The clinical utility of the MMPI-2 Antisocial Practices Content Scale

This study explored the ability of the MMPI-2 Antisocial Practices Content Scale (ASP) to correctly classify DSM-IV Antisocial Personality Disorder (APD). ASP scores and scores on the MMPI-2 Psychopathic Deviate (Pd) scale were compared in an APD group (n = 10), a Borderline Personality Disorder group (n = 16), a Narcissistic Personality Disorder group (n = 9), an Other Personality Disorder group (representing personality disorders from Clusters A and C; n = 14), and a nonclinical population (NC; n = 67). The ASP exhibited an ability to differentiate APD from other personality disorders and was significantly correlated to DSM-IV diagnostic criteria for APD while the Pd was not. Diagnostic efficiency statistics (sensitivity, specificity, positive predictive power, negative predictive power, overall correct classification rate, and kappa) were calculated under four different conditions in a clinically relevant manner (Kessel & Zimmerman, 1993. Psychological Assessment, 53, 395-399). The results of this study illustrate the usefulness of the ASP as a tool for the assessment of antisocial attitudes, beliefs, and behaviors in individuals suspected of having APD. This information may be valuable to clinicians who are planning treatment or assessing treatment outcome for clients with APD.     

The psychometric identification of psychopathy in mentally abnormal offenders

This study addressed the question of the degree of commonality, at a psychometric trait level, shared between two distinct concepts of psychopathy: a North American concept, defined in terms of chronic antisocial behaviour with early onset; and a European concept, defined in terms of personality deviation. Four groups of Broadmoor patients were identified who conformed to DSM-III criteria for the following diagnostic categories: Antisocial Personality Disorder (APD) (n = 12); Other Personality Disorders (OPD) (n = 9); Schizophrenic Disorders (SD) (n = 10); and a Mixed (M) group who met the criteria for both Schizophrenic Disorders and Antisocial Personality Disorder (n = 12). Thus subjects in both the APD and M groups, having a DSM-III diagnosis of Antisocial Personality Disorder, conformed to the North American concept of psychopathy. All diagnostic groups, together with a non-psychiatric control group of psychiatric nurses, were investigated using a composite battery of psychometric measures which tapped the two concepts of psychopathy. The only measure to discriminate successfully between patient groups with an APD diagnosis and other groups was Gough's (1969) Socialisation, which is itself a measure of the North American concept. Measures of personality deviation, including Blackburn's (1987) Belligerence and Withdrawal measures, failed to successfully discriminate DSM-III APD's from others. Thus the degree of trait commonality between the two concepts was found to be minimal. The study also addresses a fundamental question raised recently by both Hare and Harpur (1986) and Raine (1986) in criticism of a study by Howard, Bailey and Newman (1984): Are Broadmoor psychopaths “psychopathic” in the North American sense? Results of the study clearly indicate that they indeed are.     

Predicting institutional adjustment with the Lifestyle Criminality Screening Form and the Antisocial Features and Aggression scales of the PAI

I included scores on the Antisocial Features (ANT) and Aggression (AGG) scales of the Personality Assessment Inventory (PAI; Morey, 1991) and ratings on the Lifestyle Criminality Screening Form (LCSF; Walters, White, & Denney, 1991) along with age and prior disciplinary record in a series of negative binomial regression analyses of total, nonaggressive, and aggressive incident reports (IRs) received in a 2-year follow-up of 120 male maximum security federal prisoners. Findings indicated that the AGG scale, but not the LCSF or ANT, predicted total and nonaggressive IR counts. The LCSF achieved significant receiver operating characteristic (ROC) results in predicting dichotomized aggressive IRs, the ANT achieved significant ROC results in predicting dichotomized total and nonaggressive IRs, and the AGG achieved significant ROC results in predicting all 3 dichotomized categories of IR. Supplemental analyses revealed that the AGG continued to predict total and nonaggressive IRs when the Psychological Inventory of Criminal Thinking Styles (PICTS; Walters, 1995) Proactive scale was included in the negative binomial regression but not when the PICTS Reactive scale was included in the negative binomial regression.     

