Antisocial Antisocial Personality Disorder Personality Disorder Karin Neufeld, MD MPH Karin Neufeld, MD MPH Addiction Treatment Services Addiction Treatment Services Department of Psychiatry Department of Psychiatry Johns Hopkins University School of Johns Hopkins University School of Medicine Medicine
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Antisocial Personality Disorder Karin Neufeld, MD MPH Addiction Treatment Services Department of Psychiatry Johns Hopkins University School of Medicine.
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–80% substance use disorder (SUD)80% substance use disorder (SUD) High legal costHigh legal cost
–40% of prisoners40% of prisoners
–$41 billion/yr for US prison system$41 billion/yr for US prison system
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ObjectivesObjectives
Review diagnosisReview diagnosisDescribe epidemiologyDescribe epidemiologyReview risk factorsReview risk factorsDescribe the courseDescribe the courseReview treatment Review treatment
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Key PointsKey Points
Very common in SUD patientsVery common in SUD patients Genes and environment involvedGenes and environment involved Associated with great sufferingAssociated with great suffering Treatment is helpfulTreatment is helpful
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ObjectivesObjectives
Review diagnosisReview diagnosis
Describe epidemiologyDescribe epidemiology
Review risk factorsReview risk factors
Describe the courseDescribe the course
Review treatment Review treatment
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DSM-IV Diagnosis 1DSM-IV Diagnosis 1 Persistent violation of others’ rights Persistent violation of others’ rights
with 3+ of: with 3+ of: - Disobey the lawDisobey the law- Lying or conningLying or conning- ImpulsivityImpulsivity- Irritability, aggressiveness, physical fightsIrritability, aggressiveness, physical fights- Disregard for safetyDisregard for safety- No sustained work historyNo sustained work history- Lack of remorseLack of remorse
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DSM-IV Diagnosis 2DSM-IV Diagnosis 2 >18 y/o18 y/o Early CD < 15yrsEarly CD < 15yrs
– Aggression to people or animalsAggression to people or animals
– Destruction of propertyDestruction of property
– Deceitfulness or theftDeceitfulness or theft
– Serious violation of rulesSerious violation of rules
R/O other major mental illnessR/O other major mental illness
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ASPD PrevalenceASPD Prevalence General population ~ 3%General population ~ 3%
– M ~ 6%; F ~ 1%M ~ 6%; F ~ 1%
General medical clinics ~ 8%General medical clinics ~ 8% Mental health settings ~ 10%Mental health settings ~ 10% SUD treatment ~ at least 25%SUD treatment ~ at least 25% Prisoners ~ 40%Prisoners ~ 40%
– M ~ 50%; F ~ 20%M ~ 50%; F ~ 20%
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Associated DemographicsAssociated Demographics M:F = 6:1M:F = 6:1 Young (25 – 44) > Older (45 +)Young (25 – 44) > Older (45 +) Race: no differenceRace: no difference School drop-out: 5x by 11 yrs School drop-out: 5x by 11 yrs Abuse/neglect in childhood Abuse/neglect in childhood
– 50% 50% risk of adult criminal behavior risk of adult criminal behavior
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AdulthoodAdulthood
Data limited Data limited (Black et al 1995)(Black et al 1995)
29 yr follow-up of hospitalized ASPD29 yr follow-up of hospitalized ASPD 24% of sample died24% of sample died Of remainder alive:Of remainder alive:
–27% remission27% remission–31% improved31% improved–42% no change42% no change
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Psychiatric ComorbidityPsychiatric Comorbidity
Lifetime prevalence in ASPD:Lifetime prevalence in ASPD:– 70% alcohol use disorder70% alcohol use disorder
– 50 % drug use disorder50 % drug use disorder
80% of ASPD in tx: multiple SUD80% of ASPD in tx: multiple SUD Severity of SUDSeverity of SUD 4x SUD treatment episodes4x SUD treatment episodes
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Morbidity and MortalityMorbidity and Mortality
MorbidityMorbidity– HIV and high risk behaviorsHIV and high risk behaviors– Medical problemsMedical problems– InjuriesInjuries
MortalityMortality– Risk of violent death (6x in youth)Risk of violent death (6x in youth)– Risk of suicideRisk of suicide
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ObjectivesObjectives
Review diagnosisReview diagnosisDescribe epidemiologyDescribe epidemiologyReview risk factorsReview risk factorsDescribe the courseDescribe the courseReview treatment Review treatment
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Treatment of ASPDTreatment of ASPD
Effectiveness? Effectiveness? Clinical fatalismClinical fatalism Patients rarely ask for ASPD txPatients rarely ask for ASPD tx
–Poor insightPoor insight
–Lifelong disturbanceLifelong disturbance
Often come for tx of SUDOften come for tx of SUD
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Treatment ElementsTreatment Elements Thorough history and examThorough history and exam Therapeutic relationshipTherapeutic relationship
–Firm behavioral limitsFirm behavioral limits
–Professional boundariesProfessional boundaries
–Maintain your empathyMaintain your empathy
–Negotiate behavioral goals in advanceNegotiate behavioral goals in advance
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Treatment ExpectationsTreatment Expectations Not curativeNot curative Focus on improved functionFocus on improved function Decrease problem behaviorsDecrease problem behaviors
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Treatment Outcomes Treatment Outcomes SUD literature = best impact dataSUD literature = best impact data ASPD and opioid dependenceASPD and opioid dependence
–Same retention in methadone txSame retention in methadone tx
– Drug use Drug use
– High risk behaviors High risk behaviors
Psychotherapy response mixedPsychotherapy response mixed Good response to behavioral txGood response to behavioral tx
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PharmacotherapyPharmacotherapy Poor to no dataPoor to no data Mood stabilizers ~ Mood stabilizers ~ impulsive impulsive
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SummarySummary
Very common in SUD patientsVery common in SUD patients Genes and environment involvedGenes and environment involved Associated with great sufferingAssociated with great suffering Treatment is helpfulTreatment is helpful