Antisocial Personality Disorder, Psychopathy,

1
Antisocial Personality Disorder,Psychopathy,
Mentalization

• Glen O. Gabbard, M.D.
• Brown Foundation Chair of Psychoanalysis
• and
• Professor of Psychiatry,
• Baylor College of Medicine

2
DSM-IV Diagnostic Criteria for 301.7Antisocial
Personality Disorder

• There is a pervasive pattern of disregard for a
  violation of the rights of others occurring since
  age 15 years, as indicated by 3 (or more) of
  the following
• Failure to conform to social norms with respect
  to lawful behaviors as indicated by repeatedly
  performing acts that are grounds for arrest
• Deceitfulness, as indicated by repeated lying,
  use of aliases, or conning others for personal
  profit or pleasure
• Impulsivity or failure to plan ahead

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DSM-IV Diagnostic Criteria for 301.7Antisocial
Personality Disorder (cont.)

• Irritability and aggressiveness, as indicated by
  repeated physical fights or assaults
• Reckless disregard for safety of self or others
• Consistent irresponsibility, as indicated by
  repeated failure to sustain consistent work
  behavior or honor financial obligations
• Lack of remorse, as indicated by being
  indifferent to or rationalizing having hurt,
  mistreated or stolen from another

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DSM-IV Diagnostic Criteria for 301.7Antisocial
Personality Disorder (cont.)

• The individual is at least age 18 years
• There is evidence of conduct disorder with onset
  before age 15 years
• The occurrence of antisocial behavior is not
  exclusively during the course of schizophrenia or
  manic episode

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Items in the Hare Psychopathy Checklist Screening
Version (PCLSV)

• Factor 1 Interpersonal/Affective
• Superficial
• Grandiose
• Manipulative
• Lacks remorse
• Lacks empathy
• Doesnt accept responsibility

• Factor 2
• Social Deviance
• Impulsive
• Poor behavior controls
• Lacks goals
• Irresponsible
• Adolescent antisocial behavior
• Adult antisocial behavior

- Hare et al. 1995
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Psychopathy and ASPD inCriminal Populations

• About 60-75 of prison inmates meet DSM IV
  criteria for ASPD
• About 1/3 of those meet Hare criteria for
  Psychopathy
• Hence 20-25 of the prison population are likely
  to be psychopaths
• 
  -Coid 1998

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Neurobiological Findings

• 25 psychopaths were compared with 18 BPD subjects
  and 24 controls.
• Psychopaths had decreased electrodermal
  responsiveness, absence of startle reflex, and
  less facial expression.
• Conclusion Psychopaths have a pronounced lack of
  fear and a general deficit in emotion processing.
• - Herpertz et al, Arch Gen Psych 58737-745, 2001

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Neurobiological Findings (cont.)

• Compared with healthy subjects and psychiatric
  control subjects, patients with ASPD have an 11
  reduction in prefrontal gray matter.
• This structural deficit may relate to low
  autonomic arousal.
• - Raine et al. Arch Gen Psych 57119-127, 2000

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• GENE-ENVIRONMENT
• INTERACTION
• AND
• ETIOLOGY

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Dunedin Study

• A birth cohort of 1037 children
• (52 male)
• Assessed at ages
• 3, 5, 7, 9, 11, 13, 15, 18, 21
• 96 intact at age 26
• -Caspi et al Science 297851-854, 2002

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Dunedin Study (cont.)

• 8 experienced severe maltreatment
• 28 experienced probable maltreatment
• 64 experienced no maltreatment

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Dunedin Study (cont.)

• Males with low MAOA activity genotype who were
  maltreated in childhood had elevated antisocial
  scores
• Males with high MAOA activity did not have
  elevated antisocial scores, even when they had
  experienced childhood maltreatment

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Dunedin Study (cont.)
Childhood Maltreatment
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Differential Parenting and Antisocial
Behavior708 Families Were Studied with at Least
2 Same-Sexed Adolescent Siblings

• 93 with monozygotic twins
• 93 with dizygotic twins
• 95 with ordinary siblings
• 181 with full siblings in stepfamilies
• 110 with half siblings in stepfamilies

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Differential Parenting and Antisocial Behavior
(cont.)

• 130 with genetically unrelated siblings in
  stepfamilies
• Data on parenting style were collected by
  questionnaire and by video recording of
  interactions between parents and children
• Almost 60 of variance in adolescent antisocial
  behavior and 37 of a variation in depressive
  symptoms could be accounted for by conflictual
  and negative parental behavior directed
  specifically at the adolescent

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Parenting Adolescent Antisocial Behavior

• 720 families with at least 2 children were
  assessed regarding whether latent genetic factors
  interact with parent-child relationships in
  predicting adolescent antisocial behavior.
• Risk of antisocial behavior in adolescents was
  characterized by means of a genetically informed
  design.
• -Feinberg et al, Arch Gen Psych 64457-465, 2007

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Parenting Adolescent Antisocial Behavior (cont.)

