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Antisocial Personality Disorder: A Current Review

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Curr Psychiatry Rep (2013) 15:427
DOI 10.1007/s11920-013-0427-7

PERSONALITY DISORDERS (C SCHMAHL, SECTION EDITOR)

Antisocial Personality Disorder: A Current Review

Andrea L. Glenn & Alexandria K. Johnson & Adrian Raine

Published online: 20 November 2013

# Springer Science+Business Media New York 2013

Abstract The Diagnostic and Statistical Manual of Mental Introduction

Disorders (DSM 5) classification of antisocial personality
disorder (ASPD) describes individuals who engage in repeti- Antisocial personality disorder (ASPD) describes individuals
tive irresponsible, delinquent, and criminal behavior. The with a pervasive pattern of disregard for, and violation of, the
diagnosis is highly controversial, with many researchers and rights of others that begins in childhood or early adolescence
clinicians arguing that the category is too heterogeneous, and continues into adulthood. Based on the DSM-IV criteria
overinclusive, and demonstrates considerable overlap with for ASPD, recent epidemiological studies report a prevalence
other disorders. This review focuses on recent studies that of 2-3 % in the general population [1], with estimates of
have improved our understanding of the characteristics of approximately 3 % in men and 1 % in women. In prison
individuals who fit the ASPD definition by exploring how samples, studies have found rates of ASPD to be 47 % in
subtypes differ and how comorbid conditions influence the men and 21 % in women [2]. In addition to the costs placed on
presentation of ASPD. In addition, we discuss research on the the criminal justice system, APSD inflicts considerable costs
etiology of ASPD that has identified genetic and environmen- on health and social service agencies.
tal factors that may contribute to the development and persis- How to best define the construct of ASPD is a topic of
tence of antisocial behavior, and brain imaging research that debate that has gained traction in recent years. Many re-
has improved our understanding of the relationships between searchers have expressed concerns that the current ASPD
ASPD and other psychopathology. Finally, we discuss prom- criteria place too much emphasis on observable behaviors,
ising preliminary research on treatment for this disorder. rather than on the underlying personality structure [3]. How-
ever, the newly released update of the DSM, the DSM-5,
Keywords Crime . subtypes . DSM 5 . Psychopathy . retains the same diagnostic criteria for ASPD as was included
Substance use . Brain imaging . Genetics . Child abuse . in the previous edition. Criteria include behaviors such as
Treatment . Personality disorder repeatedly performing acts that are grounds for arrest, repeat-
ed lying, repeated fights or assaults, disregard for the safety of
oneself and others, repeated failure to sustain consistent work
This article is part of the Topical Collection on Personality Disorders
behavior, and mistreating other individuals. The personality
A. L. Glenn (*) disorders work group, charged with ensuring that the diagnos-
Center for the Prevention of Youth Behavior Problems, Department
tic criteria for personality disorders reflects current under-
of Psychology, University of Alabama, Box 870348,
Tuscaloosa, AL 35487, USA standing based on up-to-date research, suggested an alternate
e-mail: [email protected] model for personality disorders that differed in significant
ways from the retained criteria. This proposed model is in-
A. K. Johnson
cluded in the DSM-5 under Section III, which is reserved for
Department of Psychology, University of Alabama, Box 870348,
Tuscaloosa, AL, USA emerging measures and models. The alternate model places a
e-mail: [email protected] much greater emphasis on personality characteristics than the
current model, evaluating traits such as egocentrism, empathy,
A. Raine
and self-direction, and seems to be more closely aligned with
Departments of Criminology, Psychiatry, and Psychology, University
of Pennsylvania, 3809 Walnut Street, Philadelphia, PA 19104, USA the construct of psychopathy by including traits such as ma-
e-mail: [email protected] nipulativeness, callousness, deceitfulness, and impulsivity.
427, Page 2 of 8 Curr Psychiatry Rep (2013) 15:427

