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antisocial personality disorder

 
Dictionary: antisocial personality disorder
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n.
A personality disorder characterized by chronic antisocial behavior and violation of the law and the rights of others.


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Children's Health Encyclopedia: Antisocial Personality Disorder
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Definition

Antisocial behavior is that which is verbally or physically harmful to other people, animals, or property, including behavior that severely violates social expectations for a given environment. Antisocial personality disorder in adults is also referred to as sociopathy or psychopathy.

Description

Antisocial behavior can be broken down into two components: the presence of antisocial (i.e., angry, aggressive, or disobedient) behavior and the absence of prosocial (i.e., communicative, affirming, or cooperative) behavior. Most children exhibit some antisocial behavior during their development, and different children demonstrate varying levels of prosocial and antisocial behavior. Some children—for example, the popular but rebellious child—may exhibit high levels of both antisocial and prosocial behaviors. Others—for example, the withdrawn, thoughtful child—may exhibit low levels of both types of behaviors.

High levels of antisocial behavior are considered a clinical disorder. Young children may exhibit hostility towards authority, and be diagnosed with oppositional-defiant disorder. Older children may lie, steal, or engage in violent behaviors, and be diagnosed with conduct disorder. A minority of children with conduct disorder whose behavior does not improve as they mature will go on to develop adult antisocial personality disorder.

A salient characteristic of antisocial children and adolescents is that they appear to have no feelings. They demonstrate no care for others' feelings or remorse for hurting others, and tend not to show their own feelings except for anger and hostility, and even these are communicated through aggressive acts and are not necessarily expressed through affect. One analysis of antisocial behavior is that it is a defense mechanism that helps children avoid painful feelings, or avoid the anxiety caused by lack of control over the environment.

Antisocial behavior may also be a direct attempt to alter the environment. Social learning theory suggests that negative behaviors are reinforced during childhood by parents, caregivers, or peers. In one formulation, a child's negative behavior (e.g., whining, hitting) initially serves to stop the parent from behaving in ways that are aversive to the child (the parent may be fighting with a partner, yelling at a sibling, or even crying). The child will apply the learned behavior at school, and a vicious cycle sets in: he or she is rejected, becomes angry and attempts to force his will or assert his pride, and is then further rejected by the very peers from whom he might learn more positive behaviors. As the child matures, "mutual avoidance" sets in with the parent(s), as each party avoids the negative behaviors of the other. Consequently, the child receives little care or supervision and, especially during adolescence, is free to join peers who have similarly learned antisocial means of expression.

Demographics

Mental health professionals agree, and rising rates of serious school disciplinary problems, delinquency, and violent crime indicate, that antisocial behavior in general is increasing. Thirty to 70% of childhood psychiatric admissions are for disruptive behavior disorders, and diagnoses of behavior disorders are increasing overall. A small percentage of antisocial children (about 3% of males and 1% of females) grow up to become adults with antisocial personality disorder, and a greater proportion suffer from the social, academic, and occupational failures resulting from their antisocial behavior.

Causes and Symptoms

Factors that contribute to a particular child's antisocial behavior vary, but they usually include some form of family problems (e.g., marital discord, harsh or inconsistent disciplinary practices or actual child abuse, frequent changes in primary caregiver or in housing, learning or cognitive disabilities, or health problems). Attention deficit/hyperactivity disorder is highly correlated with antisocial behavior.

A child may exhibit antisocial behavior in response to a specific stressor (such as the death of a parent or a divorce) for a limited period of time, but this is not considered a psychiatric condition. Children and adolescents with antisocial behavior problems have an increased risk of accidents, school failure, early alcohol and substance use, suicide, and criminal behavior. The elements of a moderate to severely antisocial personality are established as early as kindergarten. Antisocial children score high on traits of impulsiveness, but low on anxiety and reward-dependence—the degree to which they value, and are motivated by, approval from others. Yet underneath their tough exterior, antisocial children have low self-esteem.

Although antisocial personality disorder is only diagnosed in people over age 18, the symptoms are similar to those of conduct disorder, and the criteria for diagnosis include the onset of conduct disorder before the age of 15. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision (DSM-IV-TR), people with antisocial personality disorder demonstrate a pattern of antisocial behavior since age 15.

