Chapter 1. Classification and Definition of Antisocial Personality Disorder
Publication: Textbook of Antisocial Personality Disorder
Antisocial personality characteristics are as old as recorded history and consequently not easy to define. They have three different but overlapping features. These can be summarized as the three I’s:
1.
Insensitivity: lack of awareness and consideration for the needs of others
2.
Infringement: violation of the basic rights of another person
3.
Injury: deliberately aggressive behavior intended to harm
The first of these is a self-concept, and the other two are components of interpersonal social function that can range from sudden impulsive behavior to planned sadism. The three I’s set the stage for more formal considerations of antisocial behavior.
DSM-I and DSM-II
Clinical descriptions of antisocial behavior date to the early nineteenth century, but formal definitions are more recent. The first official definition was included in DSM-I (American Psychiatric Association 1952). The stimulus for the development of DSM was World War II. Existing systems of classification had failed to fully capture the range of mental disorders apparent among war veterans, leading the American Psychiatric Association to conclude that a classification acceptable to all its members was needed. The DSM, later known as DSM-I, came in at 132 pages and contained 106 diagnoses (Black and Grant 2014). It was published as a slim paperback with a plastic binder, contributing to its relative rarity today.
Personality disorders were relegated to their own category independent of other disorders and were considered “disorders of psychogenic origin or without clearly defined tangible cause or structural change” (American Psychiatric Association 1952, p. 7). DSM-I descriptions were prose paragraphs that incorporated behavioral and traitlike criteria. These descriptions tended to be short and were intended to serve as a diagnostic guide for clinicians.
Sociopathic personality disturbance, generally abbreviated as sociopathy, was a new category used to describe individuals whose maladaptive behavior was directed toward the social environment: “Individuals to be placed in this category are ill primarily in terms of society and of conformity with the prevailing cultural milieu, and not only in terms of personal discomfort and relations with other individuals” (American Psychiatric Association 1952, p. 38). Subtypes included antisocial reaction, dyssocial reaction, sexual deviation, and addiction, which included alcoholism and drug addiction.
Diagnosis in DSM-I and DSM-II (American Psychiatric Association 1968) was influenced greatly by the work of Adolf Meyer, who believed that all mental illnesses should be viewed in the context of the whole person and should be regarded as reactions rather than discrete illnesses. Hence, the term antisocial reaction was applied to those who were “always in trouble, profiting neither from experience nor punishment, and maintaining no real loyalties to any person, group, or code” (p. 38). Those with the dyssocial reaction “manifest disregard for the usual social codes, and often come into conflict with them, as a result of having lived all their lives in an abnormal moral environment” (p. 38). In other words, such individuals had no manifest psychiatric disorder but followed criminal lifestyles.
Personality disorders were generally regarded as developmental defects along the lines of the nineteenth-century ideas of degeneration and, as such, were not regarded as treatable through any form of clinical intervention. The modern notion of psychopathy and, indirectly, the path of antisocial personality developed from the work of American psychiatrist Hervey Cleckley (1976), detailed in his book The Mask of Sanity: An Attempt to Clarify Some Issues About the So-Called Psychopathic Personality, a remarkable example of psychiatric progress being made by clinical observation. Cleckley identified 21 characteristics of psychopathy, perhaps the first attempt in psychiatry to list criteria (Table 1–1). Indicating which of these characteristics have been retained in about the same form in later classifications (and referred to later in this chapter) is useful. It is a measure of Cleckley’s impact that his original concepts have been widely adopted, most significantly by psychologist Robert Hare, whose work is discussed elsewhere (see Chapter 16, “New Insights Into the Causes of and Potential for Prevention of Psychopathy—A Syndrome Distinct From Antisocial Personality Disorder”).
