Download Antisocial Personality Disorder and Substance Abuse

Antisocial Personality
Disorder and Substance
Abuse
November 18, 2003
By:
Ms. K. Meetze
Ms. R. Melton
Mr. M. Melvin
Ms. B. Mooza
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)
2)
3)
4)
5)
6)
7)
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
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
Antisocial Personality Disorder
DSM-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.
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)
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.
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.
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.
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.
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.
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.
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.
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.
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).
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).
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).
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.
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).
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.
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.
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.
In a study done by Goldstein et al.
ASPD patients have a poorer agreement between selfreported 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.
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.
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.
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.
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.
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):11791192.
Tomasson, Kristinn & Vaglum, Per. “Psychopathology and alcohol consumption among
treatment-seeking alcoholics: a prospective study” Addiction 91 (1996): 1019-1030.