The adult with antisocial personality disorder displays at least three of the following behaviors:

  • fails to conform to social norms, as indicated by frequently performing illegal acts, and pursuing illegal occupations
  • is deceitful and manipulative of others, often in order to obtain money, sex, or drugs
  • is impulsive, holding a succession of jobs or residences
  • is irritable or aggressive, engaging in physical fights
  • exhibits reckless disregard for the safety of self or others, misusing motor vehicles, or playing with fire
  • is consistently irresponsible, failing to find or sustain work or to pay bills and debts
  • demonstrates lack of remorse for the harm his or her behavior causes others

An adult diagnosed with antisocial personality disorder will demonstrate few of his or her own feelings beyond contempt for others. Authorities have linked antisocial personality disorder with abuse, either physical or sexual, during childhood, neurological disorders (which are often undiagnosed), and low IQ. Those with a parent with an antisocial personality disorder or substance abuse problem are more likely to develop the disorder. The antisocially disordered person may be poverty-stricken, homeless, a substance abuser, or have an extensive criminal record. Antisocial personality disorder is associated with low socioeconomic status and urban settings.

When to Call the Doctor

When symptoms of antisocial behavior appear, a child should be taken to his or her health care provider as soon as possible for evaluation and possible referral to a mental health care professional. If a child or teen reveals at any time that he/she has had recent thoughts of self-injury or suicide, or if he/she demonstrates behavior that compromises personal safety or the safety of others, professional assistance from a mental health care provider or care facility should be sought immediately.

Diagnosis

Antisocial behavior and childhood antisocial disorders such as conduct disorder may be diagnosed by a family physician or pediatrician, social worker, school counselor, psychiatrist, or psychologist. A comprehensive evaluation of the child should ideally include interviews with the child and parents, a full social and medical history, review of educational records, a cognitive evaluation, and a psychiatric exam.

One or more clinical inventories or scales may be used to assess the child, including the Youth Self-Report, the School Social Behavior Scales (SSBS), the Overt Aggression Scale (OAS), Behavioral Assessment System for Children (BASC), Child Behavior Checklist (CBCL), the Nisonger Child Behavior Rating Form (NCBRF), Clinical Global Impressions scale (CGI), and Diagnostic Interview Schedule for Children (DISC). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Treatment

The most important goals of treating antisocial behavior are to measure and describe the individual child's or adolescent's actual problem behaviors and to effectively teach him or her the positive behaviors that should be adopted instead. In severe cases, medication will be administered to control behavior, but it should not be used as a substitute for therapy. A child who experiences explosive rage may respond well to medication. Ideally, an interdisciplinary team of teachers, social workers, and guidance counselors will work with parents or caregivers to provide services to help the child in all aspects of his or her life: home, school, work, and social contexts. In many cases, parents themselves need intensive training on modeling and reinforcing appropriate behaviors in their child, as well as in providing appropriate discipline to prevent inappropriate behavior.

A variety of methods may be employed to deliver social skills training, but especially with diagnosed anti-social disorders, the most effective methods are systemic therapies which address communication skills among the whole family or within a peer group of other antisocial children or adolescents. These probably work best because they entail actually developing (or redeveloping) positive relationships between the child or adolescent and other people. Methods used in social skills training include modeling, role-playing, corrective feedback, and token reinforcement systems. Regardless of the method used, the child's level of cognitive and emotional development often determines the success of treatment. Adolescents capable of learning communication and problem-solving skills are more likely to improve their relations with others.

Unfortunately, conduct disorders, which are the primary form of diagnosed antisocial behavior, are highly resistant to treatment. Few institutions can afford the comprehensiveness and intensity of services required to support and change a child's whole system of behavior. In most cases, for various reasons, treatment is terminated (usually by the client) long before it is completed. Often, the child may be fortunate to be diagnosed at all. Schools are frequently the first to address behavior problems, and regular classroom teachers only spend a limited amount of time with individual students. Special education teachers and counselors have a better chance at instituting long-term treatment programs—if the student stays in the same school for a period of years. One study showed teenage boys with conduct disorder had had an average of nine years of treatment by 15 different institutions. Treatments averaged seven months each.

Studies show that children who are given social skills instruction decrease their antisocial behavior, especially when the instruction is combined with some form of supportive peer group or family therapy. But the long-term effectiveness of any form of therapy for anti-social behavior has not been demonstrated. The fact that peer groups have such a strong influence on behavior suggests that schools that employ collaborative learning and the mainstreaming of antisocial students with regular students may prove most beneficial to the antisocial child. Because the classroom is a natural environment, learned skills do not need to be transferred. By dividing the classroom into groups and explicitly stating procedures for group interactions, teachers can create opportunities for positive interaction between antisocial and other students.

