صفات ضداجتماعی در جانبازان روانپزشکی بیمار بدون اختلال شخصیت ضد اجتماعی: ارتباط با اختلالات محور I و اثرات آن بر عملکرد

Abstract The prevalence of antisocial traits was investigated in a group of veterans who were in treatment at an out-patient psychiatric clinic and who did not meet diagnostic criteria for an antisocial personality disorder. Standardized DSM-III-R interviews were used to diagnose Axis I disorders and antisocial personality disorders and traits. Frequencies of antisocial traits were compared between patients and controls as well as between diagnostic subgroups in the clinical population. Odds ratios were used to assess the effect of antisocial traits on several standardized measures of functioning. There was no overall difference in the dimensional measure of antisocial traits between the clinical and normal groups. There were trends for the frequency of individual traits to vary by Axis I diagnosis. The amount of antisocial traits (measured dimensionally) negatively affected measures of functioning for the overall clinical population. Different specific antisocial traits were associated with trends towards poorer functioning in the alcohol, major depression and post-traumatic stress syndrome subgroups. It is recommended that future research in the area of antisocial traits pay careful attention to the possible negative effects on functioning of subthreshold antisocial traits and also to Axis I comorbidity. © 1997 Elsevier Science Ireland Ltd.

Introduction The concept of antisocial personality has been approached from many different perspectives. In DSM-III-R (American Psychiatric Association, 1987), it is conceptualized as a syndrome with definite familial and probable genetic components (Robins, 1966; Crowe, 1974). Eysenck (1977)considered antisocial personality to have definite genetic components, while Hare (1968)focused on the concept of a biological deficit in the limbic system. Millon (1981)and many other dimensional theorists viewed sociopathy as a personality trait which exists to a greater or lesser extent throughout most of the population and which may be normally distributed. Although a complete review of the concept of antisocial personality is beyond the scope of this article, it appears that many theorists believe that antisocial traits that do not reach the threshold necessary to qualify for a formal diagnosis may, nonetheless, have negative effects on behavior and functioning (the dimensional concept of sociopathy). The term `antisocial' is used in this article because it best describes the DSM measures used in this study. The behavioral/descriptive approach of DSM should be distinguished from the more theoretical orientation of researchers such as Hare (1968), whose concept posits an emotional deficit — lovelessness and lack of guilt — combined with an impulse disorder that has its roots in a deficit in the central nervous system. This report focuses on veterans in an out-patient psychiatric clinic and examines the prevalence of modest levels of antisocial traits in this population and the effects of these traits, if present, on general functioning. The study's goals were: (a) to determine if veterans in a psychiatric out-patient clinic who do not meet criteria for antisocial personality disorder have more antisocial traits than screened control veterans; (b) to explore whether the presence of antisocial traits differs by Axis I diagnosis; and (c) to examine how the presence of antisocial traits affects functioning in this population.