1. Superficial attractiveness |
2. Apparently free from any neurotic or psychotic symptom |
3. Little or no sense of personal responsibilitya |
4. Disregard for the trutha |
5. Does not accept blame for his or her actionsa |
6. Has no sense of shamea |
7. Is “undependable”; cheats and lies without any compunctiona |
8. “Execrable” judgment |
9. Inability to learn or profit from experiencea |
10. Gross egocentricitya |
11. Poverty of affect with no depth of feeling |
12. Lacking insight; cannot see self as others see him or hera |
13. No appreciation for kindness or consideration shown by others |
14. Alcohol indulgencesa |
15. When drinking, places self in disgraceful or ignominious position seeking a state of stupefaction |
16. Not suicidal |
17. Sex life shows peculiarities with interest in casual sex |
18. No evidence of familial inferiority or heredity |
19. No evidence of early maladjustment |
20. I nability to follow any plan consistentlya |
21. Has a life plan that ends in failure |
aConcepts that have been retained.
Source. Cleckley 1976.
One problem with the word psychopath is that it has been used indiscriminately over the years. This was most apparent in the work of German psychiatrist Kurt Schneider (1923) who described 10 different personalities that now form the basis of the categorical classification of personality disorder. All were described as psychopathic, contributing to later confusion about the appropriate use of the term. Nonetheless, his ambiguous term encapsulated the core of personality disorder—that is, the inability to form and sustain interpersonal relationships (Tyrer et al. 2015). Only one, the “affectionless psychopathic,” would now be regarded as clinically antisocial.
The recognition that psychopathy was better linked to antisocial characteristics was emphasized by David Henderson in his book Psychopathic States (1939). He described three groups of psychopaths: 1) those who were predominantly aggressive toward others or themselves, including individuals with drug addiction and alcoholism; 2) those who were predominantly passive or inadequate, their aggressiveness being confined to mild threats, sulks, minor delinquencies, petty thieving, and swindling; and 3) those who were predominantly creative. His descriptions were widely adopted in the United Kingdom in the subsequent 30 years, with the “inadequate psychopath” making more of an impression than the other two but not being of much value in advancing knowledge.
DSM-III and ICD-9
The term antisocial personality was first used in DSM-II (American Psychiatric Association 1968). The disorder was listed as a specific type of personality disorder no longer linked to addictions or deviant sexuality. Antisocial personality combined elements of the antisocial and dyssocial reactions of DSM-I. The diagnosis was used for “individuals who are basically unsocialized and whose behavior pattern brings them repeatedly into conflict with society. . . . They are grossly selfish, callous, irresponsible, impulsive, and unable to feel guilt or to learn from experience and punishment” (p. 43).
DSM-III (American Psychiatric Association 1980) introduced diagnostic criteria that were strongly influenced by the work of sociologist Lee Robins (1966) in her seminal monograph, Deviant Children Grown Up. (Her book is further discussed in Chapters 2, “Antisocial Personality Disorder Throughout Time—Evolution of the Concept,” and 6, “Natural History and Course of Antisocial Personality Disorder.”) Robins’ painstaking study involved the follow-up of nearly 80% of a total of 150 subjects and a comparison control group. The study was also helped by having accurate descriptions of the behaviors shown by the children rather than by later groups who were described in less informative psychodynamic language. Robins showed that the outcomes of children and adolescents with antisocial propensities were much worse than those of children with “neurotic” disorders, even though it was the latter who predominated in child guidance clinics. The study also placed sociopathy firmly within antisocial behavior and so reverted to supporting Henderson’s view that social deprivation and neglect were at the core of the disorder.
DSM-III also introduced a multiaxial system to fully describe an individual’s psychiatric condition. In this scheme, antisocial personality disorder (ASPD) was placed on Axis II along with other personality disorders and the developmental disorders. The multiaxial system was eliminated in DSM-5 (American Psychiatric Association 2013), in part because it was frequently ignored by clinicians. Also, the scheme had been criticized for marginalizing personality disorders and for creating an artificial separation between major mental disorders and personality disorders (Black and Grant 2014).