Prognosis

Early and intensive intervention is the best hope for children exhibiting antisocial behaviors or diagnosed conduct disorder. For those who grow into adults with antisocial personality disorder, the prognosis is not promising; the condition is difficult to treat and tends to be chronic. Although there are medications available that could quell some of the symptoms of antisocial personality disorder, noncompliance or abuse of the drugs prevents their widespread use. The most successful treatment programs are long-term, structured residential settings in which the patient systematically earns privileges as he or she modifies behavior.

Prevention

A supportive, nurturing, and structured home environment is believed to be the best defense against anti-social behavioral problems. Children with learning disabilities and/or difficulties in school should get appropriate academic assistance. Addressing these problems when they first appear helps to prevent the frustration and low self-esteem that may lead to antisocial issues later.

Parental Concerns

A child with antisocial behavioral problems can have a tremendous impact on the home environment and on the physical and emotional welfare of siblings and others sharing the household, as well as their peers at school. While seeking help for their child, parents must remain sensitive to the needs of their other children. This may mean avoiding leaving siblings alone together, getting assistance with childcare, or even seeking residential or hospital treatment for the child if the safety and well-being of other family members is in jeopardy. Parents should also maintain an open dialog with their child's teachers to ensure that their child receives appropriate educational assistance and that classmates are not put at risk.

See also Aggression; Conduct disorder; Oppositional defiant disorder.

Resources

Books

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision (DSMIV-TR). Washington, DC: American Psychiatric Press, Inc., 2000.

Connor, Daniel. Aggression and Antisocial Behavior in Children and Adolescents: Research and Treatment. New York: Guilford Press, 2002.

Eddy, J. Mark. Conduct Disorders: The Latest Assessment and Treatment Strategies. Kansas City, MO: Compact Clinicals, 2003.

Periodicals

Cellini, Henry R. "Biopsychological Treatment of Antisocial and Conduct-Disordered Offenders." Federal Probation 66, no. 2 (September 2002): 78+.

Connor, Daniel F. "Aggression and Antisocial Behavior in Youth." Brown University Child & Adolescent Behavior Letter 18, no. 9 (September 2002): 1+.

Organizations

The American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Ave., N.W., Washington, D.C. 20016-3007. (202) 966-7300. Web site: www.aacap.org

Web Sites

The National Mental Health Association. www.nmha.org.

NYU Child Study Center. Changing the Face of Child Mental Health. www.aboutourkids.org.

[Article by: Paula Ford-Martin]


Wikipedia: Antisocial personality disorder
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Not to be confused with Avoidant personality disorder.
Dissocial personality disorder
Classification and external resources
ICD-10 F60.2
ICD-9 301.7
MeSH D000987

Antisocial personality disorder (ASPD or APD) is defined by the American Psychiatric Association's Diagnostic and Statistical Manual as "...a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood."[1] The individual must be age 18 or older, as well as have a documented history of a conduct disorder before the age of 15.[1] People having antisocial personality disorder are sometimes referred to as "sociopaths" and "psychopaths", although some researchers believe that these terms are not synonymous with ASPD.[2]

Contents

History

The history of the origins of antisocial personality disorder are closely related to the history of psychopathy - see history of psychopathy.

Symptoms

Characteristics of people with antisocial personality disorder may include:[3]

  • Persistent lying or stealing
  • Superficial charm[4][5]
  • Apparent lack of remorse[4] or empathy; inability to care about hurting others
  • Inability to keep jobs or stay in school[4]
  • Impulsivity and/or recklessness[4]
  • Lack of realistic, long-term goals — an inability or persistent failure to develop and execute long-term plans and goals
  • Inability to make or keep friends, or maintain relationships such as marriage
  • Poor behavioral controls — expressions of irritability, annoyance, impatience, threats, aggression, and verbal abuse; inadequate control of anger and temper
  • Narcissism, elevated self-appraisal or a sense of extreme entitlement
  • A persistent agitated or depressed feeling (dysphoria)
  • A history of childhood conduct disorder
  • Recurring difficulties with the law
  • Tendency to violate the boundaries and rights of others
  • Substance abuse
  • Aggressive, often violent behavior; prone to getting involved in fights
  • Inability to tolerate boredom
  • Disregard for the safety of self or others
  • Persistent attitude of irresponsibility and disregard for social rules, obligations, and norms
  • Difficulties with authority figures [6]

