Antisocial Personality Disorder and Substance Abuse

1. Antisocial Personality Disorder and Substance Abuse November 18, 2003 By: Ms. K. Meetze Ms. R. Melton Mr. M. Melvin Ms. B. Mooza

2. Antisocial Personality Disorder DSM-IV Criteria • A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following: 1) failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest 2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure 3) impulsivity or failure to plan ahead 4) Irritability and aggressiveness, as indicated by repeated physical fights or assaults 5) reckless disregard for safety of self or others 6) consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations 7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

3. Antisocial Personality DisorderDSM-IV Criteria (continued) • B. The individual is at least age 18 years. • C. There is evidence of Conduct Disorder with onset before age 15 years. • D. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.

4. Substance Abuse DSM-IV Criteria • A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12 month period: 1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance; substance related absences, suspensions, or expulsions from school; neglect of children or household) 2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

5. Substance Abuse DSM-IV Criteria (continued) 3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct) 4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights) B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

6. Antisocial Personality Disorder Statistics • Overall, approximately 3% of men and 1% of women in the general population meet the criteria for ASPD. • Data from the Epidemiological Catchment Area (ECA) Study (NIMH, 1991) indicate that of the 22.5% of the U.S. population who have a mental illness (83.6% being diagnosed with antisocial personality disorder), approximately 29% also have a substance abuse disorder.

7. Substance Abuse Statistics • According to the 2002 National Survey of Substance Abuse Treatment Services (N-SSATS) released by the Substance Abuse and Mental Health Services Administration (SAMHSA) this month, nearly half of the 1.1 million people receiving treatment services on a given day had both drug and alcohol problems. • 21 % were in treatment for alcohol alone • 31% for only drug abuse • 48% for both • 8% were under the age of 18 yrs.

8. Diagnosing ASPD Among Substance Abusers (Messina, 2001) • There is a lot of debate among social scientists and clinicians over the accurate measurement of ASPD. • Social scientists mostly use DSM criteria to assess ASPD, but many of them have raised concerns about possible limitations. Some argue that the DSM overemphasizes observable behavioral criteria instead of underlying personality traits. • Structured and semistructured interviews and self-report inventories were created in the late 1980s and widely used to increase the reliability and validity of DSM diagnoses. • Structured and semistructured interviews decrease the information variance because they require clinicians to ask the same questions. Self-inventories were brought about by a need for diagnostic procedures that took less time, were not as expensive, and that could properly diagnose psychiatric disorders. • Two of the most used diagnostic scales for assessing personality disorders, also used with substance-abusing populations, are the Structured Clinical Interview for the DSM-III-R, Axis and the Millon Clinical Multiaxial Inventory, 2nd edition.

9. SCID (Messina, 2001) • The SCID is a semistructured clinical interview developed in 1985 for making Axis I and Axis II diagnoses using the DSM-III-R classifications. • The scaled questions and the questionnaire focus primarily on antisocial behavior in childhood that has continued into adulthood. • It is used to diagnose past and current mental disorders in a study population including psychiatric patients, medical patients, subjects in the community, and substance abusers. • The reliability of the SCID has been tested in several clinical and nonclinical population. The reliability can vary according to the circumstances in which it is being used. • Studies have shown good to excellent test-retest reliability of the SCID in psychiatric and substance-abusing populations. • The validity of the SCID may vary according to the scale, the specific disorder, and the criterion measure, but it often generates the highest agreement with the criterion diagnosis.

10. MCMI (Messina, 2001) • The MCMI was one of the first diagnostic scales measuring ASPD with a drug abuse scale embodied in it. • It is a self-report inventory consisting of 175 true-false items designed to assess basic personality styles, severe personality disorders, and clinical syndromes. It also measures personality characteristics associated with substance abuse. • The MCMI has been recently used with substance-abusing populations to identify a substance abuse problem, to assess the personality of the known abuser, or to predict treatment response. • The reliability and validity of this test have been the subject of several reviews.

11. SCID vs. MCMI (Messina, 2001) • Studies show that there is a small degree of agreement between the SCID and the MCMI, making it clear that these two diagnostic scales are very different. • The low diagnostic agreement between the two scales may be due to the different types of information collected by the two scales. • It has been suggested that the SCID-II overstresses observable behavioral characteristics, giving too large a role to criminality in the diagnosis of ASPD. • Conversely, the MCMI-II focuses on capturing pathological personality traits, as well as antisocial behaviors. • Researchers asking similar questions about the association of ASPD to treatment outcomes, but using different diagnostic scales, may obtain inconsistent answers. It is difficult to draw definite conclusions regarding the proper measurement of ASPD in substance-abusing samples without additional empirical evidence.

