Front Matter

Contributors

Foreword

Introduction

Donald W. Black, M.D.

Nathan J. Kolla, M.D., Ph.D., FRCPC

PART I

Definition and History

1 Classification and Definition of Antisocial Personality Disorder

Peter Tyrer, M.D.

Alireza Farnam, M.D.

Alireza Zahmatkesh, M.D.

Rahil Sanatinia, M.D., Ph.D.

2 Antisocial Personality Disorder Throughout Time—Evolution of the Concept

Erik Simonsen, M.D.

PART II

Clinical Concepts

3 Epidemiology of Antisocial Personality Disorder

Risë B. Goldstein, Ph.D., M.P.H.

4 Psychiatric and Medical Comorbidity of Antisocial Personality Disorder

Patrick T. McGonigal, M.A.

Mark Zimmerman, M.D.

Mario J. Scalora, Ph.D.

5 Clinical Symptoms and Assessment of Antisocial Personality Disorder

Donald W. Black, M.D.

Nancee Blum, M.S.W.

PART III

Etiology and Pathophysiology

6 Natural History and Course of Antisocial Personality Disorder

Donald W. Black, M.D.

Risë B. Goldstein, Ph.D., M.P.H.

7 Family, Twin, and Adoption Studies in Antisocial Personality Disorder and Antisocial Behavior

Wendy S. Slutske, Ph.D.

Christal N. Davis, M.A.

8 Molecular Genetics of Antisocial Personality Disorder

Christopher Adanty, B.Sc.

Zhuoran Ma, B.S.

Anvesh Roy, M.D.

Anil Srivastava, M.D.

Nasia Dai, B.Sc.

Vincenzo De Luca, M.D., Ph.D.

9 Social Theories of Causation

Joel Paris, M.D.

Donald W. Black, M.D.

10 Biological Risk Factors for Antisocial Personality Disorder

Jaeger Lam, M.A.

Anthony C. Ruocco, Ph.D.

11 Neurophysiology of Antisocial Personality Disorder

Marijn Lijffijt, Ph.D.

Nithya Ramakrishnan, B.E., M.S.

Nicholas Murphy, Ph.D.

Dylan A. Fall, M.D.

Alan C. Swann, M.D.

12 Central and Peripheral Biomarkers of Antisocial Personality Disorder

Laura Dellazizzo, M.Sc.

Alexandre Dumais, M.D., Ph.D., FRCPC

13 Structural MRI Studies of Antisocial Personality Disorder

Olivia Choy, Ph.D.

14 Functional MRI Studies of Antisocial Personality Disorder

R. James Blair, Ph.D.

15 SPECT and PET Studies of Antisocial Personality Disorder and Aggression

Nathan J. Kolla, M.D., Ph.D., FRCPC

Sylvain Houle, M.D., Ph.D., FRCPC

16 New Insights Into the Causes of and Potential for Prevention of Psychopathy—A Syndrome Distinct From Antisocial Personality Disorder

Sheilagh Hodgins, Ph.D., FRSC

PART IV

Clinical Management

17 Psychosocial Treatment of Antisocial Personality Disorder

James McGuire, Ph.D.

18 Pharmacological Treatment of Antisocial Personality Disorder

Mario Moscovici, M.D.

Roland M. Jones, M.B.Ch.B., B.Sc., M.Sc., Ph.D., FRCPsych

19 Treatment Issues With Antisocial Personality Disorder

Donald W. Black, M.D.

PART V

Special Problems, Populations, and Settings

20 Criminal Justice System and Antisocial Personality Disorder

Robert L. Trestman, M.D., Ph.D.

Elham Rahmani, M.D., M.P.H.

Nayan Bhatia, M.D.

21 The Antisocial Child

Allan M. Andersen, M.D.

Samuel Kuperman, M.D.

22 The Antisocial Woman

Brittany Bishop, M.Sc.F.S.

Birgit Völlm, M.D., Ph.D.

Najat Khalifa, M.D.

23 The Antisocial Sexual Offender

Liam E. Marshall, Ph.D.

24 Prevention of Antisocial Personality Disorder

Eva R. Kimonis, Ph.D.

Georgette E. Fleming, Ph.D.