Robert Spitzer, a psychiatrist at Columbia University interested in nomenclature, led the DSM-III Task Force Committee. A major goal of the committee was to improve diagnostic reliability by introducing diagnostic criteria that were objective and based on existing data rather than expert opinion whenever possible (American Psychiatric Association 1980). The ASPD criteria borrowed from the Washington University criteria (Feighner et al. 1972) and the Research Diagnostic Criteria (Spitzer et al. 1978). These criteria sets emphasized the continuity between adult and childhood behavior problems.
ASPD became the most reliably diagnosed personality disorder almost overnight because so many of its diagnostic criteria were not opinions but rather ones that were clearly documented (Coccaro et al. 1997). Criterion B could be achieved by satisfying 3 or more of 12 symptoms: truancy, expulsion from school, referral to juvenile court, running away from home, persistent lying, repeated casual sex, repeated substance abuse, theft, vandalism, poor school grades below those expected, rule-breaking (at home or at school), and the initiation of fights (American Psychiatric Association 1980, p. 320). The symptoms had to have an onset before age 15 years, and the person must be at least 18 years old (Criterion A). These two requirements were a consequence of Robins’ (1966) influence, because she was convinced that ASPD could not develop after age 18 years (even though her research was unable to fully answer this question).
A similar list of events and behaviors had to be present after age 18 years. Four or more of the following nine symptoms were required for the diagnosis (Criterion C): inability to sustain work behavior, failure of parenting (if children in family), inability to accept lawful social norms (e.g., thefts, selling drugs, multiple arrests), inability to sustain enduring attachments, aggressive behavior with physical assaults, failure to honor financial obligations, impulsivity or failure to plan ahead and lack of fixed address, repeated lying, and reckless behavior (American Psychiatric Association 1980, pp. 320–321).
The changes in DSM-III undercut some of the previous definitions of psychopathy, especially Cleckley’s “no evidence of early maladjustment,” and this separation has persisted ever since. But Cleckley’s work on psychopathy was incorporated in part because the text description of DSM-III included several of Cleckley’s core traits: “stealing, fighting, truancy, and resisting authority are typical early childhood signs” (American Psychiatric Association 1980, p. 318). “In adolescence, unusually early or aggressive sexual behavior, excessive drinking, and use of illicit drugs are frequent.” In adulthood, these types of maladaptive behaviors continue, “with the addition of inability to sustain consistent work performance or to function as a responsible parent and failure to accept social norms with respect to lawful behavior” (p. 318).
The World Health Organization (1977, p. 1108) developed a similar general definition for ICD-9:
[D]eeply ingrained maladaptive patterns of behavior generally recognisable by the time of adolescence or earlier and continuing throughout most of adult life, although often becoming less obvious in middle or old age. The personality is abnormal either in the balance of its components, their quality and expression or in its total aspect. Because of this deviation or psychopathy the patient suffers or others have to suffer and there is an adverse effect upon the individual or on society.
DSM-III-R, DSM-IV, and ICD-10
ASPD criteria were simplified for DSM-III-R (American Psychiatric Association 1987) and DSM-IV (American Psychiatric Association 1994), based in part on results of data reanalyses and field trials, but the fundamental concept of the disorder did not change. In response to criticism, the authors of DSM-III-R added the symptom “lacks remorse” to acknowledge one of the most striking aspects of ASPD, a trait identified by Cleckley. Changes were made to the text but not to the ASPD criteria from DSM-IV to DSM-5.
DSM-5 criteria specify that the person be at least age 18 years and have three or more of seven maladaptive traits (e.g., deceitfulness, impulsivity, irritability and aggressiveness, recklessness, irresponsibility; Box 1–1). As specified since DSM-III-R, the individual must have met the criteria for conduct disorder before age 15 years. Schizophrenia and mania must be ruled out as a cause of the disturbance.
Box 1–1. DSM-5 Criteria for Antisocial Personality Disorder
A.
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.
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 bipolar disorder.
Source. Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA, American Psychiatric Association, 2013. Copyright © 2013 American Psychiatric Association. Used with permission.