12. History of Misdiagnosis • Historically, far too many clients have been misdiagnosed as mentally ill—depressed, schizophrenia, bipolar, or personality disordered—when their symptoms were clearly attributable to drug or alcohol use. • Conversely, countless mentally ill clients have had psychiatric symptoms falsely attributed to substance abuse. • In both cases, the misdiagnosis leads to negative outcomes, with either the substance abuse disorder or the mental illness left untreated.

13. Studies have shown…. • It has been shown that people with substance abuse disorders have unusually high rates of additional psychiatric disorders. • For example, in drug-dependent patients participating in drug treatment programs, the lifetime prevalence rate for ASPD is 44%. • Comorbid disorders complicate treatment and have been associated with higher rates of relapse after treatment. • The comorbidity rates of substance abuse and ASPD are broken down as follows: African-American men 49% African-American women 26% Caucasian men 52% Caucasian women 39% • This information is important because it helps professionals design effective treatments for their patients (Compton, 2000).

14. There have been many studies conducted that show alcoholism is positively correlated with ASPD. • The results of one such study show that serious antisocial behavior (including conduct disorder and ASPD), gender, and a family history of problem drinking are all significantly associated with alcoholism. • However, having either antisocial personality or a family drinking problem identified only 49% of male alcoholics and only 14% of female alcoholics. • This shows that these criteria are inefficient screeners for primary prevention of alcoholism. • Thus, more data is needed to better understand the development of alcoholism, as well as the lack of development of this disorder in people with major risk factors, such as ASPD (Lewis, 1991).

15. Narcotic addiction has also been studied in ASPD patients. • One interesting study by Lewis et al. showed that ASPD men with narcotic addiction had a lower prevalence rate of alcoholism, compared to ASPD men without an addiction. • The authors of that study theorized that narcotic use and addiction might impede the development of alcoholism. • Opiates may give stronger positive reinforcement because they bind directly to opiate receptors, versus the more indirect pathway that alcohol takes to produce an effect. • This could cause a delay in the development of problematic drinking if narcotics are preferred by addicts (Lewis, 1987).

16. Common personality factors observed in individuals with ASPD, alcoholism, and drug abuse are “impulsivity, a failure to inhibit behavior which had previously led to negative consequences, and valuing immediate euphoria or gain over long-term consequences.” • Cloninger proposed a tridimensional model to explain the deviance found in people with ASPD. • He proposed that they are “high in novelty seeking, low in reward dependence, and low in harm avoidance” (Lewis, 1991). • These factors could help explain why there is a connection between ASPD and alcoholism, but more research is warranted in this field to be able to better help future patients.

17. There is a growing realization among researchers that ASPD is highly correlated with substance abuse (Messina, 2001). • It has been found that those with ASPD are high consumers of alcohol and there is an association between cognitive impairment and high alcohol consumption. • It has been found that among men and women ASPD and other substance use disorders are associated with more alcohol consumption in the year following treatment. • ASPD among men and social phobia among women predict higher frequency of loss of control (Tomasson, 1996).

18. Schuckit et al. (1985) • Schuckit assessed the relationship between ASPD and drinking behaviors in 577 people who entered an alcoholism treatment program. • The study found that those people who had ASPD before they developed drinking problems consumed significantly more drinks per day and experienced significantly more alcohol-related problems (e.g., being fired or demoted or spending time in jail) compared with people who did not meet the criteria for ASPD.

19. Schuckit et al. (cont.) • When analyzed together, these findings suggest that: 1. people with ASPD experience higher rates of alcohol abuse and dependence than the general population, and 2. people who drink to excess are more likely to experience alcohol-related problems than other alcoholics.

20. According to Bucholz et al. • ASPD and alcohol dependence have been found to be related in both clinical and general population samples. • The comorbidity of ASPD and alcohol abuse is both clinical and etiological… • clinical: poorer prognosis of antisocial alcoholics in treatment • etiological: types II and B, they tend to be more familial than their non-ASPD partners • There have been reported increased rates of ASPD in the alcoholic population. • Recent data suggests a strong genetic relation between alcohol dependence and ASPD.