Index

Color Gallery

Graduate Student, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Centre for Addiction and Mental Health, Toronto, Ontario, Canada

Assistant Professor, Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa

Resident Physician, Virginia Tech Carilion School of Medicine and Carilion Clinic, Roanoke, Virginia

Master of Science in Forensic Science, Trent University, Peterborough, Ontario, Canada

Professor Emeritus, Department of Psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa; and Associate Chief of Staff for Mental Health, Iowa City Veterans Administration Health Care, Iowa City, Iowa

Director, Center for Neurobehavioral Research in Children, Boys Town National Research Hospital, Boys Town, Nebraska

Retired Adjunct Instructor, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa

Assistant Professor, Department of Psychology, Nanyang Technological University, Singapore

Graduate Student, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Centre for Addiction and Mental Health, Toronto, Ontario, Canada

Doctoral Candidate, Department of Psychological Sciences, University of Missouri, Columbia, Missouri

Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Centre for Addiction and Mental Health, Toronto, Ontario, Canada

M.D.-Ph.D. student, Research Center of the Institut Universitaire en Santé Mentale de Montréal; and Department of Psychiatry and Addictology, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada

Clinician-Researcher, Research Center of the Institut Universitaire en Santé Mentale de Montréal; Department of Psychiatry and Addictology, Faculty of Medicine, University of Montreal; Institut National de Psychiatrie Légale Philippe-Pinel, Montreal, Quebec, Canada

MS4 Medical Student, Mental Health Line, Michael E. DeBakey VA Medical Center; and MS4 Medical Student, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas

Professor of Psychiatry, Medical Faculty, Tabriz University of Medical Sciences, Tabriz, Iran

Lecturer, School of Psychology, The University of New South Wales, Sydney, Australia

Staff Scientist, Social and Behavioral Sciences Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland

Professeur, Département de Psychiatrie et Addictologie, Université de Montréal, and Centre de Recherche de l’Institut Universitaire en Santé Mentale de Montréal, Montreal, Quebec, Canada

Brain Health Imaging Centre, Centre for Addiction and Mental Health, Toronto, Ontario, Canada

Forensic Psychiatrist and Clinician Scientist, Department of Forensic Psychiatry, Centre for Addiction and Mental Health; and Assistant Professor, University of Toronto, Toronto, Ontario, Canada

Associate Professor in Forensic Psychiatry, Department of Psychiatry, Queen’s University; and Regional Psychiatry Lead, Correctional Service Canada, Ontario, Canada

Professor, School of Psychology; and Director, Parent-Child Research Clinic, The University of New South Wales, Sydney, Australia

Clinician Scientist, Brain Health Imaging Centre, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Head, Violence Prevention Neurobiological Research Unit, Centre for Addiction and Mental Health; Associate Professor of Psychiatry, Criminology and Sociolegal Studies, Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada; and Waypoint/University of Toronto Research Chair in Forensic Mental Health Science, Penetanguishene, Ontario, Canada

Professor, Departments of Psychiatry and Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa

Doctoral Candidate, York University, Toronto, Ontario, Canada

Principal Investigator, Research Service Line, Michael E. DeBakey VA Medical Center; and Assistant Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas

Graduate Student, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Centre for Addiction and Mental Health, Toronto, Ontario, Canada

Research Clinician, Waypoint Centre for Mental Health Care and Rockwood Psychotherapy and Consulting, Penetanguishene, Ontario, Canada; and Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada

Doctoral Student, Department of Psychology, University of Nebraska-Lincoln, Lincoln, Nebraska

Emeritus Professor, Institute of Population Health, University of Liverpool, Liverpool, United Kingdom

Psychiatry Resident, Department of Forensic Psychiatry, Centre for Addiction and Mental Health, Toronto, Ontario, Canada

Investigator, Research Service Line, Michael E. DeBakey VA Medical Center; and Assistant Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas

Emeritus Professor of Psychiatry, Department of Psychiatry, McGill University, Montreal, Quebec, Canada; and Research Associate, Jewish General Hospital, Montreal, Quebec, Canada

Resident Physician, Virginia Tech Carilion School of Medicine and Carilion Clinic, Roanoke, Virginia

Investigator, Research Service Line, Michael E. DeBakey VA Medical Center; and Senior Scientific Programmer, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas

Lecturer, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Centre for Addiction and Mental Health, Toronto, Ontario, Canada

Professor of Psychology and Psychological Clinical Science, University of Toronto, Toronto, Ontario, Canada

Research Associate, Division of Psychiatry, Imperial College, London, United Kingdom

Associate Professor, Department of Psychology, University of Nebraska-Lincoln, Lincoln, Nebraska

Professor of Psychiatry, University of Copenhagen, Copenhagen, Denmark; and Director, Psychiatric Research Unit, Slagelse, Denmark

Curators’ Distinguished Professor, Department of Psychological Sciences, University of Missouri, Columbia, Missouri

Staff Physician, Department of Psychiatry, Humber River Hospital, Toronto, Ontario, Canada

Staff Psychiatrist, Mental Health Line, Michael E. DeBakey VA Medical Center; and Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas

Professor and Chair, Virginia Tech Carilion School of Medicine and Carilion Clinic, Roanoke, Virginia