Narcissism, Perfectionism, and Self-Termination from Treatment in Outpatient Cocaine Users

This study examines perfectionism in individuals with a Diagnostic and Statistical Manual-IV, Text Revised [American Psychiatric Association, 2000. Diagnostic and statistical manual of mental disorders (4th ed.). Text revision (DSM-TV-TR). Washington, DC: American Psychiatric Association] diagnosis of Narcissistic Personality Disorder and a coexisting diagnosis of cocaine abuse or dependence. Participating clients were treated in outpatient settings that provided cognitive-behavioral therapy. Clients were administered Hewitt and Flett's (1991b) [Journal of Personality and Social Psychology, 60, 456-470] Multidimensional Perfectionism Scale prior to treatment. Scores for dimensions of perfectionism were compared with those obtained from cocaine abusers in treatment with diagnoses of Antisocial Personality or Affective Disorder. Clients with Narcissistic Personality Disorder were characterized by relatively higher levels of other-oriented and socially prescribed perfectionism. Survival analysis suggests that self-termination from treatment by cocaine-abusing clients with a diagnosis of Narcissistic Disorder is related to high levels of other-oriented perfectionism. The clinical implications and limits of this study are discussed.     

Moral mires and the grip of the group: Morality as internalized group norms

I argue that morality is a set of internalized group norms. It is a reliable guide in a complex social world where group status and membership are not guaranteed by birth, but have to be asserted and maintained continuously. Morality is acquired through the process of socialization when children learn in their experience with peers, from observation of adults, and by instructional stories, such as fairy tales. Failure to internalize group norms results in a clinical condition of Psychopathy, or Antisocial Personality Disorder. Research into Antisocial Personality Disorder suggests that likely pathways of group norm internalization are states of arousal associated with social situations.     

Externalizing pathology and the five-factor model: a meta-analysis of personality traits associated with antisocial personality disorder, substance use disorder, and their co-occurrence

In this meta-analysis we examined Five-Factor Model of personality (FFM) characteristics of externalizing disorders. Two pathologies, Antisocial Personality Disorder (APD) and Substance Use Disorder (SUD), have significant levels of co-occurrence that may be due to shared personality traits. Results from 63 samples (N = 15,331) were analyzed in order to summarize and compare five-factor results for APD, SUD, and co-occurring APD/SUD. Shared and unique personality features were identified at both the domain and the facet level of the FFM. Moderation analyses indicated that sample source (clinical versus community) and diagnosis (psychopathy versus DSM-based APD) accounted for some of the variability at the domain level. Results are discussed with respect to personality and externalizing disorders.     

Family Correlates of Oppositional and Conduct Disorders in Children With Attention Deficit/Hyperactivity Disorder

Comorbidities among children with ADHD are key determinants of treatment response, course, and outcome. This study sought to separate family factors (parental psychopathology and parenting practices) associated with comorbid Oppositional Defiant Disorder (ODD) from those associated with Conduct Disorder (CD) among children with Attention Deficit/Hyperactivity Disorder. Clinic-referred families (n = 149) were diagnosed using DSM-IV criteria. Parents completed measures of parenting practices. Comorbid ODD and CD were significantly associated with maternal negative/ineffective discipline. Comorbid CD, but not ODD, was significantly associated with lack of maternal warmth and involvement, paternal negative/ineffective discipline, and with paternal Antisocial Personality Disorder (APD). However, the risk of CD posed by parenting appeared concentrated among children without a father having APD. While consistent discipline appears important for addressing comorbid ODD and CD, paternal psychopathology and the quality of the relationship between mother and child may pose risk specifically for comorbid CD. Efforts to prevent and/or treat CD should consider not only provision of structure and prudent discipline, but also the affective qualities of the relationship between the primary caretaker and child.     

The prediction of violent and nonviolent criminal behavior in a methadone maintenance population

The utility of traits associated with Antisocial Personality Disorder in making risk assessments of violent and nonviolent crimes was examined in 254 subjects sampled from a methadone maintenance population. A factor analysis of a number of baseline measures resulted in five factors measuring hostility, insecure attachment, impaired reality testing, antisocial personality, and empathy. These factors were used in logistic regression analysis to predict charges for violent and nonviolent crimes over a 2-year period. Individuals with high scores on the antisocial personality factor had an increased risk of both violent and nonviolent criminal charges. Individuals with low scores on the empathy factor were at high risk for violent crimes. In an analysis using the factor components rather than the factors, the measures of perspective-taking and a socialization were associated with violent criminal charges, and the measure of psychopathy, but not antisocial behavior, was associated with nonviolent criminal charges. The results support the use of measures of personality traits in addition to measures of a history of antisocial behavior in making violence risk assessments in substance-dependent patients. The DSM construct and diagnosis of Antisocial Personality Disorder may be enhanced by greater emphasis on personality traits associated with antisocial behavior.     

