Motivation and emotion/Book/2015/Antisocial Personality Disorder and emotion

Overview
Antisocial personality disorder (APD) is identified by severe antisocial behaviour emerging in early childhood and displayed consistently across the lifespan, recognisable by severe emotional deficits including impaired empathic experience, difficulty with emotion recognition, and remorselessness (De Brito & Hodgins, 2009). The personality characteristics associated with APD are marked by anti-sociality and being closely related to psychopathy, provokes fear in the general public. However, how much is really known about this socially debilitating condition? Providing theoretical and clinical definitions, uncovering the childhood determinants, identifying the emotional implications and shedding light on preventions and treatments are essential in educating people about antisocial personality disorder.

Antisocial Personality Disorder Explained


Antisocial behaviour is clinically differentiated by an array of characteristics, including a failure to conform to social norms, such as conflict with law enforcement, repeated and compulsive lying and deceitfulness, like using aliases to con other people, impulsivity, severe recklessness and a disregard for the safety of oneself and others (American Psychiatric Association, 2013). Aggression and irritability are also highly prevalent, with reports of frequent physical conflicts and even assault being common in APD (Paris, Chenard-Poirier, & Biskin, 2013). Similarly, high irresponsibility, such as neglecting a child’s needs, and a failure to meet obligations and financial agreements are also seen regularly in people diagnosed with APD (see Figure 1). Engagements in risky sexual promiscuity and dangerous substance use, such as sharing intravenous needles, are also common occurrences. With this in mind, the most common characteristic and most frequently mentioned in literature is the severe emotional deficit that seems to significantly impair the emotion recognition in people suffering from APD (American Psychiatric Association, 2013). With little to no evidence of remorse for inflicting mistreatment on others, antisocial behaviour involves rationalising any form of exploitation of, or harm to, another person by believing that they were deserving of such treatment (Goldstein, et al., 2006). Antisocial personality disorder (APD) is a severe psychological disorder that is debilitating for not only those suffering with the disorder but also for the people close to them.

Antisocial Personality Disorder and Psychopathy - What's the Difference?
Antisocial personality disorder (APD) is a profoundly debilitating mental disability characterised by an enduring pattern of antisocial, irresponsible and high-risk behaviours. APD is characterised by a severe lack of remorse and empathy, significant interpersonal and behavioural impairments and a pervasive pattern of disregard for, and violation of, the rights of others (American Psychiatric Association, 2013; Lahey, Loeber, & Burke, 2005). This pervasive pattern has also been referred to as psychopathy, however some research argues that these two conditions are markedly different. APD and psychopathy are identified by remorselessness and severe deficits in affective experience, however individuals with APD are described in terms of criminal and socially deviant behaviour, whereas psychopathy can be found in socially-well adjusted and successful people (American Psychiatric Association, 2013; Rogstad & Rogers, 2008). The Psychopathy Checklist-Revised (Hare, 1999) is a widely accepted instrument for diagnosing psychopathy, and has identified that psychopathic individuals tend to score highly on the two facets of 'antisocial behaviour' and in particular, 'emotional detachment', whereas an individual with APD would score highly no 'antisocial behaviour' alone (Rogstad & Rogers, 2008). Since the concept of psychopathy does not necessarily require a history of criminal behaviour, and many psychopathic individuals are endowed with high socioeconomic status and intelligence, they may never be identified as psychopathic and included in prevalence research. Individuals with APD on the other hand are much more likely to have a long history of violence, criminality and drug and alcohol abuse, and be identifiable by a criminal record (Lahey, Loeber, & Burke, 2005).

Personality Characteristics
Specific pathological personality traits that are dominant in APD usually become identifiable in the early developmental stages of childhood (Paris, Chenard-Poirier, & Biskin, 2013). The personality trait profile that differentiates APD is marked by two central characteristics, antagonism and disinhibition. Antagonism is defined as active hostility and encompasses traits such as callousness, deceitfulness, manipulation and antipathy (see Figure 2; Paris, Chenard-Poirier, & Biskin, 2013).

Callousness has been further identified as the hallmark of psychopathology and is prevalent throughout the entirety of a person’s life with APD (Paris, Chenard-Poirier, & Biskin, 2013). Disinhibition has been described as a lack of self-control that manifests in conflict with social norms, and includes traits such as impulsivity, risk-taking and irresponsibility, impacting cognitive, instinctual and emotional responses (American Psychiatric Association, 2013). Individuals with marked antisocial tendencies have been described to be interpersonally charismatic, but emotionally shallow, with a parasitic and impulsive lifestyle categorised by a long strong of antisocial and potentially vicious acts (Rogstad & Rogers, 2008). These individuals tend to be opinionated, overconfident and have an inflated sense of self, expressing superficial charm by verbalising technical terms or jargon to impress others (American Psychiatric Association, 2013). Highly exploitative in sexual relationships, an individual with APD may also engage with multiple sexual partners and struggle with monogamy (Paris, Chenard-Poirier, & Biskin, 2013). These distinctive personality traits violate most social norms, and greatly impair individuals with APD interacting and integrating normally within the community.