This potential future direction of ASPD is deserving of careful offer some evidence that ASPD may in fact be a heteroge-
consideration and further research. neous diagnosis.
ASPD has high rates of comorbidity with several psychi- A follow-up study focused on participants within the sample
atric disorders, including psychopathy, substance abuse, anx- who were court-ordered to attend substance abuse treatment
iety, depression, bipolar disorder, and borderline personality found correlations suggestive of differences in the etiology of
disorder. One of the primary questions that has been the focus substance abuse among the four previously identified sub-
of research in the last few years is how the category of APSD groups and a fifth non-ASPD subgroup [7]. Specifically, this
relates to other constructs. Understanding the overlap between study reported that for the two non-psychopathic subgroups
these constructs, as well as how ASPD may contain subtypes, (non-psychopathic ASPD and non-ASPD) negative emotional-
will likely provide information about etiology and may be ity and impulsivity were both significantly correlated with drug
beneficial in developing treatment programs. use, whereas in the three psychopathic ASPD subgroups only
impulsivity was significantly correlated with drug use (and only
in two of the three psychopathic subgroups). Similarly, within
Subtypes of ASPD and Associations with Other Disorders the two non-psychopathic subgroups, impulsivity was signifi-
cantly correlated with alcohol abuse, whereas this relationship
Several recent studies suggest that people who meet criteria for was not significant among the three psychopathic subgroups.
ASPD can be subtyped into more precise and homogeneous Another study [8] attempted to replicate the same four
groups based on characteristics that offer greater acuity than clusters found by Poythress et al., this time using the Psycho-
solely the tendency to act in ways that are irresponsible and pathic Personality Inventory (PPI) [9]. Despite the poor clas-
illegal. In particular, recent research has examined associations sification accuracy reported, the four subtypes still showed
with psychopathy, substance use, and mood disorders. significant differences, with those in the non-psychopathic
ASPD subgroup being the least likely to commit any infrac-
tion and the least likely to commit a violent infraction while in
Associations with Psychopathy prison. Results from these studies offer support for the idea
that individuals with ASPD who do not demonstrate psycho-
Antisocial personality disorder has perhaps the most overlap pathic traits differ in meaningful ways from those diagnosed
with the construct of psychopathy. Psychopathy, while not with ASPD who also meet criteria for psychopathy.
recognized in the diagnostic criteria of DSM 5, describes In addition to studies that have examined subtypes based on
individuals with many of the features of ASPD, but who, in psychological characteristics, a number of recent studies have
addition, demonstrate a characteristic set of interpersonal and also examined the underlying biological factors that may either
affective features, including superficial charm, manipulative- unify or distinguish individuals with ASPD. In a sample of
ness, callousness, and shallow affect [4, 5]. Although some female offenders, Anton et al. [10] examined the process of
individuals diagnosed with ASPD may have psychopathic fear-potentiated startle, finding distinct patterns of cognitive
traits, others may not. Some suggest that although psychopa- processing and fear reactivity between psychopathy and ASPD.
thy and ASPD share many features, the underlying psychobi- Specifically, psychopathy was associated with selective atten-
ological processes may be distinct. tion that favored goal-relevant information and filtered out
The current diagnostic criteria for ASPD are primarily peripheral information, including information related to threats.
behavior based, in contrast to the construct of psychopathy, Those with ASPD, on the other hand, displayed a more distinct
which contains interpersonal and affective features in addition fear deficit as well as possible deficits in executive functioning,
to behavioral criteria. There has been some debate as to as evidenced by greater fear-related distraction when conditions
whether the personality features captured by the psychopathy placed participants under greater cognitive demand. Drislane
construct are simply associated features of the maladaptive et al. [11] also examined differing responses to threat cues
behavior essential to ASPD, or whether psychopathy and between those with psychopathy and ASPD. Psychopathic
ASPD differ more substantially. Examining this question participants (nearly all of whom also met criteria for co-
within a sample of 691 offenders who met criteria for ASPD, morbid ASPD) had a diminished defensive response to threat
Poythress et al. [6] conducted a cluster analysis which re- compared to non-psychopathic ASPD participants, whose
vealed that these offenders could be separated into meaningful threat-response did not significantly differ from those who did
subgroups based on significant differences in personality traits not meet criteria for either ASPD or psychopathy. Moreover,
commonly identified within the psychopathy literature (e.g., results showed that the deficit in defensively responding to
low anxiety/fear, impulsivity, dominance). Poythress et al. [6] threat which psychopaths in this study displayed was associated
identified four ASPD subtypes (primary, secondary, and “fear- with the affective-interpersonal features of the disorder. This
ful” psychopathy, as well as non-psychopathic ASPD) within finding highlights the importance of affective-interpersonal
their sample. The four subgroups identified within ASPD traits in distinguishing psychopathy from ASPD.
Curr Psychiatry Rep (2013) 15:427 Page 3 of 8, 427