Diagnostic criteria (DSM-IV-TR = 301.7)

The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR, a widely used manual for diagnosing mental disorders, defines antisocial personality disorder (in Axis II Cluster B) as:[1]

A) There is a pervasive pattern of disregard for and the rights of others occurring since the age of 15, as indicated by three (or more) of the following:
  1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;
  2. deceitfulness, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
  3. impulsivity or failure to plan ahead;
  4. irritability and aggressiveness, as indicated by repeated physical fights or assaults;
  5. reckless disregard for safety of self or others;
  6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
  7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.
B) The individual is at least 18 years of age.
C) There is evidence of Conduct disorder with onset before age 15.
D) The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode.

Deceit and manipulation are considered essential features of the disorder. Therefore, it is essential in making the diagnosis to collect material from sources other than the individual being diagnosed.[7]

It is a requirement of DSM-IV that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Criticism

Researchers have heavily criticized the ASPD DSM-IV criteria because not enough emphasis was placed on traditional psychopathic traits such as a lack of empathy, superficial charm, and inflated self appraisal.

These latter traits are harder to assess than behavioral problems (like impulsivity and acting out). Thus, the DSM-IV framers sacrificed validity for reliability. That is, the ASPD diagnosis focuses on behavioral traits, but only limited emphasis is placed on affective and unemotional interpersonal traits.

Many have argued[weasel words] that psychopathy/sociopathy are incorrectly put together under ASPD. These clinicians and researchers[who?] are upset that an important distinction has been lost between these two disorders. In other words, ASPD and psychopathy are considered to be the same, or similar. However, they are not the same since antisocial personality disorder is diagnosed via behavior and social deviance, whereas psychopathy also includes affective and interpersonal personality factors.[8]

Also, ASPD, unlike psychopathy, does not have biological markers confirmed to underpin the disorder.[citation needed] Other criticisms of ASPD are that it is essentially synonymous with criminality. Nearly 80%–95% of felons will meet criteria for ASPD — thus ASPD predicts nothing in criminal justice populations. Whereas, psychopathy scores (using the Hare Psychopathy Checklist-Revised (PCL-R)) is found in only ~20% of inmates and PCL-R is considered one of the best predictors of violent recidivism.[citation needed] Also, the DSM-IV field trials never included incarcerated populations.

The official stance of the American Psychiatric Association as presented in the DSM-IV-TR is that psychopathy and sociopathy are obsolete synonyms for antisocial personality disorder. The World Health Organization takes a similar stance in its ICD-10 by referring to psychopathy, sociopathy, antisocial personality, asocial personality, and amoral personality as synonyms for dissocial personality disorder.[citation needed]

Diagnostic criteria (ICD-10) - dissocial personality disorder‎

The World Health Organization's ICD-10 defines a conceptually similar disorder to antisocial personality disorder called (F60.2) Dissocial personality disorder.[9]

It is characterized by at least 3 of the following:
  1. Callous unconcern for the feelings of others and lack of the capacity for empathy.
  2. Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations.
  3. Incapacity to maintain enduring relationships.
  4. Very low tolerance to frustration and a low threshold for discharge of aggression, including violence.
  5. Incapacity to experience guilt and to profit from experience, particularly punishment.
  6. Markedly prone to blame others or to offer plausible rationalizations for the behavior bringing the subject into conflict.
  7. Persistent irritability.
The criteria specifically rule out conduct disorders.[10] Dissocial personality disorder criteria differ from those for antisocial and sociopathic personality disorders.[11]

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Millon's variations

Theodore Millon identified five variations of antisocial [12]. Any individual antisocial may exhibit none, one or more than one of the following:

  • covetous antisocial - variant of the pure pattern where individuals feel that life has not given them their due.
  • reputation-defending antisocial - including narcissistic features
  • risk-taking antisocial - including histrionic features

Differential diagnosis: associated and overlapping conditions

The following conditions commonly coexist with antisocial personality disorder:[13]

Prevalence (epidemiology)

Antisocial personality disorder in the general population is about 3% in males and 1% in females.[1][13]

It is seen in 3% to 30% of psychiatric outpatients.[1][13] The prevalence of the disorder is even higher in selected populations, such as people in prisons (who include many violent offenders).[14] Similarly, the prevalence of ASPD is higher among patients in alcohol or other drug (AOD) abuse treatment programs than in the general population (Hare 1983), suggesting a link between ASPD and AOD abuse and dependence.[15]

Causes (etiology)

The exact cause of ASPD is not known, but biological or genetic factors may play a role. Brain structure deregulation, specifically within the prefrontal cortex and amygdala, plays an important contribution.

