Antisocial personality disorder (ASP) is particularly germane to alcohol and drug abuse because it co-occurs in a large proportion of those who abuse alcohol or drugs, and it confounds the diagnosis of, influences the course of, and is an independent risk factor for the development of alcohol or drug abuse disorder. Additionally, scientific evidence suggests that alcohol and drug abuse complicated by ASP is more heritable than is substance abuse without ASP.
In the latest diagnostic classification system Diagnostic and Statistical Manual-4th edition (DSM-IV), ASP is defined as a disorder that begins in childhood or early adolescence and continues into adulthood; it is characterized by a general disregard for and violation of the rights of others. At least three of the following behaviors must have occurred in any twelve-month period of time before the age of 15, with two before age 13 : running away from home overnight twice, staying out late at night despite parental rules to the contrary (before age 13), truancy (beginning before age 13), initiating physical fights, using weapons in fights, cruelty to animals and to people, vandalism, forcing someone into sexual activity, arson, frequent lying to obtain favors or goods, frequently bullying, breaking into someone's house or car, and stealing from others (either passively like shoplifting, or aggressively, like mugging). In addition, three of the following behaviors must have occurred since the age of 15 : consistent irresponsibility (e.g., inability to sustain consistent work behavior or to honor financial obligations), failure to conform to social norms by repeatedly engaging in arrestable behaviors, irritability and aggressiveness, deceitfulness (e.g., frequent lying or conning of others), reckless behaviors indicating disregard for safety of oneself or of others, impulsivity or failure to plan ahead, and lack of remorse for hurtful or manipulative behaviors.
A large percentage of alcohol and drug abusers meet criteria for ASP. For example, in one multisite study of 20,000 community respondents, 15 percent of the alcoholic participants compared to 2.6 percent of the population as a whole, met criteria for ASP. Comparable data from clinical samples indicate that from 16 percent to 49 percent of treated alcoholics met criteria for ASP.
A substantial proportion of those with ASP also abuse alcohol or drugs—three times as many men with a diagnosis of ASP as without abuse alcohol and five times as many abuse drugs. For females, the association is even stronger—twelve times as many women with ASP as without abuse alcohol and thirteen times as many abuse drugs. The strong association between ASP and alcohol or drug abuse may actually be caused by antisocial behaviors that occur when under the influence of alcohol or drugs judgment is impaired. It is possible, however, to distinguish primary abusers, those for whom the antisocial behaviors are a result of their substance use, from secondary abusers, for whom substance abuse is just one manifestation of a wide spectrum of antisocial behaviors. This differentiation is particularly important in understanding the genetic transmission of disease, where genetic factors responsible for the co-morbid state might be transmitted separately from those that cause substance abuse.
The course of alcohol or drug abuse is affected by ASP. Alcoholics with ASP have a more chronic and more severe course, an earlier onset of alcohol symptoms (for example, average age of onset of 20 compared to nearly 30 for those without ASP), as well as a significantly longer history of problem drinking. Furthermore, evidence is mounting that ASP alcoholics have poorer response to treatment—relapsing much earlier than alcoholics without ASP—and they may respond only to certain therapies.
Antisocial behavior problems in childhood have been identified as an independent risk factor in the development of alcoholism. One of the first studies to document this was carried out by Robins (1962) in a follow-up study of child-guidance clinic attendees; a marked excess of alcoholism was observed among those with antisocial behavior in childhood. This finding has subsequently been replicated in numerous other studies.
Data from several studies indicate that alcoholism complicated by ASP or ASP-like behaviors may be more heritable than non-ASP alcoholism. Evidence from a Swedish adoption study indicated the adopted-out sons of fathers with ASP-like alcoholism had a risk of alcoholism nine times that of adopted-out sons of other fathers.
The causes of ASP are not known, but data are accumulating from neurochemical studies that provide some clues. Neuropharmacological studies have established associations of aggressive, impulsive, hostile, and low socialization behaviors with low Serotonin levels. Another neurotransmitter, Dopamine, is linked to novelty-seeking behavior. The interactions among neurotransmitters have led researchers to postulate an association of multiple neurotransmitter dysfunctions, with a loss of impulse control and an increased appetite for novel experiences.
ASP is a common concomitant of alcohol and drug abuse that affects their course and treatment; it may represent a highly heritable subtype of such abuse. Although its etiology is unknown, evidence from neuropharmacology studies has provided some leads. As with many personality disorders, there is no known treatment for ASP. It is an important disorder to consider in alcohol and drug abuse.
(See also: Addictive Personality ; Childhood Behavior and Later Drug Use ; Conduct Disorder and Drug Use )
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Kathleen K. Bucholz
Revised by Rebecca J. Frey
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