A recent study examining the brain through structural MRI two disorders difficult. DeShong and Kurtz [14] found evi-
also revealed, as in the prior study, that, at least in some dence in support of using a four factor model of impulsivity
respects, participants with ASPD but not psychopathy appear [15] to more accurately distinguish the two disorders. Results
more similar to the control group than they do to participants showed that each disorder was uniquely associated with two
with co-morbid psychopathy and ASPD. Gregory et al. [12•] of the four impulsivity factors. Borderline features were asso-
found that, compared to violent offenders who met criteria for ciated with urgency (acting rashly in reaction to intense neg-
ASPD but not psychopathy, violent offenders who met criteria ative affect) and a lack of perseverance, whereas ASPD was
for both disorders had significantly reduced gray matter volume associated with sensation seeking and a lack of premeditation.
in areas of the brain related to empathy, morality, and process- Impulsivity is also a common feature in bipolar disorder. In
ing prosocial emotions such as guilt. The gray matter of the a study comparing the role of impulsivity in individuals with
former group appeared similar to that of non-offenders without bipolar disorder only, ASPD only, ASPD with bipolar disor-
either disorder. These studies provide further evidence that der, and controls without either disorder, Swann et al. [16]
although there are some shared deficits, ASPD and psychopa- found that although both disorders are associated with impul-
thy are characterized by distinct neurobiological processes, sivity, when ASPD was co-morbid with bipolar disorder sig-
suggesting that there are differences in the etiology of these nificant deficits in the ability to delay reward were present
disorders. These studies support the idea that there may be a compared to participants with either disorder alone. This
distinct subgroup of individuals with ASPD for whom antiso- suggests that perhaps the mechanisms underlying impulsivity
cial behavior results from different underlying pathology. in the two disorders may be slightly different or perhaps when
the disorders are combined the ability to compensate for
Associations with Mood Disorders impulsivity is diminished. In another study of bipolar disorder
concurrent with ASPD, Mueser et al. [17] examined schizo-
Many characteristics common to mood disorders (e.g., emo- phrenia, schizoaffective disorder, or bipolar disorder and
tional reactivity, impulsivity) overlap with characteristics found that among these patients, those who also had co-
commonly associated with ASPD. The examination of ASPD morbid ASPD had: greater functional impairment, greater
as it presents co-morbidly with specific mood disorders can strain on relationships with relatives, higher rates of drug
aid in better understanding the variety of possible mechanisms abuse, more severe depression, and less education. Overall,
that may underlie the problematic behaviors characteristic of the results from these studies suggest that when ASPD is co-
ASPD. morbid with other disorders, associated negative effects are
For example, in a recent study [13•] examining the presence exacerbated.
of anxiety disorders among offenders diagnosed with ASPD,
two-thirds of the participants were reported to have symptoms Associations with Substance Use Disorders
of an anxiety disorder at some point in their lifetime. Offenders
whose ASPD was accompanied by co-morbid anxiety had Studies have reported that 80–85 % of individuals with ASPD
significantly greater ASPD symptoms, as well as significantly also meet criteria for a substance use disorder (SUD) [18, 19].
increased suicidal ideation and suicide attempts, and greater This is compared to the estimated US population lifetime
alcohol and drug abuse compared to offenders with ASPD prevalence rates of 13.5 % for alcohol use disorders and
alone. Those with co-morbid ASPD had more convictions for 6.1 % for other drug use disorders [18]. A recent study found
homicide, attempted homicide, and physical and sexual aggres- that approximately 71 % of patients in a rural inpatient psy-
sion. One possible explanation for these associations between chiatric facility diagnosed with ASPD abused alcohol, and
ASPD behaviors and anxiety is that the low-activity variant of approximately 62 % abused multiple substances. Over half
the MAOA gene is associated with both enhanced reactivity to abused cannabis and nearly one third abused amphetamines
threat as well as an increased likelihood to experience anger, [19]. A study examining heavy episodic drinking among
making a carrier of this gene more prone to anxiety and more college undergraduates found that ASPD was significantly
likely to engage in reactive aggression. This possibility offers correlated with heavy episodic drinking. In fact, ASPD sever-
some evidence that among offenders with ASPD, the mecha- ity accounted for 9–26 % percent of the variance in heavy
nisms underlying violent behavior may differ for those who episodic drinking behavior within this particular sample [20].
also have co-morbid anxiety. In the previously mentioned study by Mueser and colleagues
Impulsivity is another feature that is present in ASPD as [17], it was found that among participants with a serious
well as several other disorders. Recent studies have examined mental illness, those who had a co-occurring ASPD diagnosis
how impulsivity may differ in individuals with ASPD depend- were significantly more likely to abuse drugs and to use drugs
ing on whether another diagnosis is present. For example, more frequently, especially amphetamines and opiates. A
borderline personality disorder and ASPD share impulsivity recent study by Schiffer et al. [21] attempted to identify
as a common characteristic, which can make differentiating structural differences within the brains of violent offenders
427, Page 4 of 8 Curr Psychiatry Rep (2013) 15:427

