiology Review risk factors Describe the course Review treatment Copyright Alcohol Medical Scholars Program 14
Genetics
Family studies: h ASPD Twin studies: ~ 70% heritability – Vulnerability g CD, ASPD, SUD – Adoption studies: (Cadoret) h CD, ASPD, SUD Copyright Alcohol Medical Scholars Program 15
Genetic and Environmental Impact
4x 9x 7x ASPD Biological Parent Childhood Aggression 8x ASPD SUD Adverse Adoptive Home (Cadoret 1995, 1997) Copyright Alcohol Medical Scholars Program 16
EEG Studies
Event related potential ERP i Amplitude (P300) Not specific Attentional problems Standard Target 300 msec 300 msec Copyright Alcohol Medical Scholars Program 17
Neuroimaging
MRI: i Prefrontal volume PET & SPECT: i Prefrontal function Poor executive function www.brainexplorer.org
Copyright Alcohol Medical Scholars Program 18
ASPD Biologic Markers
Increased aggression: – i synaptic serotonin (5HT) Serotonin transporter protein (STP) – h STP activity ~ h aggression Cadoret ’03 – Opposite findings exist Monoamine oxidase (MAO) – Neuronal 5HT metabolism Copyright Alcohol Medical Scholars Program 19
MAO Transporter Intrasynaptic Serotonin
www.drugabuse.gov
Copyright Alcohol Medical Scholars Program 20
MAO A Genotype and Environmental Interaction
Low MAOA
Caspi
et al
, 2002 Science, 297, p851-4.
None Probable Childhood Maltreatment Severe
Copyright Alcohol Medical Scholars Program 21
MAO A Genotype and Environmental Interaction
Low MAOA High MAOA
Caspi
et al
, 2002 Science, 297, p851-4.
None Probable Childhood Maltreatment Severe
Copyright Alcohol Medical Scholars Program 22
Objectives
Review diagnosis Describe epidemiology Review risk factors Describe the course Review treatment Copyright Alcohol Medical Scholars Program 23
Childhood
Irritable/impulsive temperament 3 y/o – ASPD 3 X’s more likely Conduct disorder (CD) – 25% develop ASPD – h educational difficulties – Earlier the CD: h ASPD Copyright Alcohol Medical Scholars Program 24
Adulthood
Data limited (Black et al 1995) 29 yr follow-up of hospitalized ASPD 24% of sample died Of remainder alive: –27% remission –31% improved –42% no change Copyright Alcohol Medical Scholars Program 25
Psychiatric Comorbidity
Lifetime prevalence in ASPD: – 70% alcohol use disorder – 50 % drug use disorder 80% of ASPD in tx: multiple SUD h Severity of SUD 4x SUD treatment episodes Copyright Alcohol Medical Scholars Program 26
Morbidity and Mortality
Morbidity – h HIV and high risk behaviors – – h h Medical problems Injuries Mortality – – h h Risk of violent death (6x in youth) Risk of suicide Copyright Alcohol Medical Scholars Program 27
Objectives
Review diagnosis Describe epidemiology Review risk factors Describe the course Review treatment Copyright Alcohol Medical Scholars Program 28
Treatment of ASPD
Effectiveness? Clinical fatalism Patients rarely ask for ASPD tx –Poor insight –Lifelong disturbance Often come for tx of SUD Copyright Alcohol Medical Scholars Program 29
Treatment Elements
Thorough history and exam Therapeutic relationship –Firm behavioral limits –Professional boundaries –Maintain your empathy –Negotiate behavioral goals in advance Copyright Alcohol Medical Scholars Program 30
Treatment Expectations
Not curative Focus on improved function Decrease problem behaviors – i Impulsive actions – Anticipate novelty seeking – h Empathy in patient Copyright Alcohol Medical Scholars Program 31
Treatment Outcomes
SUD literature = best impact data ASPD and opioid dependence –Same retention in methadone tx – i Drug use – i High risk behaviors Psychotherapy response mixed Good response to behavioral tx Copyright Alcohol Medical Scholars Program 32
Pharmacotherapy
Poor to no data Mood stabilizers ~ i impulsive aggression SSRI’s ~ maybe i aggression Antipsychotics not effective Avoid habit forming drugs – i.e. benzodiazepines Copyright Alcohol Medical Scholars Program 33
Summary
Very common in SUD patients Genes and environment involved Associated with great suffering Treatment is helpful Copyright Alcohol Medical Scholars Program 34