If the parent of an individual has had the disorder, that individual has a greater chance of having the disorder. A number of environmental factors in the childhood home, school, and community may also contribute to the disorder, such as losing respect or "giving up" on authority figures after observance of their hypocrisy and/or misbehaviors. Robins (1966) found an increased incidence of sociopathic characteristics and alcoholism in the fathers of individuals with antisocial personality disorder. He found that, within such a family, males had an increased incidence of ASPD, whereas females tended to show an increased incidence of somatization disorder instead.[16]

Bowlby (1944) saw a connection between antisocial personality disorder and maternal deprivation in the first five years of life. Glueck and Glueck (1968) saw reasons to believe that the mothers of children who developed this personality disorder usually did not discipline their children and showed little affection towards them. But it is also important to point out that correlation does not imply causation.

Adoption studies show that both genetic and environmental factors can contribute to the development of the disorder. These studies have also shown that genetic factors are more important for adults with the disorder, while environmental factors are more important in antisocial children. [16][17]

Currently, genetic and environmental factors are thought to contribute to the organic causes of the disorder, namely, deregulation of the amygdala and orbitofrontal cortex. The prefrontal lobes are responsible for forming goals and objectives, coordinating skills, and evaluating our actions. The OFC of the prefrontal lobes has connections to the amygdala, is part of the limbic system, and is specifically noted for regulating and modulating stress/arousal responses, as well as response-reversal [1] [18].

Antisocial individuals, because of an impaired amygdala show impaired initial response learning. Additionally, when psychopaths and amygdalar-lesioned patients are presented with a peripheral emotional image (e.g. a picture of a corpse, or the sound of a crying baby) while completing a simple task, their performance remains relatively unaffected. They show impaired recognition of, and reaction to, fearful facial and vocal affect.

In general, the combination of an inattentiveness to emotionally charged stimuli (whether presented in full view or as a peripheral distraction) as well as an inability to shift attention to an alternative route of reward (and thus, avoid punishment) can account for much of a APD individual’s deviant behavior. They do not notice emotion and are unable to empathize—and thus feel unaffected when their actions have detrimental effects on other people.

They also continue to commit acts of crime or violence long after the rewards have stopped and the punishment has begun (e.g. repeat offenders who have been incarcerated multiple times)[19]. They also are quick to display aggressive and impulsive behavior. This reactive antisocial aggression is perhaps in part a result of elevated levels of frustration experienced when they are unable to modify their behavior in the ever-changing environment.[20]

Potential markers

In the past, the presence of three behavioral markers, known as the Macdonald triad, was found in some children who went on to develop sociopathy. The triad consists of bedwetting, a tendency to abuse animals, and pyromania.[21]

The ASPD etiology is currently associated with abusive, chaotic, or emotionally deprived home environments and with low socioeconomic status and urban settings. However, there are concerns that this diagnosis is misapplied to individuals in which this behavioral strategy is contingent with economic or other survival[1]. ASPD is also highly co-morbid with ADHD and Substance-Abuse Disorders[1].

Current neuropsychology recognizes that in addition to the outwardly antisocial behaviors (lying, manipulation, and disregard for the law or other people), ASPD individuals show impairment in both their orbitofrontal cortex (problems with task-switching and other executive functioning) and their amygdala (shown through their impaired fear response and emotional reaction)[19][22]. ASPD patients also have poor fear conditioning (which implicates the hippocampus) and show a general under-arousal to stimuli[23]. Indeed, in children as young as three, a slower heart rate correlates with aggression (though not specifically psychopathy) [24].

Treatment

Wiki letter w.svg This section requires expansion.

To date there have been no controlled studies reported which found an effective treatment for ASPD[25]. Some studies have found that the presence ASPD does not significantly interfere with treatment for other disorders, such as substance abuse[26], although others have reported contradictory findings[27].