High-lethality status in patients with borderline personality disorder

Recurrent suicidal behaviors in patients with Borderline Personality Disorder (BPD) are often considered communicative gestures; however, 10% complete suicide. This study seeks to identify risk factors for suicide within a BPD sample by comparing patients with High- and Low-Lethality attempts. BPD attempters (n = 113) were assessed on demographic, diagnostic, and personality variables: clinical symptoms, suicidal behaviors; childhood, family, and treatment histories; social adjustment; and recent life events. Forty-four High-Lethality attempters, defined by a score of 4 or more on Beck's Medical Lethality Scale, were compared to 69 Low-Lethality attempters. Discriminating variables were entered in a multivariate logistic regression model to define predictors of High-Lethality status. High-Lethality attempters were older, with children, less education, and lower socioeconomic class (SES) than Low-Lethality attempters. They were more likely to have Major Depressive Disorder (MDD), co-morbid Antisocial Personality Disorder (ASPD), and family histories of substance abuse. They reported greater intent to die, more lifetime attempts, hospitalizations, and time in the hospital. High-Lethality status was best predicted by low SES, co-morbid ASPD, extensive treatment histories, and greater intent to die. These characteristics resemble profiles of patients who complete suicide, are not specific for BPD, and do not include impulsivity, aggression, or severity of BPD criteria.     

Adult Antisocial Behavior And Affect Regulation Among Primary Crack/Cocaine-Using Women

The relationship between deficits in affect regulation and Adult Antisocial Behavior (ASB) in primary crack/cocaine-using women was explored in a sample of 80 inner-city women. Narrative early memories were coded for two components of affect regulation, Affect Tolerance and Affect Expression, using the Epigenetic Assessment Rating Scale (EARS; Wilson, Passik, & Kuras, 1989 ). ASB was measured by the adult criteria of Antisocial Personality Disorder on the SCID-SAC ( Spitzer, Williams, Gibbon, & First, 1993 ). Analyses compared primary crack/cocaine-using women with and without ASB on the affect regulation measures. Findings using memories of primary caretakers revealed that women with ASB had significantly poorer capacity for Affect Tolerance and Affect Expression than women without ASB, suggesting that ASB is significantly associated with differences in the capacity to regulate emotional experience among primary crack/cocaine-using women.     

Intermittent explosive disorder and other psychiatric comorbidity among court-referred and self-referred aggressive drivers

We assessed possible Axis I and Axis II disorders in two groups of aggressive drivers (n=20, court-referred; n=10, self-referred) and 30 non-aggressive driver controls, using the SCID and SCID-II. Aggressive drivers were more likely than controls to be positive for any Axis I and Axis II disorders. They were also more likely to meet the criteria for Intermittent Explosive Disorder (IED), current or past alcohol or substance abuse or dependence and Antisocial PD and Borderline PD. The self-referred aggressive drivers were more likely than court-referred aggressive drivers to meet the criteria for a current or past Anxiety Disorder. Re-analysis of aggressive driver data on the basis of presence or absence of IED revealed differences only in Axis II disorders: those with IED were more likely to meet the criteria for any Axis II disorder and Antisocial PD.     

The criterion validity of the Borderline Personality Features Scale for Children in an adolescent inpatient setting

The purpose of the current study was to examine the criterion validity of the Borderline Personality Features Scale for Children (BPFS-C) by assessing the performance of the self-report and a newly developed parent report version of the measure (BPFS-P) in detecting a borderline personality disorder (BPD) diagnosis in adolescent inpatients. This study also examined parent-child agreement and the internal consistency of the BPFS subscales. An inpatient sample of adolescents (n = 51) ranging from ages 12-18 completed the BPFS and were administered the Child Interview for DSM-IV Borderline Personality Disorder (CI-BPD) by trained clinical research staff. ROC analyses revealed that the BPFS-C has high accuracy (AUC = .931; Se = .856; Sp = .840) in discriminating adolescents with a diagnosis of BPD, as measured by the CI-BPD, while the BPFS-P has moderate accuracy (AUC = .795; Se = .733; Sp = .720). Parent-child agreement on total scores was significant (r = .687; p < .005). Cronbach's alphas suggested internal consistency for the four subscales of the BPFS. These findings support the criterion validity of this measure, particularly the self-report version, in adolescent inpatient settings.     