as compared to non-offenders while accounting for long-term disorder [26–28]. Recently Basoglu et al. [29] examined two
substance abuse, which often co-occurs alongside violence and variants of the synaptosomal-associated protein 25 (SNAP25)
can have substantial effects on brain structures. Results showed gene, a gene that has been associated with attention-deficit
that greater gray matter volume in the mesolimbic reward hyperactivity disorder and cognitive performance, and may be
system of the brain may be associated with violence, whereas associated with the functioning of several neurotransmitters.
decreased gray matter in the prefrontal cortex, orbitofrontal Specific variants of these two polymorphisms were more
cortex, and premotor area is associated with substance abuse. frequently present in male participants with ASPD than in
sex-matched healthy controls. Notably, these polymorphisms
Summary were not associated with psychopathic traits, suggesting that
they may be associated with traits that are seen across the
The fact that there is significant overlap between ASPD and spectrum of externalizing behavior such as novelty seeking
several other forms of psychopathology makes understanding and reward dependence, rather than traits that are unique to
the developmental of it even more complicated. When exam- psychopathy.
ining the biological and environmental factors associated with Although single genes only contribute to a small proportion
antisocial personality disorder it is important that researchers of the overall variance in antisocial behavior [30], identifying
consider whether these factors are specific to antisocial per- genes that confer risk may aid in the development of treatment
sonality disorder, or are factors that may more broadly con- methods that could potentially be tailored to specific risk
tribute to the co-occurrence of antisocial personality disorder factors of the individual. In addition, it may improve our
and other disorders. understanding of the biological pathways that lead to antiso-
cial behavior.

Etiology of ASPD Environmental Factors

Results from a growing body of research, including from Although genes may contribute to half of the variance in
prospective longitudinal studies, suggest a complex interplay antisocial behavior, this still leaves a large proportion of vari-
between biological (genetic/physiological/neurobiological) ance that results from environmental influences. In many cases,
and environmental factors contribute to the development and it is difficult to tease apart the influences of genes versus the
maintenance of ASPD. In the last few years, several studies environment because the two are confounded. If one or both
have furthered our knowledge in this area. parents are antisocial, it is likely that genetic risk factors for
antisocial behavior will be transmitted to the child. Because of
Genetics this, it is difficult to determine the extent to which environmen-
tal influences associated with having an antisocial parent have
Extensive research has shown that genetic factors contribute an effect. A child with an antisocial parent may be more likely
to approximately half of the variance in antisocial behavior to experience maltreatment, or may witness violence in the
[22, 23]. Recently, Barnes, Beaver, and Boutwell [24•] home. Data from an epidemiologic survey suggests that child-
assessed how genetic contributions to antisocial behavior hood witnessing of intimate partner violence increases the risk
may differ depending on the developmental trajectories that for adult perpetration of intimate partner violence [31]. Antiso-
have been defined by Moffitt. This model defines two groups cial parents may also have poorer parental management strate-
of offenders—life-course persistent offenders who manifest gies (harsh and inconsistent discipline, less supervision of the
antisocial behavior beginning in childhood and whose prob- child, lack of warmth toward the child), and may be less able to
lems remain relatively stable throughout adulthood, and provide adequate resources for the child.
adolescence-limited offenders, who exhibit behavioral prob- Berg-Nielsen and Wichström [32] recently examined the
lems primarily in adolescence. In a study of sibling pairs, influence of parents’ personality disorder status on child prob-
Barnes, Beaver and Boutwell found that genetic factors ex- lems at the preschool age. Similar to prior work showing that
plained a larger percent of the variance in being classified as a parent antisociality places older children and adolescents at risk
life-course persistent offender than being an adolescent- for developing a range of externalizing and internalizing prob-
limited offender. These findings support Moffit’s theory [25] lems [33], they found that parents’ personality disorder symp-
which suggested that environmental influences contribute toms (antisocial, borderline, or narcissistic) explained 13.2 % of
more to the development of adolescent-limited offending. the variance in children’s behavioral symptoms. Although this
Although it is clear that there is a significant genetic con- study does not disentangle the genetic versus environmental
tribution to antisocial behavior, an important next step is to contributions to the generational transmission of behavioral and
understand which specific genes confer risk. Several genes emotional problems, it demonstrates that these problems can be
have been examined in relation to antisocial personality observed as early as the preschool years.
Curr Psychiatry Rep (2013) 15:427 Page 5 of 8, 427