• The central finding was that parental negativity
  and warmth moderate the influence of genetic
  factors on adolescent antisocial behavior.
• Genetic influence on antisocial behavior was
  greatest at higher levels of parental negativity
  and low levels of warmth.
• -Feinberg et al, Arch Gen Psych 64457-465, 2007

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• A CLINICALLY USEFUL
• CLASSIFICATION SYSTEM

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Antisocial Personality Disorder
BPD/ASPD True Psychopath Successful
(Impulsive (Premeditated Psychopath
Reactive Nonreactive Aggression)
Aggression)
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• BPD/ASPD Co-Morbidity
• Impulsive Reactive Aggression

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Co-Morbid ASPD/BPD Patients

• Emotional states aroused in the context of an
  attachment relationship lead to pre-mentalizing
  modes of organizing experience
• The coherence of self-experience is destroyed and
  violence is possible.
• -Bateman Fonagy, J Clinical
  Psychology In Session
  64181-194, 2008
• 
  

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Co-Morbid ASPD/BPD Patients (cont.)

• These patients inflate their self-esteem by
  demanding respect from others, controlling the
  people around them, and creating an atmosphere of
  fear.
• The shame associated with loss of self-esteem is
  experienced in psychic equivalence mode where the
  patient must do something immediate
• - Bateman Fonagy, J Clinical
  Psychology In Session
  64181-194, 2008
• - Gilligan 2000

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Co-Morbid ASPD/BPD Patients (cont.)

• Recognition of the other as having a separate
  mind inhibits violence.
• Common path to violence is the momentary
  inhibition of the capacity for mentalizingmentali
  zation protects against violence.

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Antisocial Individuals

• Those with impulsive aggression, rather than
  proactive or premeditated aggression, have the
  same brain findings as BPD patients volume loss
  and decreased activity of the frontal cortex,
  especially of OFC and increase of subcortical
  activity, including the amygdala.
• -Roth
  and Buchheim in press
  

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• TRUE PSYCHOPATHY
• Premeditated Nonreactive Aggression

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• The average psychopath will commit four crimes by
  the age of 40.
• Almost all research on psychopathy involves
  males, and little is known about
  psychopathy in females.

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Neurobiological Features of Psychopathy

• Reduced autonomic responses to aversive stimuli
• Lack of fear
• Deficits in emotion processing
• -Roth Buchheim in press
  

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Neurobiological Features of Psychopathy (cont.)

• Decreased volume of frontal and hippocampal areas
• Decreased frontal metabolism including OFC and
  ACC
• Increased amygdalar activity
• No impairment in intellectual cognitive abilities
• -Roth and Buchheim in
  press

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Do Psychopaths LackEmpathy?
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Empathy Psychopathy

• Psychopaths have better understanding of the
  suffering of others, but they have no concern for
  the pain of others.
• Mentalizing abilities are spared in psychopaths
  TMET scores are similar to those of healthy
  subjects.
• -Blair
  2005
  

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Empathy Psychopathy (cont.)

• Psychopaths are able to recognize emotions in
  faces, but they disconnect that recognition from
  their own emotions.
• They do terrible things to other people because
  they are unlike healthy subjects they do not
  share the pain they inflict.
• Psychopaths have a deficit in emotional empathy,
  i.e., they lack compassion and concern not the
  capacity for mentalization.
• 
  

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• It was as if they could only understand emotions
  linguistically. They knew the words but not the
  music, as it were
• -Robert Hare 2008

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• SUCCESSFUL
• PSYCHOPATHS

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Successful Psychopaths

• Often called white collar psychopaths, the
  designation refers to those who have been
  undiscovered so far.
• They demonstrate even greater autonomic
  reactivity than controls and unsuccessful
  psychopaths.
• -Ishikawa et al,
  2001

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Successful Psychopaths (cont.)

• Unsuccessful psychopaths have a 22 reduction in
  prefrontal gray matter volumes, while healthy
  controls and successful psychopaths do not.
• Decreased prefrontal volume may result in poor
  decision-making and unregulated compulsive
  behavior that contributes to unsuccessful
  psychopaths getting caught.
• Yang et al,
  2005

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Successful Psychopaths (cont.)

• The combination of normal prefrontal volume and
  high autonomic functioning may allow successful
  psychopaths to react sensitively to environmental
  cues signaling danger and therefore to avoid
  conviction. They have good intelligence, good
  understanding of norms and intact motor
  empathybut they lack emotional empathy.

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Successful Psychopaths (cont.)