Hare Psychopath Checklist-Revised (PCL-R)
Some models that are used to conceptualise and measure psychopathic tendencies emphasise the importance of personality features, more so than behavioural patterns of anti-sociality (Rogstad & Rogers, 2008). One diagnostic tool modelled by Canadian psychologist Robert D. Hare in 1991, known as the Psychopathy Checklist-Revised, identifies two underlying dimensions as the key significant features of psychopathy. This diagnostic model widely utilised by clinicians assesses the interpersonal and affective features (dimension 1) and the antisocial behaviours/social deviance of an individual by factor analysis (Dimension 2; Hare, 1999). This measurement tool is comprised of an analytic interview and a historical assessment of an individual thought to display psychopathic tendencies. The PCL-R is a valid and predictive measure of psychopathic tendencies and has received much support in literature and in practice.

Other Scales of Measurement
Other effective scales of measurement of psychopathic characteristics include self-report inventories:
 * Levenson Self-Report Psychopathy Scale (LSRP; Levenson, Kiehl, & Fitzpatrick, 1995)
 * Psychopathic Personality Inventory (PPI; Lilienfeld & Andrews, 1996)

Both the Levenson Self-Report Psychopathy Scale (LSRP) and the Psychopathy Personality Inventory (PPI) measure interpersonal manipulation, callous affect, erratic lifestyle and antisocial behaviour, and demonstrate good internal consistency being well supported in literature (Falkenbach, Poythress, Falki, & Manchak, 2007). Additionally, the PPI demonstrates substantial convergent and discriminant validity, although it must be recognised that by being self-report inventories these two scales of psychopathy may not be entirely reliable across different samples.

Prevalence


Twelve-month prevalence rates drawn from the DSM-5 reveal that 0.2-3.3% of the population are reported to suffer from APD (American Psychiatric Association, 2013). Antisocial personality disorder is also suggested to be five times more common in males than in females, and the highest prevalence rates are reported to be greater than 70% and are evident among severe samples of males with alcohol use disorder (American Psychiatric Association, 2013; Paris, Chenard-Poirier, & Biskin, 2013). Little epidemiological research has provided quantifiable prevalence rates of APD across the general population, however it is suggested that 75% of incarcerated individuals meet the diagnostic criteria for antisocial personality disorder (Paris, Chenard-Poirier, & Biskin, 2013; Rogstad & Rogers, 2008). Research investigating personality pathology also reveals a clear and evident gender difference (Cale & Lilienfeld, 2002). A plausible theory explaining this evident gender difference is centered on aggressiveness, such that the most pervasive and consistent difference impacting interpersonal behaviour is the extent to which aggression is displayed (Paris, Chenard-Poirier, & Biskin, 2013). It is known that men naturally exert more dominance and aggression than women, and the evident link between testosterone and aggression could partially explain the gender difference in APD (Paris, Chenard-Poirier, & Biskin, 2013).

Childhood Experiences


Experiences in childhood are believed to influence people throughout the course of their life, some experiences leaving more severe impressions than others. Negative childhood experiences can therefore be incredibly damaging on a developing mind, particularly traumatic events such as emotional, psychological or physical abuse (See Figure 4; Rubio, Krieger, Finney, & Coker, 2014). This type of complex trauma can cause a range of damaging problems for children that may continue into adulthood and manifest as conditions such as APD (Paris, Chenard-Poirier, & Biskin, 2013). Complex trauma evolves from early exposure to harmful violence, including all forms of abuse (emotional, physical and psychological), emotional neglect, domestic violence, parental detachment and poor family support (Rubio, Krieger, Finney, & Coker, 2014). Adolescents that are exposed to harmful violence may internalise such traumatic experiences and become withdrawn and depressed, however it is also common for traumatised adolescents to externalise such experiences and exert aggression and violence (American Psychiatric Association, 2013). Common diagnoses for adolescents who tend to externalise complex trauma include attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and conduct disorder (CD; American Psychiatric Association, 2013).

Conduct disorder is a particularly concerning diagnosis for an adolescent and is closely related to the development of APD later in life, although, with effective treatment, not all children go on to develop APD.The dominant traits prevalent in APD are known as callous unemotional (CU) traits, and these traits can emerge in conduct disorder, particularly if the child has poor parental attachment (Lennox & Dolan, 2014; Rubio, Krieger, Finney, & Coker, 2014). The DSM-5 outlines that the risk of developing APD in adulthood is increased if the individual experienced an onset of conduct disorder before the age of 10 years, in addition to symptoms of ADHD. This risk factor is further increased with the presence of child abuse, erratic and inconsistent parenting and emotional neglect (American Psychiatric Association, 2013).