See also

References

  1. ^ a b c d e f g Antisocial personality disorder - Diagnostic and Statistical Manual of Mental Disorders Fourth edition Text Revision (DSM-IV-TR) American Psychiatric Association (2000) - pages 645–650
  2. ^ Mayo Clinic Staff (2006-10-09). "Antisocial personality disorder -". MayoClinic.com. http://www.mayoclinic.com/health/antisocial-personality-disorder/DS00829. Retrieved 2008-08-17. 
  3. ^ "Antisocial Personality, Sociopathy, and Psychopathy"
  4. ^ a b c d "Antisocial Personality Disorder". Psychology Today. 2005. http://psychologytoday.com/conditions/antisocial.html. Retrieved 2007-02-20. 
  5. ^ "Antisocial Personality Disorder". Mayo Foundation for Medical Education and Research. 2006. http://www.mayoclinic.com/health/antisocial-personality-disorder/DS00829. Retrieved 2007-02-20. 
  6. ^ "Antisocial Personality Disorder Treatment". Psych Central. 2006. http://psychcentral.com/disorders/sx7t.htm. Retrieved 2007-02-20. 
  7. ^ "Antisocial Personality Disorder". http://www.behavenet.com/capsules/disorders/antisocialpd.htm. Retrieved 2007-12-15. 
  8. ^ Hare, R.D., Hart, S.D., Harpur, T.J. Psychopathy and the DSM—IV Criteria for Antisocial Personality Disorder (pdf file)
  9. ^ Dissocial personality disorder - International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)
  10. ^ "602 F60.2 Dissocial personality disorder". World Health Organization. http://www.who.int/classifications/apps/icd/icd10online/?gf60.htm+F602. Retrieved 2008-01-12. 
  11. ^ Early Prevention of Adult Antisocial Behavior. Cambridge University Press. p. 82. http://books.google.com/books?id=KtXU8R8oZYwC&pg=PA82&lpg=PA82&dq=dissocial+personality+disorder&source=web&ots=lVx_gb_9mM&sig=U_bMqyc-KlzHKEvzXBdeZxplN2E. Retrieved 2008-01-12. 
  12. ^ Millon, Theodore, Personality Disorders in Modern Life, 2004
  13. ^ a b c Internet Mental Health - antisocial personality disorder
  14. ^ Hare 1983
  15. ^ "Antisocial Personality Disorder, Alcohol, and Aggression". Alcohol Research & Health. National Institute on Alcohol Abuse and Alcoholism. 2006. http://pubs.niaaa.nih.gov/publications/arh25-1/5-11.pdf. Retrieved 2007-02-20. 
  16. ^ a b "Antisocial Personality Disorder (APD)". Armenian Medical Network. 2006. http://www.health.am/psy/antisocial-personality-disorder/. Retrieved 2007-02-20. 
  17. ^ Lyons et al., 1995
  18. ^ Muller, et al., 2003
  19. ^ a b Blair, Mitchell, et al., 2006
  20. ^ Crowe & Blair, 2008
  21. ^ J. M. MacDonald. The Threat to Kill. American Journal of Psychiatry, 125-130 (1963)
  22. ^ Kumari, Taylor, Barkataki et al., 2009
  23. ^ Mitchell, Leonard, Richell, & Blair, 2006
  24. ^ Random Samples
  25. ^ J. E. Fisher & W. T. O'Donohue (eds). (2006). Practitioner's Guide to Evidence-Based Psychotherapy, p63
  26. ^ S. Darke, R. Finlay-Jones, S. Kaye, & T. Blatt. Anti-social personality disorder and response to methadone maintenance treatment. Drug and Alcohol Review, vol. 15, 271-276 (1996)
  27. ^ A. I. Alterman, M. J. Rutherford, J. S. Cacciola, J. R. McKay, & C. R. Boardman. Prediction of 7 months methadone maintenance treatment response by four measures of antisociality. Drug & Alcohol Dependence, vol. 49, 217-223 (1998)

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Dictionary. The American Heritage® Dictionary of the English Language, Fourth Edition Copyright © 2007, 2000 by Houghton Mifflin Company. Updated in 2009. Published by Houghton Mifflin Company. All rights reserved.  Read more
Children's Health Encyclopedia. © 2006 through a partnership of Answers Corporation. All rights reserved.  Read more
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