Dimensional Approaches
Concern was expressed after the introduction of DSM-III that the separation of those with and without personality disorder of all types was blurred (Widiger et al. 1984; Zimmerman and Coryell 1990). This led some experts to consider a dimensional approach in which personality traits are described along a continuum from no dysfunction to severe dysfunction. There has been growing consensus that a major share of differences among individuals can be described by four or five major traits. In the best known (“five-factor”) model (Costa and McCrae 1992), the traits are extraversion, agreeableness, conscientiousness, neuroticism, and openness to experience. The antisocial element of this model is the negative pole of agreeableness. The advantage of a trait model was that it allowed persistent traits such as antagonism to be linked to the category of antisocial personality, giving it greater weight as a concept while retaining the category.
Arguments supporting a dimensional definition have taken root, and one approach has been the development of a broad-ranging model that includes clinical syndromes such as personality disorders (Hierarchical Taxonomy of Psychopathology [HiTOP]; Krueger et al. 2018). HiTOP is a new initiative in diagnosis organized by a multidisciplinary group (mainly psychologists) to improve both the terminology and the measurement of psychopathology driven by empirical data. Its aim is to improve the classification of psychopathology beyond traditional diagnostic systems.
Both major classifications in psychiatry, DSM and ICD, have attempted to apply a dimensional system. The DSM-5 Personality and Personality Disorders Work Group developed a hybrid model for the revision of DSM-IV’s personality disorders (Box 1–2). The model includes assessment of impairments in personality functioning, a reduction from 10 to 6 categories, and an assessment of 5 broad areas of pathological personality trait domains. The model was at variance with DSM-IV’s categorical system and previous ICD classifications. The American Psychiatric Association Board of Trustees rejected the model, which was thought to be unwieldy and premature (Black and Grant 2014).
Box 1–2. DSM-5 Section III Alternative Model for Antisocial Personality Disorder
A.
Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:
1.
Identity: Egocentrism; self-esteem derived from personal gain, power, or pleasure.
2.
Self-direction: Goal setting based on personal gratification; absence of prosocial internal standards, associated with failure to conform to lawful or culturally normative ethical behavior.
3.
Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another.
4.
Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary means of relating to others, including by deceit and coercion; use of dominance or intimidation to control others.
B.
Six or more of the following seven pathological personality traits:
1.
Manipulativeness (an aspect of Antagonism): Frequent use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to achieve one’s ends.
2.
Callousness (an aspect of Antagonism): Lack of concern for feelings or problems of others; lack of guilt or remorse about the negative or harmful effects of one’s actions on others; aggression; sadism.
3.
Deceitfulness (an aspect of Antagonism): Dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events.
4.
Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior.
5.
Risk taking (an aspect of Disinhibition): Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard for consequences; boredom proneness and thoughtless initiation of activities to counter boredom; lack of concern for one’s limitations and denial of the reality of personal danger.
6.
Impulsivity (an aspect of Disinhibition): Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing and following plans.
7.
Irresponsibility (an aspect of Disinhibition): Disregard for—and failure to honor—financial and other obligations or commitments; lack of respect for—and lack of follow-through on—agreements and promises.
Note. The individual is at least 18 years of age.
Specify if:
With psychopathic features.
Source. Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA, American Psychiatric Association, 2013. Copyright © 2013 American Psychiatric Association. Used with permission.
What is now referred to as the “alternative model” appears in Section III, “Emerging Measures and Models” (American Psychiatric Association 2013). With the alternative model, all personality disorders—including ASPD—are defined in terms of typical impairments in self (identity and self-direction) and interpersonal (empathy and intimacy) functioning, as well as pathological personality traits shown to be empirically related to the disorder. Regarding ASPD, the first criterion (A) is concerned with an egotistical identity; self-direction concentrating on personal gratification and failure to conform to normal ethical behavior; lack of empathy; lack of remorse; and incapacity for mutual intimate relationships, leading to a tendency to exploitation and control of others. This criterion could equally apply fully to psychopathy. Added to this are pathological personality traits (the dimensional aspect of the classification) separated into antagonism, including manipulative behavior, deceitfulness, callousness, and hostility toward others, and disinhibition, characterized by irresponsibility, impulsivity, and excessive risk taking.