21. In a study done by Goldstein et al. • ASPD patients have a poorer agreement between self-reported post treatment drug behavior and hair data. This adds to evidence that the DSM-IV requirement of childhood onset of ASPD is very important to look at in substance abusers. This will also help identify this chronically antisocial and drug addicted group, to be at much higher risk for early post treatment failure. • ASPD is one of the most frequently diagnosed disorders with a comorbidity of substance abuse on a study of outpatient alcoholism treatment. Clients with ASPD were assigned cognitive behavior therapy and others were assigned interpersonal focused treatments. They found that the clients with ASPD who participated in cognitive behavior therapy were less likely to become involved with alcohol 2 years post treatment.

22. In a study done by Gerra et al. • Early aggressive behavior predicts substance abuse later on and early onset alcohol abuse. Therefore, children with Conduct Disorder are more likely to abuse drugs in the future. • Their study showed increased rates of irritability, impulsivity, and ASPD when paired with substance abuse regardless of the individuals’ drug use history. • New studies suggest a comorbidity between biological changes underlying proneness to substance abuse and aggressive or violent traits.

23. Gender Differences (Ross, 1988) • Many more men than women are affected by substance abuse in treatment and general populations. • Most studies of the prevalence of mental disorders in patients with alcohol and drug problems have ignored, or only examined in passing, gender differences. • Many professionals believe that women with alcohol problems are more pathological and show more maladjustment and abnormality than their male counterparts. This is based on the assumption that, since there is a stronger social taboo against excessive drinking among women than men, to the extent that women exhibit alcoholism they are also indicating greater pathology by its expression. • Studies have shown that there is a greater amount of psychiatric treatment among women with alcohol problems. Studies have also shown more frequent reports by these women than alcoholic men of depressed or sad mood, feelings of inadequacy, low self-esteem, and anxious affect. An elevated rate of suicide attempts relative to men has also been revealed.

24. Gender Differences (continued)(Ross, 1988) • Women consistently report more physical and emotional symptoms than men, that they more frequently seek help for these discomforts, and that physicians perceive women’s complaints as more often related to some form of mental disorder as compared to men. • Overall, studies show no significant differences between the sexes in the prevalence of alcohol or drug disorders as a whole. • However, several other differences were shown: Women are more likely to receive a lifetime or current diagnosis of barbiturate/sedative/hypnotic abuse or dependence; more likely to have an anxiety disorder or psychosexual dysfunctions and bulimia. Men are more likely given lifetime and current diagnoses of cannabis abuse/dependence and tobacco dependence significantly more often than female patients and more likely to receive the diagnosis of ASPD.

25. Bibliography American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: 1994. Bucholz, K.K., V.M. Hesselbrock, A.C. Health, J.R. Kramer, and M.A. Schuckit (2000). Research report. A latent class analysis of antisocial personality disorder symptom data from a multi-centre family study of alcoholism. Retrieved November 10, 2003, from EBSCOhost Research Databases. Compton, III, W.M., Cottler, L.B., Abdallah, A.B., et al. “Substance Dependence and Other Psychiatric Disorders Among Drug Dependent Subjects: Race and Gender Correlates.” The American Journal on Addictions 9 (2000): 113-125. Goldstein, Rice B., Carol Bigelow, Jane McCusker, Benjamin F. Lewis, Kenneth A. Mundt, and Sally I. Powers (2001). Research article. Antisocial Behavioral Syndromes and Return to Drug Use Following Residential Relapse Prevention/Health Education Treatment. Retrieved November 10, 2003, from EBSCOhost Research Databases. Gerra, G., A. Zaimovic, G. Moi, M. Bussandri, R. Delsignore, R. Caccavari, & F. Brambilla (2003). Research article. Neuroendocrine correlates of antisocial personality disorder in abstinent heroin-dependent subjects. Retrieved November 10, 2003, from EBSCOhost Research Databases.

26. Bibliography (continued) Lewis, C.E. & Bucholz, K.K. “Alcoholism, Antisocial Behavior and Family History.” British Journal of Addiction 86 (1991): 177-194. Lewis, C.E., Halikas, J.A., Morse, C., et al. “Alcoholism in Narcotic Addicts with Antisocial Personality. British Journal of Addiction 82 (1987): 305-311. Messina, Nena, et al. “Diagnosing Antisocial Personality Disorder Among Substance Abusers: The SCID versus The MCMI-II” The American Journal of Drug Alcohol Abuse 27 (2001): 699-717. Ross, Helen E., Ph.D., et al. “Sex Differences in the Prevalence of Psychiatric Disorders in Patients With Alcohol and Drug Problems” British Journal of Addiction 83 (1988):1179-1192. Tomasson, Kristinn & Vaglum, Per. “Psychopathology and alcohol consumption among treatment-seeking alcoholics: a prospective study” Addiction 91 (1996): 1019-1030.