Another factor that has been examined is television view- compared to non-deprived violent individuals and healthy
ing. In a 26-year longitudinal study assessing a birth cohort of controls. The thalamus is a region which filters incoming
1037 individuals, young adults who had spent more time sensory information. Although speculative, the authors sug-
watching television during childhood and adolescence were gest that a thalamic deficit may make it more difficult for
significantly more likely to have a diagnosis of ASPD and individuals to suppress intrusive memories and thoughts re-
more likely to have a criminal conviction [34]. These associ- lated to prior abuse and maltreatment. They also found a
ations remained significant when controlling for sex, IQ, negative relationship between psychosocial deprivation and
socioeconomic status, previous antisocial behavior, and pa- volume in the inferior frontal region of the prefrontal cortex
rental control. The authors speculate about the mechanisms across all individuals. This region is involved in inhibition and
that could explain the effect of television viewing on antisocial behavioral control; deficits in this region may contribute to an
behavior. One possibility is based on observational learning inability to plan and regulate one’s behavior.
theory, whereby the behaviors that are viewed on television
are imitated or internalized. Youth may also become emotion- Brain Imaging
ally desensitized to violence or the suffering of others, or may
develop normative beliefs about the use of aggression and Prospective longitudinal studies implementing neuropsycho-
violence in response to particular situations. Additional mech- logical tests in children as young as 3 years suggest that
anisms include reduced social interactions with peers and/or abnormalities in brain functioning may contribute to the de-
parents, poorer educational achievement, and increased risk of velopment of ASPD [38]. A number of neuroimaging studies
unemployment [34]. have identified brain regions in which the structure or function
In another prospective longitudinal study, Shi et al. [35] differs in antisocial groups [39]. One of the most replicated
examined different components of the early childhood envi- findings is that individuals with antisocial personality disorder
ronment that were related to ASPD features nearly 20 years have reduced volume and functioning in the prefrontal cortex
later. They found that quality of early care, as indexed by [40]. A recent study suggests that differences in the structure
clinician referral for problems in the parent-infant relationship of the prefrontal cortex may partially explain the gender
during the first 18 months of life, was a significant predictor of differences in antisocial behavior. Raine et al. [41•] found that
ASPD in adulthood. Signs of maternal withdrawal, such as there are significant differences between men and women in
interacting silently, failing to greet the infant, and using toys gray matter volume specifically in the orbitofrontal and mid-
instead of the self to soothe the infant were also found to be dle frontal regions of the prefrontal cortex. Controlling for
predictive of later ASPD outcomes. At age 8, disorganized these brain differences reduced the gender difference in anti-
attachment was predictive of later ASPD. Similarly, Liu et al. social personality by 77.3 %. These findings suggest that part
[36] found that childhood abuse was associated with ASPD of the gender difference in antisocial behavior is attributable to
features in adulthood. Psychosocial deprivation, including gender differences in the volume of prefrontal brain regions.
abuse and neglect, has been found to be very common in Other recent studies have questioned whether reduced vol-
individuals with ASPD [37]. In both of these studies, genetic umes in prefrontal regions are associated with ASPD gener-
factors may also be involved. Parents who demonstrate lower ally, or whether they are a result of comorbid conditions. As
quality caregiving may also pass on genes to their offspring mentioned above, two studies have examined differences in
that confer risk for antisocial behavior. Twin and adoption the brain in different subgroups of individuals with ASPD.
studies will be necessary to determine whether these environ- Gregory et al. [12•] found reduced prefrontal gray matter only
mental factors themselves confer risk for antisocial behavior, in individuals with comorbid psychopathic traits. No prefron-
or whether there may be confounding genetic factors. tal volume differences were observed between controls and
One of the ways in which environmental factors such as individuals with ASPD and low levels of psychopathic traits.
childhood abuse may result in antisocial behavior is through Schiffer et al. [21] examined the potential effects of substance
direct effects on biological systems. The environment can use on findings in antisocial groups. Using a 2 (violent of-
influence how genes are expressed (e.g., whether genes are fenders / non-offenders) × 2 (substance use disorders / no
“turned on or off”) and can alter hormone and neurotransmit- substance use disorders) design, they were able to examine
ter levels, which in turn affect brain functioning. Environmen- the effects of antisocial behavior and substance use separately.
tal factors early in life may have a particularly pronounced They found that although men with SUDs exhibited smaller
effect on biological systems. A recent brain imaging study gray matter volume in the prefrontal cortex, there were no
highlights this idea. Kumari et al. [37] examined how psycho- differences in this region between violent offenders and non-
social deprivation, including childhood physical and sexual offenders. These findings differ from those of Raine et al.
abuse, related to brain structure in violent individuals with [41•], who found that individuals with ASPD did demonstrate
ASPD. They found that the volume in the thalamus was reductions in the prefrontal cortex compared to non-antisocial
reduced in psychosocially deprived violent individuals substance abuse control participants. In the study by Gregory
427, Page 6 of 8 Curr Psychiatry Rep (2013) 15:427