An important qualifying characteristic is that the person concerned is at least age 18 years. Also, with the alternative model definition, a specifier is available for those “with psychopathic features.” These individuals have a lack of anxiety or fear and a “bold interpersonal style that may mask maladaptive behaviors” (American Psychiatric Association 2013, p. 765). This definition corresponds to psychopathy, a related construct discussed elsewhere (Chapter 16).
ICD-10 and ICD-11
ICD-10 (World Health Organization 1992) categories are similar to those in DSM-IV, and its equivalent to ASPD is “dissocial personality disorder” (dissocial covering more disturbance than just antisocial characteristics), diagnosed by the presence of at least three of six characteristics (Table 1–2). Furthermore, persistent irritability and the presence of conduct disorder during childhood and adolescence are not required for the diagnosis.
≥ 3 of the following required for the diagnosis |
1. Callous unconcern for the feelings of others |
2. Gross disparity between behavior and expected social norms, with irresponsibility and disregard for rules and obligations |
3. Incapacity in maintaining enduring relationships, though having no difficulty in establishing them |
4. Having a very low tolerance to frustration and a low threshold for aggressive behavior, including violence |
5. Incapacity to experience guilt or to profit from experience, particularly punishment |
6. Marked readiness to blame others or to offer plausible rationalizations for the behavior that has brought the person into conflict with society |
Source. World Health Organization 1992. |
The ICD-11 (World Health Organization 2018) working group expressed concern with two major deficiencies in the current classifications of personality disorder, and this affected all its discussions and influenced the description of antisocial personality characteristics (Tyrer et al. 2011). The first was the almost total absence of the recording of any personality disorders in official statistics, with the exception of emotionally unstable and dissocial personality disorders (and then only rarely), and the frequent use of “mixed personality disorder” when clinicians could not decide on any specific label. The same problem had been noted by those involved in using the DSM-IV category “personality disorder not otherwise specified” (Verheul et al. 2007).
Another concern was the high level of comorbidity among personality disorder diagnoses (Tyrer et al. 2011), likely a result of the overlap between the criteria for individual personality categories. It is more accurate to describe these features as co-occurrence than as comorbidity. It is not surprising that those with ASPD who have strong attention-seeking attributes could easily be described as narcissistic and that those who could easily make relationships but not maintain them could be described as borderline. Another interesting aspect of comorbidity is that individuals with many different categories of personality disorder were generally considered more disturbed than were those with only one or two. This was encapsulated in the assessment criteria for an unusual category called “dangerous and severe personality disorder,” identified in England as requiring special attention with regard to treatment and public protection (Maden and Tyrer 2003). Strict conditions were agreed in advance for such offenders:
A.
Psychopathy Checklist—Revised (PCL-R; Hare and Neumann 2006) score of 30 or more
B.
PCL-R score of between 25 and 29 (or Short-Version equivalent) and at least one personality disorder diagnosis using the International Personality Disorder Examination (IPDE; Loranger et al. 1994) other than antisocial personality disorder
OR
C.
Two personality disorder diagnoses, one of which is antisocial personality disorder (or equivalent on the IPDE).
In actual practice, many of those so diagnosed did not fully share these requirements (Tyrer et al. 2007).
