اختلال شخصیت ضد اجتماعی بر روی یک زنجیره با اختلالات فکری و روانی قرار دارد

Background Antisocial personality disorder (ASPD) and psychopathy are different diagnostic constructs. It is unclear whether they are separate clinical syndromes or whether psychopathy is a severe form of ASPD. Methods A representative sample of 496 prisoners in England and Wales was interviewed in the second phase of a survey carried out in 1997 using the Schedules for Clinical Assessment in Neuropsychiatry, the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis II personality disorders, and the Psychopathy Checklist–Revised. Results Among those 18 years and older (n = 470), 211 (44.9%) received a diagnosis of ASPD, of whom 67 (31.8%) were classified as psychopaths, indicated by Psychopathy Checklist–Revised scores of 25 and above. Symptoms of ASPD and psychopathy both demonstrated low diagnostic contrast when comparing subgroups of ASPD above and below the cutoff for psychopathy. There were no differences in demography, Axis I comorbidity, and treatment-seeking behavior. Psychopathic individuals with ASPD demonstrated comorbid schizoid and narcissistic personality disorder, more severe conduct disorder and adult antisocial symptoms, and more violent convictions. Conclusions Psychopathy and ASPD are not separate diagnostic entities, but psychopathic ASPD is a more severe form than ASPD alone with greater risk of violence. Dimensional scores of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition personality disorders (other than ASPD) may be helpful in identifying this specific subgroup.

Psychopathy has traditionally been considered as a disorder of personality, particularly the component of affective deficiency [1]. Contemporary conceptualizations [2] and [3] cover the interpersonal, affective, and impulsive personality domains of psychopathy, but emphasize the additional relevance of criminal behaviors. In contrast, the criteria for antisocial personality disorder (ASPD) in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and its predecessors are predominantly behaviorally based [4]. This results in overdiagnosis in forensic settings [5], [6] and [7], although it has been emphasized that less than half of persons with ASPD demonstrated a significant arrest record [8] and [9] and that diagnosis of ASPD was strongly related to violent acts [10]. However, due to the emphasis on overt behaviors rather than personality traits, consideration was given to whether psychopathy should replace ASPD in DSM-IV as a diagnostic category, but this proposal was excluded. The decision was made instead to shorten and simplify the old ASPD diagnostic criteria for use in DSM-IV and to note in the accompanying text that interpersonal and affective symptoms are associated features of ASPD that could be particularly useful in diagnosing the disorder in forensic settings [11]. Nevertheless, the question arises whether ASPD constitutes a personality disorder, distinct and separate from psychopathy, or whether psychopaths are merely demonstrating severe forms of ASPD. Recent research findings have suggested that ASPD with and without prominent psychopathic features may constitute 2 distinct syndromes [12]. However, the notion of a continuum between ASPD and psychopathy is supported by arguments regarding the underlying factor structure of psychopathy and that the construct should include overt antisocial tendencies, including criminal behaviors [13], [14], [15] and [16]. In contrast, it has been argued that antisocial tendencies, especially criminal behavior, should be excluded in the definition of psychopathy and that other behavioral traits, such as pathologic lying, conning, and irresponsibility, should be regarded as intrinsic and retained within the construct instead [17] and [18]. It has also been argued that antisocial behavior is a secondary symptom, or the consequence, of the abnormal personality components of psychopathy [18]. The aim of the current study was to examine the associations between ASPD and psychopathy in a representative survey of prisoners carried out in England and Wales in 1997. If psychopathic ASPD constitutes a discrete syndrome, separate from nonpsychopathic ASPD, there should be differences in the associations observed between psychopathic traits, specifically those measuring abnormal personality and those measuring antisocial behavior, when correlated with the diagnostic criteria for ASPD. Second, prisoners with both ASPD and psychopathy should demonstrate distinct differences in terms of their antisocial criteria from those with ASPD who are not psychopathic. Third, the 2 ASPD groups should demonstrate further differences in their comorbid psychopathology.

Our study did not confirm that psychopathy and ASPD are distinct diagnostic entities. Both constructs demonstrated considerable symptom overlap using the criteria for CD and adult antisocial behavior, with no evidence of a bimodal distribution and with low LRs. Although there is not a clear indication at which point an LR would indicate sufficient diagnostic contrast to demonstrate psychopathologic discontinuity between ASPD and psychopathy, values of 2 and below should be considered very low. If an individual with a high level of ASPD symptoms was 10 times more likely to have a diagnosis of psychopathy than an individual with a low level of these symptoms, it might be argued that the diagnostic LR is high enough to provide a reasonable diagnostic contrast [32]. The diagnostic LR is the traditional epidemiologic measure of diagnostic value [33], but we are not aware that it has previously been used in studies of personality disorder. Nevertheless, our findings did demonstrate that if either ASPD or psychopathy is measured using a continuous scale, psychopathy is at the far end of the continuum in terms of symptom severity. Our findings also support the notion of both personality disorders sharing many similarities in terms of demographic characteristics and comorbid Axis II psychopathology, with psychopathic ASPD reflecting a more severe form than ASPD alone. Axis I clinical syndromes did not convincingly differentiate in terms of explaining the higher level of severity of the psychopathic ASPD subtype. However, the directional relationship between comorbid schizoid and narcissistic personality disorder and the psychopathic subtype is not entirely explained by the cross-sectional method. It remains unclear whether at a higher level of symptomatic severity, ASPD presents with additional symptoms of these conditions, or whether with comorbid schizoid and narcissistic personality disorders, they result in increased severity of ASPD. The implication of these findings is that it may be possible to capture the integral components of psychopathy using DSM Axis II measures and without creating a new category of personality disorder within the DSM glossary. Few items within the PCL-R are not already measured within Axis II, although they tend to be distributed across different categories. Using a dimensional approach, severity of the core antisocial component could be measured using the ASPD construct and enhanced by additional cluster B measures, specifically narcissistic and schizoid personality disorder. Additional forms of Axis II psychopathology associated with ASPD, such as paranoid and borderline personality disorder, which are often comorbid in clinical settings, may characterize variants of severe ASPD, or psychopathy.