Human Emotion Recognition
Emotional communication can be displayed through body and facial expressions, and most people readily understand this form of communication and respond according to social norms and expectations (see Figure 5). Emotion recognition comes quite naturally to most people, and processing the emotions displayed on another person’s face facilitates emotional bonding. Emotions are deeply integrated with facial expressions, and children are quickly taught to recognise a smiling face to mean joy, a scowl to mean anger and a frown or tears to mean sadness. One emotion that is crucial to the development of emotional intelligence is empathy. Empathy is triggered by another person’s emotional state, and it involves mimicking the emotions of another to feel what they are feeling (Gabbard, 2005). For most people, perceiving another person’s pain or suffering activates empathy and increases helping behaviour (Reeve, 2015). However, in APD this social empathic reaction is impaired, raising serious concern within a social context. With emotion recognition being so crucial in the social connection between people, an affective deficit, such that is evident in APD, could be incredibly problematic for social interaction and acceptance (Hastings, Tangney, & Stuewig, 2008). Further, displaying aggression and maladaptive antisocial tendencies may inhibit an individual from understanding social cues about what is and is not acceptable behaviour (Marsh & Blair, 2008).

Theory of Mind and Emotion Recognition
Literature exploring theory of mind indicates that the capacity to mentalise is what allows people to recognise that another person has a mind of their own, one with different thoughts, beliefs, motivations and emotions (Gabbard, 2005). Theory of mind has also been described as the ability to infer what another person believes, thinks and feels from their non-verbal communication, such as facial emotionality (Gabbard, 2005). Emotion recognition is essential in this process and any deficits interfering with an individual’s ability to recognise facial emotionality could significantly impair their capacity to mentalise (see Figure 6). A significant impairment in APD is the inability to recognise the emotions of others, and previous research has identified a strong association between antisocial behaviour and impaired recognition of fearful facial affect (Bagcioglu, et al., 2014; Blair, et al., 2004; Hastings, Tangney, & Stuewig, 2008; Marsh & Blair, 2008; Rogstad & Rogers, 2008). Research suggests that the primary impairment of APD impacts the affective mentalisation aspect of theory of mind, with little known effect on the cognitive functions (Shamay-Tsoory, Harari, Aharon-Peretz, & Levkovitz, 2010). Other research indicates that it is the severe lack of remorse in individuals with APD that inhibits their ability to mentally understand another person’s perspective (Dolan & Völlm, 2009). Taken together, these findings add another piece to the puzzle that potentially further explains the emotional deficits in individuals with APD.

APD and Emotion


The severe affective deficits displayed in APD include a lack of empathy and remorse for the mistreatment of others (Brook, Brieman, & Kosson, 2013). Empathy is a cognitive and emotional construct, and is regarded as essential to the moral development of prosocial behaviour and healthy interpersonal functioning (Rogstad & Rogers, 2008). Research suggests that deficiencies in the ability to empathise prevents the development of the conscience and the ability to feel remorse for one's actions (Keysers & Gazzola, 2014; Rogstad & Rogers, 2008). Literature exploring remorse deficits in individuals with APD found that 51% of 1,422 respondents severely lacked remorse and had an elevated rate of aggressive and vicious criminality (Goldstein, et al., 2006). This dysfunction in the experience of remorse is therefore closely linked with increased aggressive criminal behaviour, highlighting the integral role empathy and remorse play in human emotion recognition (Rogstad & Rogers, 2008).

Neurobiological Explanations


Literature provides increasing evidence that genetic factors play a significant role in the emotional deficits and antisocial personality dimensions of APD (Paris, Chenard-Poirier, & Biskin, 2013). It has been suggested that individuals with APD have impaired neural functioning in the amygdala, and being responsible for many behavioural and emotional functions, could partially explain the deficits in emotion recognition (see Figure 7; Bagcioglu, et al., 2014; Kolla, Gregory, Attard, Blackwood, & Hodgins, 2014; Marsh & Blair, 2008). Other research investigating physiological changes in APD have identified that subjects with antisocial tendencies displayed a reduction in grey matter around the prefrontal cortex, the paralimbic and limbic brain structures, in addition to reduced functional connectivity between the prefrontal structures and the limbic-paralimbic structures (Contreras-Rodríguez, et al., 2015). These findings suggest that the emotional deficits and antisocial behaviour displayed by individuals with APD may be partially influenced by a weakened connection between the emotional and cognitive structures within the brain (Contreras-Rodríguez, et al., 2015). One last potential biological influence in the development of antisocial behaviour has been seen in children with low activity of the monoamine A gene (MAOA). The MAOA gene metabolises noradrenaline, serotonin and dopamine neurotransmitters, all of which are incredibly influential on emotion and behaviour (Caspi, et al., 2002).