Die Antisoziale Persönlichkeitsstörung des DSM-IV-TR - Befunde, Untergruppen und Unterschiede zu Psychopathy

The diagnosis of Antisocial Personality Disorder (ASPD) is based on robust scientific evidence identifying a group of individuals who display antisocial behaviour from a very young age that remains stable across the life-span. This population of persons with ASPD is heterogeneous, composed of distinct sub-types defined by comorbid disorders. Evidence indicates that ASPD is distinct from both psychopathy, as defined by the PCL-R, and from Dissocial Personality Disorder, as defined by ICD-10. Studies of the prevalence of ASPD are reviewed, highlighting the difficulties inherent in designing and conducting investigations of community samples that derive accurate estimates. The few studies of the socio-demographic correlates of ASPD are presented followed by a review of the evidence on disorders that are comorbid with ASPD. Finally, a hypothesis is presented for orienting future research on the aetiology of ASPD and the development of effective programmes for reducing violence among persons with ASPD.     

Die Bedeutung der Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung für die Entstehung und Prognose von Störungen des Sozialverhaltens im Kindes- und Jugendalter

Attention Deficit/Hyperactivity Disorder (ADHD) and Conduct Disorder (CD) are two of the most common neurobehavioral disorders of childhood. Despite of their high comorbidity rate both disorders can be reliably differentiated. Especially the comorbid condition is associated with a poor outcome and some of the affected children develop an Antisocial Personality Disorder. This article summarizes diagnostic criteria and epidemiological data of both disorders and emphasises the role of ADHD in the aetiology and pathogenesis of antisocial behavior. ADHD seems to have a negative impact particular in children of the early-starter subtype of CD. Findings from genetic, psychophysiological and neuroimaging studies emphasise the relevance of biological risk factors in the etiological models and developmental pathways of antisocial behavior. We present so far unpublished data of children with ADHD and ADHD/disruptive behavior disorders which indicate group-specific neurocognitive impairments in the comorbid condition. ADHD and CD seem to constitute a synergistic and interactive relationship in that each disorder aggravates the other. Recent findings point to a “true hybrid” of ADHD/CD. Considering the negative outcome of the comorbid condition, several findings suggest that high-quality treatments may have considerable impact on restoring ADHD children to better functioning.     

Are DSM-IV-TR Borderline Personality Disorder, ICD-10 Emotionally Unstable Personality Disorder, and CCMD-III Impulsive Personality Disorder Analogous Diagnostic Categories Across Psychiatric Nomenclatures?

This study examined the validity of the borderline construct which encompasses diagnostic criteria from the DSM-IV-TR Borderline Personality Disorder (BPD), ICD-10 Emotionally Unstable Personality Disorder (EUPD), and CCMD-III Impulsive Personality Disorder (IPD) in a sample of 1,419 Chinese psychiatric patients. Participants completed the Chinese Personality Disorder Inventory and the Chinese Personality Assessment Inventory-2 assessing various disordered personality features. Adequate internal consistency was found for the borderline construct (α = .83). Exploratory factor analysis revealed two components: (1) affective and cognitive disturbances, and (2) impulse dysregulation, which were replicated by confirmatory factor analysis. Item analysis indicated that the various borderline criteria displayed similar levels of diagnostic efficiency, which does not support the elimination of fear of abandonment and transient psychotic features from the EUPD and IPD criteria set. Findings of this study suggest that BPD, EUPD, and IPD may represent analogous diagnostic categories across classification systems.     

Emerging as a Personality Disorder Service

Personality Disorder Services working along psychotherapeutic lines are gaining appeal with Health Care Commissioners following the publication of the NICE guidelines for Borderline & Antisocial Personality Disorders and the emerging successful application of psychoanalytically-derived approaches.