In determining the requirements for severe personality disorder, the ICD-11 working group considered that risk of harm was the most prominent element of severity, and in the case of antisocial personality features, it was mainly the risk of harm to others rather than harm to self. So, this element is the most prominent component (Tyrer et al. 2015, 2019):
Severe personality disorder meets all diagnostic requirements for personality disorder. There are severe problems in interpersonal functioning affecting all areas of life. The individual’s general social dysfunction is profound and the ability and/or willingness to perform expected occupational and social roles is absent or severely compromised. Severe personality disorder usually is associated with severe harm to self or others that has caused long-term damage or has endangered life. (Tyrer et al. 2015, p. 722)
ICD-11 adopts a dimensional approach to the classification of personality disorders that focuses on impairments in self and personal functioning classified as mild, moderate, or severe. Personality disorders are then further described by specifying the presence of characteristic maladaptive personality traits. One or more of five trait domains can be specified: negative affectivity, detachment, dissociality, disinhibition, and anankastia. The five trait domains are like those included in DSM-5’s alternative model. Antisocial features are subsumed to the status of the trait domain dissociality:
The core of the dissocial trait domain is disregard for social obligations and conventions and the rights and feelings of others. The traits of callousness, lack of empathy, hostility and aggression, ruthlessness, and inability or unwillingness to maintain prosocial behavior are characteristically present but not always displayed at all times. (Tyrer et al. 2015, p. 723)
A proposed crosswalk from ICD-10 dissocial personality disorder to its ICD-11 personality disorder counterpart can be described by a combination of the trait domains dissociality, disinhibition, and low negative affectivity. Disinhibition involves impulsive, reckless, and irresponsible behavior, whereas low negative affectivity involves absence of vulnerability, shame, and anxiety (Bach and First 2018). Over time, the classifications for the alternative DSM-5 model for personality disorder and ICD-11 have converged.
Psychopathy does not appear in ICD-11, and it is difficult to predict how the separate notions of antisociality and psychopathy can be reconciled or whether they might be merged. The differences between them are relatively small, and they can certainly be placed on the same spectrum. The presence of insensitivity, one of the three I’s mentioned at the beginning of this chapter, is perhaps the strongest component of psychopathy. It links to callousness, indifference, and absence of remorse, enabling people with these characteristics to carry out particularly brutal and violent acts. One factor that is seldom discussed in this context is intelligence. The typical person described as psychopathic, as Cleckley had observed, is a persuasive, glib individual who cleverly plays on other people’s vulnerabilities and exploits them. People who are intelligent can do this effectively. Others who are conventionally described as antisocial do not have these intellectual skills and therefore behave in a much more crude and primitive manner (Yu et al. 2012).
Conclusion
Formal efforts to define and classify antisocial behavior took root with DSM-I in 1952 and have continued to the present. Simple prose descriptions gave way to operational diagnostic criteria in DSM-III influenced mainly by the work of sociologist Lee Robins, who emphasized the continuity between childhood and adult behavior problems. The criteria were simplified for later DSM editions, and “lack of remorse” was added to the list of possible symptoms to acknowledge perhaps the most disturbing aspect of the syndrome. More recently, dimensional models have been developed for DSM-5 and ICD-11 to describe and define personality disorders. The model developed for DSM-5 was not accepted by the American Psychiatric Association’s Board of Trustees, but the model is included in DSM-5 Section III (“Alternative DSM-5 Model for Personality Disorders”). The model introduced in ICD-11 involves describing the severity of an individual’s personality disorder and specifying the presence of one (or more) of five characteristic maladaptive personality traits. The trait domain dissociality includes antisocial behaviors; disinhibition involves impulsive, reckless, and irresponsible behavior; and low negative affectivity involves absence of vulnerability, shame, and anxiety. Research continues as experts study the dimensional models, assess their reliability and validity, and investigate their clinical utility.
Key Points
•
Insensitivity, infringement, and injury (the three I’s) are core components of antisocial behavior.
•
Formal classification of antisocial behavior began in 1952 with DSM-I and has continued to the present in DSM-5.
•
DSM-I and DSM-II included brief prose descriptions, replaced by diagnostic criteria in DSM-III that were later simplified for DSM-III-R and DSM-IV. The criteria did not change in DSM-5.
•
DSM-5 Section III includes a hybrid model (“Alternative DSM-5 Model for Personality Disorders”) that combines a categorical approach with dimensionality.
•
ICD-9 and ICD-10 included categorical definitions for antisocial behavior, replaced in ICD-11 by a dimensional model of personality disorders based on disorder severity and five trait domains; antisociality can be described by a combination of dissociality, disinhibition, and low negative affectivity.
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