Consultant in Transformation Psychiatry, Lincolnshire Partnership NHS Trust; and Emeritus Professor of Community Psychiatry, Imperial College, London, United Kingdom

Professor of Forensic Psychiatry, Department of Forensic Psychiatry, University Medicine, Rostock, Germany

Faculty of Psychology, Department of Clinical Psychology, Semnan University, Semnan, Iran

Director of Partial Hospital Program and Adult Outpatient Psychiatry, Department of Psychiatry, Rhode Island Hospital, Providence, Rhode Island

It has long been recognized that antisocial personality disorder (ASPD) accounts for greater cost and burden to society than any other major mental illness (National Institute for Clinical Excellence 2009). Yet investment to support scientific exploration of this disabling and socially and interpersonally disruptive condition has been woefully inadequate. National Institute of Mental Health funding to study ASPD—from etiology to prevention to treatment—has been negligible. In fairness, this imbalance may in part reflect the nature of the illness itself, because individuals with ASPD deny that they are ill or that they need treatment. Furthermore, the first diagnostic criterion for ASPD in DSM-5 is “Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest” (American Psychiatric Association 2013, p. 659). Although many prisoners meet the full diagnostic criteria for ASPD, prisoners are designated as a “protected class,” making it difficult, but not impossible, to carry out research with these large populations. In 1993, an interesting book was published entitled The Psychopathology of Crime: Criminal Behavior as a Clinical Disorder, by Adrian Raine (1993). Raine made the argument that if you get the best consensus you can on a definition of psychopathology, then criminal behavior, for the most part, fits the definition. Does that mean that all prisoners should be classified as mentally ill? Certainly not, even though we know that many incarcerated individuals have diagnosable psychiatric disorders, including ASPD, and that criminal behavior is often illness-driven behavior.

Early in my career, I was on the faculty at Columbia University in New York City along with Robert Spitzer, M.D., chair of the DSM-III Task Force, during the development of that new and groundbreaking diagnostic system (American Psychiatric Association 1980). Regarding ASPD, I recall Bob’s often-repeated caveat that “antisocial personality disorder is not the same thing as social deviance.” I thought I understood that because certainly “social deviance” covers a lot of behavioral territory, such as white-collar crime, illegal drug use, and shoplifting, which would not necessarily reflect the presence of ASPD. But where to draw the line between ASPD and social deviance is not so straightforward because to do so would require defining social norms, which vary widely across cultures and subcultures.

Other debates about definitional terms and boundaries are frequently encountered because antisocial behavior comes in many stripes and covers a wide swath. What do we mean, for example, by “psychopathy” and “sociopathy,” and how do they differ from ASPD? Discussions of these behavioral boundaries can become thorny and often contentious, but they are explored elegantly and extensively in this welcome new volume edited by Drs. Black and Kolla. This compendium brings together international experts on ASPD to provide, in a single source, the best knowledge we have about this challenging condition. It is important to add that we now know quite a lot, despite the historical insufficiency of research support. Look inside these pages and you will learn about not only the phenomenology and natural course of ASPD but also its neuropathology, neurophysiology, genetic risk factors, epigenetics, and social determinants. Even some promising directions regarding prevention and treatment are included. All in all, the Textbook of Antisocial Personality Disorder is an urgently needed, scholarly, and comprehensive review of one of the most daunting areas of psychopathology in our field.

John M. Oldham, M.D.

Distinguished Emeritus Professor

Baylor College of Medicine, Houston, Texas

Donald W. Black, M.D.

Nathan J. Kolla, M.D., Ph.D., FRCPC

Antisocial personality disorder (ASPD) is psychiatry’s forgotten disorder. Despite its enormous cost to individuals, families, and society, few clinicians diagnose ASPD let alone offer treatment, and few researchers investigate it. Despite high public health significance, clinicians and researchers have largely distanced themselves from ASPD, perhaps in sympathy with family members and friends who react similarly. A stark reminder of the disappointing lack of interest by funding agencies is the fact that in 2020 not a single grant funded by the National Institutes of Health (2020) targeted this disorder.

Psychiatry has wrestled with the problem of chronic antisocial behavior for more than 200 years (Black 2013). Although the terms and definitions used have evolved and shifted over the years, they are unified in describing a discrete group of people with recurrent—typically lifelong—misbehavior. These individuals rebel against every type of regulation and expectation, resist authority, and push the limits of acceptable behavior. Breaking norms is the dominant force in these individuals’ lives, all too often leading to lives of poverty, loneliness, addiction, and despair. ASPD arguably wreaks more havoc on society than most other mental disorders do because it primarily involves actions directed against the social environment.