et al., there were no differences between the ASPD groups individuals with specific brain functioning find it easier to
with and without psychopathic traits in the proportion of lie or whether frequent lying alters brain functioning), it
lifetime substance use disorders, but there were significant demonstrates that there is variation within individuals with
differences between ASPD and control participants. However, ASPD.
they found no regions in which brain volumes differed be- The source of differences in brain structure and functioning
tween offenders with ASPD without psychopathic traits and in individuals with ASPD may result from either genetic or
non-offenders. environmental influences. As noted above, some brain differ-
In sum, these studies suggest that the finding of reduced ences may result from psychosocial deprivation, such as
prefrontal gray matter volumes may be influenced by comor- childhood physical and sexual abuse [37]. Such environmen-
bid conditions such as psychopathy and substance abuse, but tal factors, particularly early in life, can significantly affect the
relationships remain unclear. Given the heterogeneity of development of the brain, and thus increase the risk for anti-
ASPD, it is difficult to integrate results from neuroimaging social behavior.
studies. In many samples it is unclear how many participants
also exhibit psychopathic traits, substance use disorders, or
other forms of psychopathology. The issue of substance use in Advances in Treatment of ASPD
particular is a complicated factor to disentangle. Research
suggests that common genetic factors contribute to risk for ASPD has long been recognized as one of the more difficult
antisocial personality and substance use problems [42]. Addi- forms of psychopathology to treat. Individuals rarely seek
tionally, the use of substances from an early age may directly treatment and many service providers are reluctant to attempt
affect brain structure and functioning. Longitudinal studies to treat these individuals. When in treatment, therapists report
will be necessary to understand the concurrent development difficulty establishing a therapeutic alliance and find poor com-
of antisocial behavior and substance use disorders. pliance with treatment. The presence of comorbid psychopa-
Additional studies have used novel tasks and methods to thology often further hinders treatment progress. High quality
further our understanding of the neurobiological differences in trials on the treatment of ASPD are lacking. One study com-
individuals with ASPD. Tang et al. [43] examined brain activity pared cognitive behavioral therapy with treatment as usual in a
during a resting period in a sample of young adult offenders community sample with a diagnosis of ASPD [45]. They found
with ASPD. Using machine learning, they were able to develop that individuals receiving CBT showed a small but nonsignif-
a classifier that could discriminate ASPD individuals from icant improvement in social functioning and physical aggres-
normal controls with 86.57 % accuracy. The authors suggest sion, but no improvements in anger or verbal aggression com-
that this classifier may be able to improve the diagnosis of pared to individuals receiving treatment as usual. One form of
ASPD and aid in the understanding of the etiology. ASPD treatment that has emerged in the last decade is mentalization-
participants were found to have decoupling between the regions based treatment [46]. Mentalization is the capacity to think
that become active while at rest (referred to as the default mode about one’s own mental state and the mental states of others.
network) and regions that are involved in attention. The default This form of treatment was originally developed for individuals
mode network is thought to be involved in processes such as with borderline personality disorder. Preliminary evidence sug-
emotion regulation, planning for the future, reflecting on past gests that this treatment may be effective in reducing self-
experiences, and self-reflection. Decreased functioning in this reported aggressive behavior individuals with ASPD with mod-
network may result in impairment in these processes. Tang et al. erate levels of psychopathic traits [47].
also used voxel-based morphometry to examine brain volumes.
They found altered gray matter volumes in the parietal lobe and
altered white matter volumes in the precuneus, but no volumet- Conclusions
ric differences in the prefrontal cortex.
Jiang et al. [44] examined the neural correlates of deception Research in the last few years has highlighted the fact that
in a sample of offenders with ASPD. Similar to findings from subtypes of ASPD exist. These subtypes differ in meaningful
healthy populations, they found that areas of the dorsolateral ways, including exhibiting different biological risk factors.
prefrontal cortex, inferior parietal lobe, and anterior cingulate Furthermore, research has begun to clarify how comorbid
were associated with lying versus truth-telling. These regions conditions such as anxiety, substance use disorders, and bipo-
have previously been associated with cognitive control and lar disorders influence the presentation of ASPD. Research on
inhibition, and thus may be necessary for inhibiting the nor- the etiology of ASPD has established that genetic factors have
mal propensity toward truth-telling. Offenders who scored a significant role in antisocial behavior that begins early and
higher on ASPD criteria associated with deception had less persists into adulthood. Specific genes and specific environ-
activity in these regions. Although this study cannot provide mental factors have been identified as contributors to the
information about causal relationships (i.e., whether disorder. Brain imaging research suggests that the
Curr Psychiatry Rep (2013) 15:427 Page 7 of 8, 427