• Professions most likely to attract psychopaths
• Law enforcement
• The military
• Politics
• Medicine
• Most agreeable vocation for psychopaths is
  business.
• - Hare, 1993

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Successful Psychopaths (cont.)

• Corporate culture encourages psychopathy.
• Traits such as ruthlessness, lack of social
  conscience, and single-minded devotion to success
  are instrumental to business.
• The capacity to read people is very useful.
• -Hare
  1993
  

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Psychopaths generally regard moral transgressions
as more serious than other transgressionsbut
they are far less likely than controls to make
reference to the victim of the transgression
when justifying why moral transgressions are
bad.



- Blair, Cognition 571-19, 1995
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• IMPLICATIONS
• FOR
• PREVENTION

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Family-Based Preventive Intervention for
Preschoolers at High Risk for Antisocial Behavior

• Low salivary cortisol levels have been related to
  conduct problems and antisocial behavior.
• Early life social experience may alter cortisol
  release.
• -Brotman et al., Arch Gen Psych 641172-1179, 2007

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Family-Based Preventive Intervention for
Preschoolers at High Risk for Antisocial
Behavior (cont.)

• 92 preschool-aged siblings of delinquent youths
  were randomized to one of two groups
• 1) 22 weekly group sessions for parents and
• preschoolers, and 10 biweekly home visits
• conducted during a 6-8-month period
• OR
• 2) A control condition consisting of
  assessments and monthly telephone calls.
• -Brotman et al., Archives of General Psychiatry
  641172-1179, 2007

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Family-Based Preventive Intervention for
Preschoolers at High Risk for Antisocial
Behavior (cont.)

• Salivary cortisol levels were measured before and
  after a social challengeentry into an unfamiliar
  peer group.
• Relative to controls, children in the
  intervention condition had increased
  cortisol levels in anticipation of the peer
  social challenge.
• -Brotman et al., Archives of General Psychiatry
  641172-1179, 2007

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Family-Based Preventive Intervention for
Preschoolers at High Risk for Antisocial
Behavior (cont.)

• CONCLUSIONS
• A family-based preventive intervention for
  children at high risk for antisocial behavior
  alters stress response in anticipation of a peer
  social challenge.
• The experimentally induced change in cortisol
  levels parallels patterns found in normally
  developing low-risk children.
• -Brotman et al., Arch Gen Psych 641172-1179, 2007

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Family-Based Preventive Intervention for
Preschoolers at High Risk for Antisocial
Behavior (cont.)

• Some research on conduct disorder suggests a
  neural deficit involving a reduced capacity to
  engage the amygdala and associated circuitry when
  encountering social threat cues.
• One possibility is that alteration of the HPA
  axis assists in modulating aggression and
  increasing amygdala activation in response to
  threat.
• -Brotman et al., Arch Gen Psych 641172-1179, 2007

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• TREATMENT OF
• ADULT
• ASPD PATIENTS

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Positive Prognostic Factors

• Presence of depression
• Presence of anxiety
• Ability to form a therapeutic alliance
• Any superego development whatsoever, including a
  socially desirable need to rationalize antisocial
  acts

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Clinical Features that Contraindicate
Psychotherapy of Any Kind

• A history of sadistic, violent behavior toward
  others that resulted in serious injury or death
• A total absence of remorse or rationalization for
  such behavior
• Intelligence that is either in the very superior
  or mildly mentally retarded range
• A historical incapacity to develop emotional
  attachments to others
• An intense countertransference fear of predation
  on the part of experienced clinicians even
  without clear precipitating behavior on the part
  of the patient

Based on Meloy, 1988.
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Countertransference with antisocial patients

• Denial
• Collusion
• Assumption of psychological complexity
• Excessive therapeutic zeal

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Countertransferencewith antisocial patients
(cont.)

• Shame and humiliation at being duped
• Hatred and contempt
• Loss of professional identity and therapeutic
  nihilism
• Fear of assault or harm

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Overview of Treatment

• No body of controlled efficacy research
• Some with positive prognostic features may be
  treatable under certain circumstances
• Therapist must be stable, persistent and
  thoroughly incorruptible
• Therapist must repeatedly confront the patients
  denial and minimization of antisocial behavior
• Therapist must help the patient connect actions
  with internal states
• Confrontations of here-and-now behavior are more
  effective than interpretations of unconscious
  material from the past

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Overview of Treatment (cont.)

• Countertransference must be rigorously monitored
  to avoid acting out by the therapist
• Therapist must avoid having excessive
  expectations for improvement
• Identify any axis I treatable conditions
• Identify situational factors that worsen
  antisocial behaviors
• Recognize the likelihood of legal problems and
  legal entanglements
• Do not begin treatment unless it is demonstrably
  safe and effective for both patient and clinician