Poorly understood in the general population, and even among some psychiatrists and psychologists, Goodwin and Guze (1989) have provided one of the best brief definitions. They describe ASPD as “a pattern of recurrent, delinquent, or criminal behavior that begins in early childhood or early adolescence and is manifested by disturbances in many areas of life: family relations, schooling, work, military service, and marriage” (p. 240). The spectrum of behaviors manifested range from relatively minor acts at one end (e.g., lying, cheating) to rape and murder at the other. ASPD is common and culturally universal, but its presence is rarely acknowledged, and determining its causes is as elusive as understanding its treatment.

In the early nineteenth century, Philippe Pinel, leader in the French Revolution and founding father of modern psychiatry, used the term manie sans delire to describe individuals who were not insane but had irrational outbursts of rage and violence. Scottish physician William Pritchard used the term moral insanity to describe otherwise normally functioning people who willfully engaged in antisocial conduct. Pritchard’s use of the term moral is prescient because many of the people he described appeared to lack a moral compass, which remains perhaps the most disturbing aspect in many individuals who have ASPD. In the twentieth century, American psychiatrist Hervey Cleckley (1976) provided the first coherent description of the disorder, which he termed psychopathy. In his book The Mask of Sanity, he outlined a set of criteria that have influenced generations of researchers. While sharing some similarities with psychopathy, ASPD is a different entity, and in this textbook, we highlight these important differences.

By the mid-twentieth century, psychiatry was ripe for a more formal and focused approach to describing antisocial behavior. Sociologist Lee Robins, working at Washington University, conducted a remarkable follow-up study of former child guidance clinic patients. Documented in Deviant Children Grown Up, Robins (1966) developed the concept of sociopathy as a distinct and identifiable disorder for those who always tend to be in trouble, have little sense of responsibility, lack judgment, blame others, and rationalize their behaviors. Her views strongly influenced the ASPD criteria developed in the late 1970s for DSM-III (American Psychiatric Association 1980). The criteria were refined in subsequent DSM editions but essentially remain true to Robins’ vision.

Assumed to be a multidetermined disorder, not unlike hypertension or schizophrenia, the cause of ASPD is thought to involve both genetic vulnerability and environmental events. Early family, twin, and adoption studies had suggested a heritable component, yet exactly what is inherited and how the disorder is transmitted are unclear. Many theories have developed to explain the disorder as either the consequence of a neurodevelopmental insult or chronic autonomic underarousal. A role has been suggested for several neurotransmitters, including serotonin, known to modulate impulsivity and aggression. Structural and functional brain imaging studies have suggested that frontal deficits might contribute to impulsivity, poor judgment, and irresponsible behavior, whereas dysfunction in temporal regions might predispose to antisocial features such as inability to follow rules and deficient moral judgment.

The cynical view of most mental health professionals is that ASPD is untreatable. That conclusion is premature because of the lack of relevant treatment research. In the entire world’s literature, only one randomized controlled treatment trial has been conducted. In that study, cognitive-behavioral therapy was tested against treatment as usual, and the study had largely negative findings. This leaves clinicians to sift through the literature searching for treatment studies that may be relevant, such as persons with impulsive personalities, prisoners, or youths with conduct disorder. In each case, some of the study participants could be antisocial, but in most of the studies, the presence or absence of ASPD is never specified.

We believe that this is the ideal time for a textbook that pulls together all the known information about ASPD. The contributors describe much of what has been learned about ASPD and other forms of antisocial behavior, including childhood conduct disorder, adult antisocial behavior, and psychopathy. We have brought together a distinguished group of collaborators who approach ASPD from their unique perspectives as researchers and clinicians. Chapters 1 and 2 review the definition and history of ASPD, while Chapters 3 through 6 cover clinical concepts such as epidemiology, comorbidity, symptoms, and course. Chapters 7 through 10 probe suspected causes of the disorder, which appear to involve a complex interplay of genetics and environment, and Chapters 11 through 15 review its neurophysiology, neurotransmitters, and neuroimaging. The relationship of ASPD to psychopathy is reviewed in Chapter 16. Current treatment recommendations for ASPD are explored in Chapters 17 through 19, and other aspects of ASPD are explored in the remaining chapters. We believe that this is the most current and comprehensive textbook on this vexing disorder and will be of great interest to clinicians tasked with caring for these patients and a useful resource for researchers probing its causes and treatments.

We are grateful for the strong interest shown by our distinguished contributors in joining our endeavor. We received invaluable guidance and support from Publisher John McDuffie and Editor-in-Chief Laura Roberts, M.D., M.A., of American Psychiatric Association Publishing. They, and their talented staff, helped make the textbook a reality. Most of all, we are grateful to the many men and women with ASPD, and their families, who opened their lives up to us as we pursued research or provided clinical care. They are the true experts.