Antisocial Personality Disorder and Addiction

According to the book Essentials of Personality Disorders, a personality disorder represents a type of psychological disorder where the person has repeatedly displayed a very rigid and mostly dysfunctional manner of behaving, functioning, and thinking about others and themselves. Someone who is diagnosed with a personality disorder will typically experience significant difficulties in their personal relations and overall functioning at work, school, and in other social situations.

Interestingly, most of the people who get diagnosed with a personality disorder do not refer themselves to a mental health clinician because they believe that they have a personality disorder. Many times, they are referred for assessment at the bequest of other people, such as family or contacts at work, or they refer themselves for other associated problems, such as feeling depressed or anxious, or having a substance use disorder. Most sources acknowledge that individuals who are diagnosed with personality disorders will typically view others as having problems that exacerbate their own issues as opposed to thinking that their behavior is problematic.

Personality disorders are considered to be dispositional, meaning that there is no actual identified specific onset to a personality disorder, but the individual displayed the symptoms of the personality disorder since an early age, and the symptoms were relatively fixed in adolescence or early adulthood. By definition, personality refers to a longstanding pattern of acting, thinking, and behaving that is relatively stable and offers a measure of predictability to an individual’s actions.

Personality disorders are relatively stable, and enduring tendencies are dysfunctional and result in distress or specific impairments with the person’s functioning. Of course, the designation of an individual’s functioning as being “dysfunctional” is based on cultural and societal definitions of what is functional and what is not.

In addition, the entire diagnostic category of personality disorders has been subject to some criticism from its inception, and even the current conceptualization of personality disorders has some issues, as do many of the diagnostic categories for psychological disorders currently used by the American Psychiatric Association. No classification system of behavior will be perfect or satisfy every critique; however, the valid criticisms of the diagnostic issues with the personality disorder categories are outlined below.

• The current diagnostic scheme for diagnosing personality disorders and other forms of mental illness is termed the categorical approach, which means that these disorders are conceptualized as discrete and mutually exclusive categories of psychological or psychiatric disorders. Unfortunately, in practice, this never seems to hold true. There is quite a bit of overlap in the diagnostic criteria for these disorders. It is clear that they are not mutually exclusive categories.
• The current diagnostic classification system used in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition) does not assign a relative weight or relative importance to specific symptoms. This results in several issues, such as the diagnosis is based on the number of symptoms an individual displays as opposed to their severity; people diagnosed with the same mental health disorder may have totally different presentations; and the measure of the relative dysfunction or impairment is made by a subjective determination performed by the mental health clinician.
• There is a high degree of overlap in the diagnostic system that results in individuals being diagnosed with two or more personality disorders and one or more co-occurring psychiatric or psychological disorders that are not personality disorders (e.g., major depressive disorder, anxiety disorders, etc.). This can often result in extremely difficult conceptualizations of the person’s problem and complicated treatment protocols.
• The diagnostic criteria used to identify the disorders in the DSM-5 are subjective interpretations of behavior. There are no medical tests that can diagnose a psychological disorder. This is resulted in quite a bit of criticism in the American Psychiatric Association’s diagnostic scheme.

The American Psychiatric Association promised to alter the diagnostic scheme of the personality disorders from the DSM-IV to the DSM-5; however, this never happened in that personality disorders have remained relatively unchanged regarding their diagnostic criteria for over 20 years, despite a number of solid research studies that have suggested a change in this diagnosis should be made. For these reasons, it is important that only individuals with specific and targeted training in the assessment and diagnosis of these disorders should be allowed to make these diagnoses. The following information regarding antisocial personality disorder is designed to be used for educational purposes only.

What Is the Cause of APS?

As with the vast majority of psychiatric or psychological disorders, there is no identifiable cause associated with antisocial personality disorder. Research attempting to ascertain the causes of APS has indicated that the disorder is more common among the first-degree relatives of individuals who are diagnosed with this disorder (suggesting a genetic component as well as an environmental or learning component), more common in identical twins if one twin has been diagnosed with the disorder (even if the twins are raised separately, again suggesting a genetic component), more common individuals who come from lower social economic backgrounds (indicating an environmental component), and far more common in males than females (however, this may simply reflect issues with the diagnosis such that males are more likely to display aggressiveness, impulsivity, and even violations of rules than females due to their upbringing and encouragement from parents and peers).