Establishing a new Personality Disorder Service is akin to constructing a ‘home’ within which the therapeutic work with patients can develop. As clinicians, we are required to question what facets are important to the development of this new home, and to further to endure the unfamiliar state of being ‘not at home’ while the identity of the service is established.

We address how this process parallels the task facing the patient as they struggle to establish their own identity. We also highlight some important tenets in the work of securing a robust identity for both the service and the patient suffering from a personality disorder.     

The intergenerational link to antisocial behavior: Effects of paternal contact

We investigated the relationship between paternal antisocial behavior and child conduct problems and we tested whether the degree of contact between father and child moderated the intergenerational link to antisocial behavior. Subjects were 92 children between the ages of 6 and 13 referred to an outpatient mental health clinic. There was a significant association between Antisocial Personality Disorder (APD) in fathers and a diagnosis of conduct problems in their children. However, the relationship between paternal APD and conduct problems in offspring was not dependent on whether or not the father was in the home or on the degree of paternal contact with their child. The theoretical implications of these findings for explaining the intergenerational link to antisocial behavior in terms of observational learning were discussed.     

Further validation of the psychopathic personality inventory among offenders: personality and behavioral correlates.

The Psychopathic Personality Inventory (PPI; Lilienfeld & Andrews, 1996) is a relatively new self-report measure that has shown considerable promise as an index of psychopathic traits in both nonoffender and offender samples. The present study examined the construct validity and predictive utility of the PPI by examining its association with theoretically relevant scales of the Personality Assessment Inventory (PAI; Morey, 1991) among 60 male prison inmates, and its ability to predict institutional misbehavior in an expanded sample (n = 89). As expected, correlations with the PAI scales were highest for the Antisocial Features (ANT) and Aggression (AGG) scales (rs = .68 and .57, respectively). The PPI also predicted various forms of nonviolent and physically aggressive disciplinary infractions significantly better than chance (point biserial correlations ranging from .26 to .37).     

Maternal Antisocial Behavior, Parenting Practices, and Behavior Problems in Boys at Risk for Antisocial Behavior

We investigated the independent contributions of maternal history of antisocial behavior and parenting practices to the worsening course of sons' behavior problems in a sample of young urban boys at risk for antisocial behavior. Mothers reported on boys' behavior problems at baseline and one year later, as well as on their own history of antisocial behavior before and after age 15, and of lifetime depression and substance use disorders (provisional DSM-III-R diagnoses). Baseline reports of parenting practices were obtained. Lower involvement, lower monitoring, and higher levels of parent–child conflict and maternal Conduct Disorder (CD) before age 15 contributed to the worsening of boys' behavior problems one year later; mothers' symptoms of Antisocial Personality Disorder after age 15 did not. Mothers' lifetime history of Major Depression and Substance Use Disorder did not add to the worsening of boys' behavior problems after accounting for these other factors. Although maternal CD contributed directly to the worsening of boys' behavior problems, the effect of parenting was more substantial. We discuss clinical implications for prevention and treatment of children's antisocial behavior, and intergenerational implications of girls' early antisocial behavior.     

A meta‐analysis of psychopathy‐, antisocial PD‐ and FFM associations

This research meta‐analytically summarizes the relationships of the Five‐Factor Model (FFM) with psychopathy and Antisocial Personality Disorder (APD). Effect sizes of the associations between psychopathy, APD and the FFM were compiled from 26 independent samples (N = 6913) for psychopathy and 57 independent samples (N = 16 424) for APD. The results revealed predominantly points of similarity and some differences in the FFM associations of both disorders. Symptoms of psychopathy and APD were negatively associated with Conscientiousness and Agreeableness facets and positively with scores on Angry–Hostility (N2), Impulsiveness (N5), Excitement Seeking (E5) and negatively with Warmth (E1). Only psychopathy had a small negative association with Anxiety (N1) and was characterized by stronger negative associations with Agreeableness and Straightforwardness (A2), Compliance (A4) and Modesty (A5) compared to APD. The moderator analyses showed that sample type, use of the NEO‐PI‐R and APD instrument moderated the APD FFM associations, while psychopathy instrument and age group were moderators in the psychopathy MA. Implications of this research for the assessment of APD and psychopathy relying on dimensional models of personality pathology are discussed. Copyright © 2009 John Wiley & Sons, Ltd.