Theoretical Explanations
Social learning theory suggests that the development of APD is influenced by the maladaptive interaction between cognitive, environmental and behavioural factors, a concept known as reciprocal determinism. This theoretical construct depicts that APD is caused by a negative family environments, an inability to self-regulate emotions, inappropriate behavioural modelling and an dysfunctional learning process in childhood (Moffitt, 1993). It is suggested that effective treatment for APD includes facilitating personal regulation in all aspects of life (cognitive, environmental and behavioural; Moffitt, 1993).

In line with social learning theory, behavioural theorists suggest that antisocial behaviour is learned through operant modelling, reinforcing inappropriate behaviour as being appropriate and providing a child with a warped sense of socially acceptable behaviour. Learning theory indicates that a child conditioned with the behaviour of an antisocial and irresponsible parent, may grow up with a dysfunctional sense of reality exhibiting similar behaviour, and thus a cycle of dysfunctional and destructive behaviour continues (Reiger, 2014).

Comparatively, the key component in Beck's cognitive model of psychopathology is the presentation of dysfunctional core beliefs about the oneself, other people and the world (Rieger, 2014). This model theorises that maladaptive core beliefs influence the processing of social information so that only information that reinforces the maladaptive beliefs is received (Reiger, 2014). Methods such as cognitive restructuring and supportive behavioural change are believed to be effective treatments to reduce the antisocial tendencies (Reiger, 2014).

Lastly, low arousal theory suggests that individual's with APD seek excessive self-stimulation to satisfy their abnormally low level of arousal (Mawson & Mawson, 1977). This theory can also provide an explanation in terms of the marked levels of impulsivity and recklessness of individuals with APD, such that a constant search for stimulation to satisfy this under arousal (Hare, 1999).

Early Interventions
The development of APD comes from a long history of violence, abuse and instability, so treatment to reverse such emotional and behavioural patterns can be particularly difficult. Early interventions are suggested to be effective in reducing the symptoms of conduct disorder and potentially preventing the development of APD (Moeller & Dougherty, 2001). For this to be successful, the maladaptive behaviours must be targeted in early childhood before the behavioural patterns become too stable and pervasive (Moeller & Dougherty, 2001). Child and family focused interventions with a base in cognitive therapy can be incredibly successful in providing anger control techniques and stimulating healthy interpersonal interactions and prosocial thoughts and emotions (Moeller & Dougherty, 2001). However, many children in low socioeconomic areas experiencing trauma, such as emotional neglect and abuse, may not ever get the chance to seek therapy, and the development of a serious mental disorder such as APD may be a likely reality. With this in mind, if awareness of such adolescent traumas becomes known, providing help and support to remove a child from this kind of trauma may potentially change the life of a young person forever.

Treatment
Cognitive behavioural therapy (CBT) is highly successful in reducing maladaptive thoughts and feelings about oneself and the world, and could be applied to APD. The collaborative style of CBT could facilitate healthy interpersonal interaction, and assist in the cognitive restructure of the antisocial tendencies. Although CBT is a well-supported method of treatment, it is not designed specifically for personality disorders and may requirement alternation in order for it to be effective (Rieger, 2014).

Schema therapy has indicated relevance in the treatment of personality disorders by further extending cognitive therapy with the addition of the schema construct (Rieger, 2014). The development of early maladaptive schemas are influenced by interpersonal stress and biological dispositions, and once developed, only process self-relevant and reinforcing information (Rieger, 2014). Schema therapy involves closely identifying the maladaptive schemas that reinforce the antisocial behaviour and attempt to change them using behavioural, cognitive and experiential techniques (Rieger, 2014). Schema therapy has growing support in literature and is believed to be quite effective in the management and reduction of antisocial tendencies, emotional irregularities and interpersonal difficulties in an individual with APD.

Conclusion


In summary, the vast array of theoretical, cognitive and biological theories assessed all provide accurate and plausible explanations as to how and why APD is developed and maintained. These findings can be drawn together as a cohesive and holistic perspective highlighting that many factors including neurobiological, psychosocial and behavioural aspects, all significantly influence the development of the antisocial and emotional deficits evident in APD. Emotion recognition is an integral part of the formation of social relationships and connections, and without this the clear interpersonal difficulties of APD seem obvious. Beginning in childhood with conduct disorder, environmental influences such as abuse and neglect can have adverse consequences on a developing mind and result in marked impulsivity and recklessness. APD has a detrimental effect on the mind, and the impaired ability of emotional interpretation makes for major set backs. However, with this in mind, active and early interventions can assist children and adolescents in the recovery of such traumas, and work towards a healthier and happier life, potentially never developing a severe mental disability like APD (see Figure 8).