Thus, it appears that antisocial personality disorder results from a combination of as yet fully unidentified genetic influences (accept for certain weak genetic associations) that interact with specific environmental factors. Because the majority of genetic influences that drive complex behaviors are triggered or affected by environmental situations, it appears that this explanation is the most valid explanation.

Antisocial Personality Disorder and Substance Abuse

There is a rich body of research that indicates that individuals diagnosed with antisocial personality disorder are at greater risk to develop substance use disorders than individuals without a mental health disorder diagnosis. People diagnosed with APS are particularly prone to alcohol use disorders, although having other substance use disorders also puts a person at an increased risk.

Early research attempted to investigate the neurobiological correlatives of this relationship and indicated that a number of neurotransmitters, such as serotonin, might be involved as well as a number of other neurobiological factors that result in increased vulnerability to substance abuse. However, research has also indicated that a number of environmental factors serve as risk factors and protective factors even for individuals with APS symptoms. Again, it appears that the relationship between APS and substance abuse is very complicated. Nonetheless, it is clear that individuals with APS are at a higher risk of developing substance use disorders.

Individuals diagnosed with APS are often diagnosed with another comorbid (co-occurring) psychiatric or psychological disorder. A number of research studies have suggested that the lifetime diagnosis of APS and any type of substance use disorder is extremely high. Some studies report co-occurring rates of APS and another type of substance use disorder as upwards of 80-90 percent.

The substances most commonly abused by individuals with APS appear to be alcohol and tobacco, but all different types of substances can be abused by an individual with APS, including illicit drugs like heroin and cocaine, cannabis products, and prescription medications. Because individuals diagnosed with APS also have high rates of other mental health disorders, such as major depressive disorder, anxiety disorders, other personality disorders, etc., they appear to be at risk for substance abuse due to a number of factors, including the need to self-medicate, having shared neurobiological risk factors for the development of these disorders, and coming from environmental backgrounds where different types of substance use is common.

Treatment

Like with other personality disorders, few people actually seek treatment for antisocial personality disorder. Most people who have ASP seek treatment for other problems, such as issues with their relationships or drug abuse, or they are referred to treatment for other issues by the legal system or their families.

Psychotherapy for APS typically involves the use of a number of principles from Cognitive Behavioral Therapy (CBT) that address the individual’s belief system and patterns of thinking and how these relate to their behavior. The techniques assist the individual in changing both their thinking and actions. Because many individuals diagnosed with APS are manipulative and secretive, the therapist must induce a very objective means of determining if the individual in treatment is actually applying these principles. This means that the therapist needs to direct the mechanism of change in such a manner that the person experiences very concrete and definable benefits that they find self-fulfilling. Thus, while therapy for antisocial personality disorder can be successful, it is often very complicated, and the individual often needs to be in therapy for quite some time. Individuals with APS are known to somewhat soften in their presentation as they age, and it may be that many individuals with APS never fully develop self-control or issues with remorse.

There are no medications that are designed to specifically treat antisocial personality disorder. Instead, medications used in the treatment of APS are usually prescribed for symptom management. This can include medications for depression, anxiety, and even issues with mood swings. An individual who has APS and a substance use disorder should have both of these issues treated concurrently.

Substance use disorder treatment for individuals diagnosed with APS is typically delivered in the same fashion as it is for other individuals. If the person needs to be enrolled in a withdrawal management protocol for abuse of alcohol or other medications that can cause severe physical dependence, this should be the first step of treatment. Again, because of the tendency for these individuals to be even less forthcoming than individuals without APS, the consequences for not complying with the substance use disorder treatment need to be very concrete and clearly stated. Individuals with substance use disorders are typically not forthcoming initially regarding their substance use, and this is only complicated when an individual has a co-occurring disorder that by definition consists of deceitfulness. When individuals with APS have very strict consequences outlined that are inescapable, they can often comply during the treatment; however, what they do after treatment may not coincide with the goals of the treatment program. As a result, many individuals with APS may go through multiple attempts at treatment to resolve their issues with substance abuse.

Treatment for a substance use disorder in an individual who has APS may include the following:

• Initial inpatient or outpatient treatment, depending on the case
• A medically assisted withdrawal management program, preferably inpatient
• Intensive individual and group therapy for both APS and the substance use disorder
• Medication management, as applicable to the situation
• Involvement in 12-Step groups and other social support groups
• Close monitoring of the person’s response to therapy and treatment
• Long-term aftercare treatment