عدم پشیمانی در اختلال شخصیت ضد اجتماعی: ارتباط اجتماعی جمعیتی، ارائه نشانه ها و همبودی با اختلالات محور I و محور II در بررسی ملی اپیدمیولوژیک در شرایط اعتیاد به الکل و مرتبط

Abstract Objective The purpose of this study was to compare sociodemographic and family history correlates, symptomatic presentation, and comorbidity with Axis I and Axis II disorders, in an epidemiologic sample of adults with DSM-IV antisocial personality disorder (ASPD) who lacked, vs those who did not lack, remorse. Methods This study is based on a nationally representative sample of adults. Lifetime prevalences of each ASPD diagnostic criterion and each comorbid mood, anxiety, substance use, and personality disorder were estimated. Logistic regression was used to examine associations of lack of remorse with ASPD symptom patterns and comorbid disorders. Diagnoses were made using the National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule–DSM-IV Version.

Introduction Under DSM-III [1], DSM-III–R [2], and DSM-IV [3] criteria, the antisocial personality disorder (ASPD) diagnosis has emphasized overt antisocial behaviors and primarily criminal acts. Although it yields good diagnostic reliability, this approach has generated controversy for its radical departure from the clinical traditions of psychopathy. Antisocial behaviors constitute only one of 3 correlated but distinct facets of psychopathy [4] and [5]. The other 2 components relate to emotional detachment [5], [6] and [7], including arrogant and deceitful interpersonal style (glibness or superficial charm, grandiosity, pathological lying, and conning or manipulativeness) and deficient affective experience (primarily lack of remorse and lack of empathy). To address concerns raised by the focus begun in DSM-III on antisocial behaviors, DSM-III–R and DSM-IV included lack of remorse and empathy in the criteria sets for ASPD, but neither system made it a requirement for the diagnosis. Among incarcerated men, prevalence estimates for ASPD range from 50% to 100%, whereas those for psychopathy are typically 30% or lower; although there is considerable overlap between individuals diagnosable with psychopathy and those diagnosable with ASPD, this overlap is not complete [8], [9], [10] and [11]. The majority of incarcerated male offenders who qualify for a diagnosis of psychopathy as measured by Psychopathy Checklist–Revised scores of more than 30, or who demonstrate high levels of psychopathic traits on such instruments as the California Personality Inventory–Socialization Scale [12], also meet DSM criteria for ASPD [8] and [9]. Conversely, only one third or fewer of incarcerated men meeting DSM criteria for ASPD are diagnosable as psychopathic [8] and [13]. DSM diagnoses of ASPD are at best weakly predictive of behavior problems during incarceration and postrelease recidivism, in part because the prevalence of ASPD among incarcerated men is so high. However, men diagnosed with both ASPD and high levels of Psychopathy Checklist–Revised–defined psychopathy show more “versatile” lifetime antisociality than men with ASPD but no or low levels of psychopathy [8], [10] and [14], including more “overt,” that is, confrontational, violent, and aggressive [15], [16] and [17], behavior, particularly against other people. Furthermore, psychopathy, including both the interpersonal/affective and the antisocial behavioral domains [18], significantly and substantially predicts disciplinary problems within correctional settings as well as both general and, in particular, violent reoffending following release [8], [9], [10], [19] and [20]. Few data are available concerning incarcerated women, but broadly similar patterns appear to prevail [21], [22] and [23]. Thus, in correctional settings, in addition to indicating more polysymptomatic and violent lifetime antisocial behavior patterns, psychopathy may be a more prognostically useful construct than DSM-defined ASPD. Data from nonforensic clinical settings concerning prevalence, co-occurrence vs divergence, and prognostic validity and utility of DSM-defined ASPD vs psychopathy, particularly in their fully diagnosable forms, are quite limited and come primarily from addictions treatment programs. As in forensic settings, ASPD is substantially more prevalent than psychopathy, with at most one third of individuals who meet criteria for ASPD also meeting criteria for psychopathy [24] and [25]. Among alcoholic inpatients, DSM-III ASPD, but not psychopathy, was associated with more problematic drinking history [26]. Conversely, both the interpersonal/affective and the behavioral factors of psychopathy were associated with more problematic heroin use history, whereas the behavioral factor, corresponding roughly to a subset of ASPD diagnostic criteria, was associated with more previous drug treatments, among male methadone patients [27]. Similarly, among treatment-seeking, cocaine-dependent women, psychopathy, but not ASPD, was associated with histories of illegal activity at treatment admission [28]. However, although evidence concerning the association of ASPD with substance abuse treatment outcomes is mixed [29], [30], [31], [32] and [33], there does not appear to be differential prediction of substance abuse treatment outcomes by psychopathy vs ASPD [25]. The more specific question of whether ASPD itself differs phenomenologically by the presence or absence of characteristics of psychopathy, including lack of remorse, has likewise received limited attention. Using the Diagnostic Interview Schedule for DSM-III–R criteria (DIS-III–R) [34], Goldstein et al [35] found statistically significant but modest differences in symptomatic presentation, primarily with respect to overt behaviors, including elevated odds of confrontational stealing and more total violent symptoms endorsed over the lifespan, as well as more total childhood criteria met, among residential addictions treatment clients with ASPD who lacked remorse (remorse-negative) than among those who did not (remorse-positive). In addition, the remorse-negative subgroup demonstrated elevated odds of lifetime major depressive disorder. However, the small size of that sample, particularly the limited number of women, limited the precision of the findings and precluded statistically meaningful sex-specific analyses. In addition, the ascertainment of the sample from a single publicly funded addictions treatment program raises questions about generalizability of the findings, and their potential clinical and public health implications, to nonclinical populations. Accordingly, the purpose of this report was to examine associations of lack of remorse with sociodemographic and family history characteristics, symptomatic presentation, and comorbidity with Axis I and Axis II disorders among respondents diagnosed with ASPD in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) [36] and [37]. This report from the NESARC advances prior research on several fronts. First, the NESARC is the first of the major psychiatric epidemiologic surveys to use DSM-IV criteria. Second, with a nationally representative sample of 43 093 respondents, the number of identified cases (1422) of ASPD in the NESARC is large enough to allow accurate, precise estimates of sociodemographic correlates (including family history of antisocial behavior, alcoholism and drug problems, and major depression), as well as comorbidity with other mental disorders by lack of remorse. In addition, the large sample size allows investigation of whether associations between lack of remorse and other characteristics under study are similar or different between men and women.

Results 3.1. Sociodemographic and family history characteristics of respondents with ASPD by lack of remorse As shown in Table 1, respondents with ASPD did not differ by lack of remorse on sex, race/ethnicity, marital status, educational attainment, past-year employment, past-year income, region of residence, or family history of behavior problems, alcohol problems, or depression. Among women, there were significant race/ethnicity differences, with remorse-negative respondents more often Black, and less often White, than respondents who were remorse positive; however, among men, there was no association between race/ethnicity and lack of remorse (sex-specific data available upon request). Remorse-negative respondents were significantly younger and more often reported family histories of drug problems. With the exception of race/ethnicity, similar patterns of sociodemographic characteristics were observed for men and women, although results significant in the total sample did not achieve significance in sex-specific analyses (data available upon request). Table 1. Demographics and family psychiatric history of respondents with antisocial personality disorder by lack of remorse (N = 1422) Characteristic, % (SE) Remorse-positive (n = 694) Remorse-negative (n = 728) P Age .04 18-29 y 35.6% (2.2) 39.3% (2.4) 30-44 y 33.0% (2.2) 37.8% (2.4) 45-64 y 28.4% (2.2) 20.5% (1.8) ≥65 y 3.0% (0.9) 2.4% (0.7) Race/ethnicity .20 White, non-Hispanic 71.0% (2.4) 70.0% (2.5) Black, non-Hispanic 9.8% (1.3) 12.6% (1.5) Native American 7.2% (1.4) 4.2% (1.0) Asian/Pacific Islander 2.0% (0.6) 2.3% (0.7) Hispanic 10.1% (1.6) 11.0% (1.7) Marital status .39 Married/cohabiting 51.4% (2.4) 50.6% (2.4) Widowed/separated/divorced 18.3% (1.8) 15.9% (1.6) Never married 30.3% (2.1) 33.5% (2.4) Educational attainment .27 <High school 22.1% (2.0) 24.2% (2.0) High school graduate 33.8% (2.0) 29.2% (2.0) >High school 44.1% (2.4) 46.6% (2.4) Employed past year 84.8% (1.7) 86.0% (1.5) .59 Past-year personal income .56 <$19 999 49.1% (2.5) 50.3% (2.5) $20 000-$34 999 24.0% (1.9) 26.3% (1.9) $35 000-$69 999 20.5% (1.8) 17.5% (1.7) ≥$70 000 6.5% (1.1) 5.9% (1.2) Region .07 Northeast 13.8% (2.7) 18.0% (3.2) Midwest 23.8% (3.5) 25.1% (3.4) South 30.9% (3.5) 31.0% (3.4) West 31.5% (3.9) 25.9% (3.6) Family psychiatric history Behavior problems 59.6% (2.4) 61.4% (2.5) .60 Alcohol problems 82.2% (1.8) 80.5% (2.0) .53 Drug problems 47.6% (2.3) 55.2% (2.6) .03 Depression 61.5% (2.2) 64.0% (2.3) .42 Table options 3.2. Symptomatic presentation of ASPD by lack of remorse 3.2.1. Childhood conduct disorder Percentages of respondents with ASPD who met each CD criterion before age 15, and adjusted ORs with 95% confidence intervals for lack of remorse, are shown in the first panel of Table 2. Remorse-negative respondents were significantly more likely than those who were remorse-positive to meet most criteria involving violence or aggression against other persons: bullying, threatening, or intimidation; initiation of physical fights; use of a dangerous weapon; and physical cruelty to people. However, lack of remorse was not significantly (P ≤ .05) associated with confrontational stealing or forcing sexual activity. Respondents did not differ either by lack of remorse on physical cruelty to animals, nor on frequent lying for secondary gain, staying out all night without permission, or truancy. Conversely, in the total sample, remorse-negative respondents were less likely than remorse-positive respondents to meet most criteria involving offenses against property, including vandalism, breaking into someone else's property, and nonconfrontational stealing. Table 2. Symptomatic presentation of ASPD by lack of remorse (N = 1422) Remorse-positive (n = 694) Remorse-negative (n = 728) Adjusted ORs (95% CI)a P Main effect, lack of remorse Sex*lack of remorse interaction I. Childhood criteria (before age 15 y), % (SE) Bullying/threatening/intimidation 41.6% (2.4) 51.5% (2.5) 1.5 (1.1-2.0) .01 .72 Starting physical fights 20.5% (1.9) 30.6% (2.1) 1.7 (1.2-2.3) .001 .92 Using dangerous weapon 21.0% (1.9) 34.8% (2.3) 2.0 (1.4-2.8) <.0001 .22 Physical cruelty to people 24.9% (1.8) 43.9% (2.5) 2.4 (1.8-3.1) <.0001 .69 Physical cruelty to animals 13.9% (1.4) 15.6% (1.8) 1.2 (0.8-1.8) .30 .90 Stealing with confrontation 1.1% (0.3) 2.5% (0.7) b Forcing someone into sex 0.4% (0.3) 0.03% (0.0) b Deliberate firesetting 12.7% (1.4) 12.4% (1.8) Men: 1.1 (0.7-1.7); Women: 0.4 (0.1-0.9) .75 .04 Deliberate vandalism 36.3% (2.2) 27.6% (2.1) 0.6 (0.5-0.9) .004 .92 Breaking into someone else's property 36.3% (2.2) 27.6% (2.1) 0.6 (0.5-0.9) .004 .92 Frequent lying for secondary gain 43.7% (2.3) 41.4% (2.3) 0.8 (0.6-1.1) .19 .84 Nonconfrontational stealing 80.0% (1.7) 71.7% (2.2) 0.6 (0.5-0.9) .003 .28 Staying out all night without parental permission 30.0% (2.3) 27.3% (2.1) 0.9 (0.7-1.3) .60 .39 Running away at least twice, or once without returning 33.6% (2.2) 26.9% (2.1) 0.7 (0.5-1.0) .04 .99 Frequent truancy 42.4% (2.4) 39.6% (2.3) 0.9 (0.7-1.2) .45 .88 II. Adulthood criteria (since age 15 y), % (SE) Repeated unlawful behaviors 84.7% (1.6) 80.7% (1.8) 0.7 (0.5-1.0) .05 .96 Deceitfulness 53.3% (2.4) 44.1% (2.3) 0.6 (0.5-0.8) .001 .86 Impulsivity/failure to plan ahead 56.8% (2.7) 50.4% (2.4) 0.8 (0.6-1.1) .11 .34 Irritability/aggressiveness 64.3% (2.2) 81.6% (2.0) 2.5 (1.8-3.4) <.0001 .74 Recklessness 75.1% (2.1) 67.8% (2.3) 0.8 (0.5-1.1) .09 .29 Consistent irresponsibility 89.0% (1.5) 84.1% (1.7) 0.6 (0.4-0.9) .02 .64 Remorse-positive (n = 694) Remorse-negative (n = 728) P III. Age at first onset and total symptoms, mean (95% CI) Age at first symptom 12.98 (12.52-13.43) 12.59 (12.11-13.06) .25 Total childhood criteria met (before 15) 4.38 (4.22-4.54) 4.53 (4.37-4.69) .19 Total adulthood criteria met, excluding lack of remorse (since 15) 4.23 (4.13-4.34) 4.09 (3.98-4.20) .06 Total violent symptoms at any agec 2.76 (2.58-2.94) 3.38 (3.20-3.55) <.001 a