consideration of comorbid conditions is particularly important symptoms on cognitive and fear processing in female offenders.
Cogn Affect Behav Neurosci. 2012;12(4):761–76. doi:10.3758/
in understanding the deficits that accompany ASPD, and also
s13415-012-0114-x.
highlight the potential for brain imaging to aid in the diagnosis 11. Drislane LE, Vaidyanathan U, Patrick CJ. Reduced cortical call to arms
of the disorder. Finally, although much work remains to be differentiates psychopathy from antisocial personality disorder. Psychol
done in the realm of treatment, preliminary evidence suggests Med. 2013;43(04):825–35. doi:10.1017/S0033291712001547.
12. • Gregory S, Ffytche D, Simmons A, Kumari V, Howard M, Hodgins
that newer methods hold promise. Continued research on the
S, et al. The antisocial brain: psychopathy matters. Arch Gen
subtypes of individuals with ASPD and its comorbidity with Psychiatry. 2012;69(9):962–72. doi:10.1001/archgenpsychiatry.
other psychopathology may prove useful in informing treat- 2012.222. This study demonstrates the importance of including
ment in these individuals. information about psychopathic traits in studies examining ASPD.
The authors find reductions in gray matter only in offenders with
ASPD and psychopathic traits.
Compliance with Ethics Guidelines
13. • Hodgins S, De Brito SA, Chhabra P, Cote G. Anxiety disorders
among offenders with antisocial personality disorders: a distinct
Conflict of Interest Andrea L. Glenn, Alexandria K. Johnson, and subtype? Can J Psychiatr Rev Can Psychiatr. 2010;55(12):784–91.
Adrian Raine declare that they have no conflict of interest. Although it was previously thought that anxiety limited criminal
activity, this study reports that two-thirds of prisoners with ASPD
Human and Animal Rights and Informed Consent This article does present with a lifetime anxiety disorder. This suggests that anxiety is
not contain any studies with human or animal subjects performed by any more prevalent than previously thought, and suggests that treatments
of the authors. may benefit from considering the role of anxiety in the development of
aggressive behavior.
14. DeShong HL, Kurtz JE. Four factors of impulsivity differentiate
antisocial and borderline personality disorders. J Pers Disord.
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