3. Results There were 134 subjects in the clinical group and 28 subjects in the control group. All subjects were male. The two groups did not differ significantly in mean age: clinical group=56.6 years (S.D. 12.8), control group=55.5 years (S.D. 11.7). As would be expected, the control group had higher socioeconomic status (Hollingshead score=4.5, S.D.=0.9), control group (Hollingshead score=3.6, S.D.=1.2; F1=19.8, P=0.0001). Similarly, the mean GAS score in the control group (84.8, S.D.=6.3) was in the direction of higher functioning than that in the clinical group (65.7, S.D.=12.2; F1=67.6, P=0.0001). There were no significant differences in mean dimensional antisocial traits as measured by the PDE between the clinical group (3.9, S.D.=3.5) and the control group (4.7, S.D.=3.0; F1=1.23, P=0.27). There were three trends toward differences between controls and patients when individual traits were examined. The clinical group more often scored positive on the trait `is irritable or aggressive' (22.3% vs. 3.3%, Fisher's exact P=0.02) while the control group had higher scores in two traits, `lack of remorse' (23.8% vs. 3.5%, Fisher's exact P=0.001) and also `deliberately destroyed others' property' (13.3% vs. 2.9%, Fisher's exact P=0.02) (see Table 1). Table 1. Comparison of individual antisocial traits in control and clinical groups (in percenta) Criteria Control subjects Clinical n=32 n=140 Repeated absences from work unexplained by illness in self or family 0 4.3 Abandonment of several jobs without realistic plans for others 7.1 13.5 Significant unemployment of 6 months or more within 5 years, when expected to work 3.6 3.5 Has never sustained a totally monogamous relationship for more than 1 year 0 2.9 Fails to plan ahead or is impulsive 0 5.8 Lacks ability to function as a parent 0 0.9 Repeatedly fails to honor financial obligations 0 3.6 Is irritable or aggressive (repeated physical fights or assaults) 3.3 22.3* Has no regard for truth, repeated lying 0 2.9 Is reckless regarding his or other people's safety 23.3 37.2 Fails to conform to social norms of lawful behavior 3.3 9.4 Lacks remorse 23.8 3.5** Was often truant before age 15 13.3 7.2 Ran away overnight at least twice, before age 15 3.3 1.4 Often initiated physical fights, before age 15 13.3 10.9 Used a weapon in more than one fight, before age 15 3.3 0.7 Forced someone into sexual activity with him, before age 15 0 2.2 Was physically cruel to animals, before age 15 0 0.7 Was physically cruel to other people, before age 15 0 2.2 Deliberately destroyed others' property (except fires), before age 15 13.3 2.9* Deliberately engaged in fire setting, before age 15 10.0 3.5 Often lied, before age 15 3.3 4.4 Stole without confronting victim more than once, before age 15 20.0 10.8 Stole with confrontation of victim, before age 15 0 0 a Not all subjects answered all questions so the n for different criteria may vary slightly. *Normals differ from clinical group by Fisher's exact test by P<0.02. **Normals differ from clinical group by Fisher's exact test by P<0.001. Table options When the clinical group was broken down into its largest diagnostic categories, there were a few trends toward certain subgroups being different from the rest of the clinical population. Compared with the rest of the clinical group, the alcohol abuse subgroup (n=39) scored higher on `is reckless regarding his or other people's safety' (P=0.02, Fisher's exact test) and `fails to conform to social norms of lawful behavior' (P=0.02, Fisher's exact test). The subgroup with panic disorder (n=16) had higher scores on `is reckless regarding his or other people's safety' (P=0.002, Fisher's exact test). When the associations between antisocial traits for the clinical groups measured as a dimension and functioning measures were examined by logistic regression, one significant finding and one trend emerged. Lower socioeconomic status was correlated with higher antisocial traits for the overall group (n=130) (odds ratio=1.2, P=0.0004), and a higher percentage of VA disability was correlated with higher antisocial traits for the alcoholic subgroup (n=28). (Sample sizes vary slightly as not all measures were available for all subjects.) Table 2 shows the relationship of specific antisocial traits and functioning variables in diagnostic subgroups large enough to permit a valid statistical test to be performed: alcohol dependence, major depression, and post-traumatic stress disorder. For the alcoholic group, three trends emerged: `abandonment of several jobs…' was related to socioeconomic status (odds ratio=18.8) and to WORK (odds ratio=20.0), while `is reckless regarding his or other people's safety' was related to FAMILY/HOME (odds ratio=4.7). For major depression, there were two trends: `fails to conform to social norms of lawful behavior' had an odds ratio of 20.0 for the WORK and SOCIAL dimensional measure and also for socioeconomic status (odds ratio of 6.6). The PTSD group had three trends: `failure to plan ahead or is impulsive' was related to three different disability outcome measures (see Table 2). Table 2. Relationship between specific antisocial traits and functioning measures in subpopulations where there was a large enough sample size to analyzea,b Predictor variable Functioning variable Sample size Odds ratio P value A. Alcohol Abandonment of several jobs without realistic plans for others SES 36 18.8 0.01 Abandonment of several jobs without realistic plans for others WORK 36 20.0 0.01 Is reckless regarding his or other people's safety FAMILY/HOME 36 4.7 0.01 B. Major depression Fails to conform to social norms of lawful behavior SES 55 6.6 0.01 Fails to confrom to social norms of lawful behavior WORK and SOCIAL 57 20.0 0.001 C. Post-traumatic stress syndrome Fails to plan ahead or is implusive VA disability 43 13.0 0.006 Fails to plan ahead or is implusive FAMILY/HOME 47 23.3 0.008 Fails to plan ahead or is implusive WORK and SOCIAL 47 16.1 0.001 aAll odds ratios are arranged in such a way that the higher odds ratio indicates poorer performance on the functioning scale. bNot all measures were available on all subjects, so n may vary slightly from analysis.