Odds of meeting the criterion among remorse-negative relative to remorse-positive individuals with ASPD, adjusted for sex, age, race/ethnicity, region, and family history of drug problems. b Adjusted odds ratio not reported because of low prevalence of endorsement of this item. c Includes: bullying, pushing around, or intimidating other people; vandalism; firesetting; robbing, mugging, or snatching someone's purse; forcing someone into sexual activity; repeatedly starting fights; swapping blows with intimates; using a dangerous weapon; hit someone and caused injury; hurting another person on purpose; and hurting an animal on purpose. Table options Except for firesetting, which was less likely to be endorsed by remorse-negative than by remorse-positive women but not associated with lack of remorse among men, there were no significant interactions between sex and lack of remorse. However, not all sex-specific ORs retained statistical significance (data available upon request). 3.2.2. Adult antisocial behaviors Consistent with the patterns of reported childhood behaviors, and as shown in the second panel of Table 2, remorse-negative respondents were significantly more likely to meet the irritability and aggressiveness criterion since age 15. However, they did not differ from remorse-positive respondents with respect to repeated unlawful behaviors, impulsivity/failure to plan ahead, recklessness, and consistent irresponsibility. Remorse-negative respondents were less likely to report deceitfulness. There were no significant interactions between sex and lack of remorse; however, as observed for childhood CD criteria, not all sex-specific ORs retained statistical significance (data available upon request). 3.2.3. Age at first onset, total criteria met, and violent symptomatology As shown in the third panel of Table 2, lack of remorse was not associated with age at first CD symptom, nor with total criteria met in either childhood or adulthood. However, remorse-negative respondents endorsed significantly more violent symptoms over their lifespans. Patterns were similar in sex-specific analyses (data available upon request). 3.3. Comorbidity of ASPD with other mental disorders Lifetime prevalences of comorbid Axis I and Axis II mental disorders and adjusted ORs by lack of remorse are shown in Table 3. Lack of remorse was not associated with any mood, anxiety, substance dependence, or other personality disorder assessed in the NESARC, among respondents with ASPD. Except for dependent personality, the prevalence of which was quite low among these respondents, there were no significant interactions of sex with lack of remorse. Table 3. Comorbid lifetime psychiatric and substance use disorders in respondents with ASPD by lack of remorse (N = 1422) Remorse-positive (n = 694) Remorse-negative (n = 728) Adjusted OR (95% CI)a P Main effect, lack of remorse Sex*lack of remorse interaction Axis I, % (SE) Major depressive disorder 23.9% (1.9) 22.1% (1.9) 0.9 (0.7-1.3) .60 .15 Dysthymic disorder 7.1% (1.2) 8.7% (1.2) 1.3 (0.8-2.1) .26 .44 Bipolar I disorder 17.7% (1.8) 21.6% (1.8) 1.2 (0.9-1.7) .19 .81 Bipolar II disorder 5.9% (1.1) 4.6% (0.9) 0.7 (0.4-1.2) .23 .45 Panic disorder 16.0% (1.7) 16.4% (1.6) 1.1 (0.8-1.5) .69 .39 Social phobia 13.2% (1.5) 17.5% (1.8) 1.5 (1.0-2.2) .05 .61 Specific phobia 21.0% (1.9) 22.9% (1.8) 1.1 (0.8-1.5) .56 .55 Generalized anxiety disorder 11.2% (1.5) 14.0% (1.7) 1.3 (0.8-2.0) .34 .41 Pathological gambling 2.5% (0.7) 2.9% (0.8) 1.2 (0.6-2.5) .69 .37 Tobacco dependence 53.2% (2.5) 56.1% (2.4) 1.1 (0.9-1.5) .37 .88 Any alcohol or drug dependence ± abuse 54.5% (2.4) 54.2% (2.3) 1.0 (0.8-1.3) .95 .37 Alcohol dependence ± abuse 49.4% (2.4) 49.0% (2.3) 1.0 (0.8-1.3) .91 .08 Any drug dependence ± abuse 23.5% (2.1) 23.4% (2.2) 1.0 (0.7-1.4) .86 .82 Axis II, % (SE) Paranoid personality disorder 20.4% (2.0) 25.1% (2.2) 1.3 (0.9-1.8) .22 .72 Schizoid personality disorder 13.8% (1.6) 16.8% (1.7) 1.2 (0.9-1.8) .24 .63 Histrionic personality disorder 12.4% (1.4) 12.4% (1.5) 0.9 (0.6-1.3) .60 .69 Avoidant personality disorder 11.2% (1.9) 10.2% (1.6) 0.9 (0.5-1.6) .69 .44 Dependent personality disorder 3.6% (0.8) 4.0% (1.1) Men: 2.0 (0.7-6.0); Women: 0.5 (0.2-1.2) .87 .04 Obsessive-compulsive personality disorder 25.0% (2.0) 29.4% (2.3) 1.2 (0.9-1.7) .20 .34 a Odds of meeting criteria for each comorbid diagnosis among remorse-negative relative to remorse-positive individuals with ASPD, adjusted for gender, age, race/ethnicity, region, and family history of drug problems.