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This chapter focuses on brain and behavioural correlates of psychopathy and antisocial personality that inform us about their motivational and emotional underpinnings. Findings related to the three components of the triarchic psychopathy model – boldness, meanness and disinhibition – are reviewed. An important distinction is drawn between ‘primary’ and ‘secondary’ variants of psychopathy, which should not be viewed as a unitary construct.
The nosological background is outlined, with particular reference to the fifth edition of the American Psychological Association's Diagnostic and Statistical Manual and the International Classification of Disease's eleventh iteration. Categorical diagnoses of antisocial personality disorder are critiqued. The question of what motivates people to engage with others, and how this may be lacking in antisocial individuals, is addressed. It is emphasised that to understand what people are like and why they behave the way they do, we need to look at both traits and values – the latter being goals that people find desirable and use as guides for their behaviour across different situations. The importance of motivation for an understanding of personality pathology is outlined in the context of a schema that re-describes PD in terms of an ‘approach vs withdrawal’ dimension that is fundamental to human motivation. Finally, the question ‘How does personality become pathological?’ is raised.
This chapter considers treatment of those with ASPD from the perspective of (1) higher levels of integration of the personality than in previous chapter and (2) managing clients at the more severe end of the ASPD spectrum (i.e., those with violent behaviour detained within secure settings). In respect of item (1) we make specific reference to and describe the phases of exploration and integration in Livesley’s Integrated Modular Treatment. As this requires an emotional maturation in the client (as compared with the establishment of emotional stability in Chapter 6), extra demands are placed on both client and therapist. In the latter case, the ‘fit’ between therapist and therapy is explored. As regards managing those with violent behaviour (including those with psychopathic traits), the principles of the two major criminological interventions (i.e., risk-needs-responsivity [RNR] and the Good Lives Model [GLM]) are compared and contrasted. There is a discussion on those who may be beyond treatment and where interventions can actually lead to harm. Finally, the differences between a forensic case formulation and a case formulation are discussed, with the former focusing on the risk that the individual may pose.
This chapter reviews what is known about the developmental antecedents of adult antisocial personality. It addresses the question of why it is that, while many people may have personality difficulties, a minority develop a severe and persistent dysfunction of personality that is more or less life-long, leading them into a pattern of chronic antisocial behaviour. Findings reviewed in this chapter suggest that the route to adult antisociality is marked by a cascade of developmental roadblocks and insults arising during childhood and adolescence. The authors emphasise the importance of adolescence as a period when things can go seriously awry and personality can deviate from a normal track. They further emphasise the critical importance of substance abuse, particularly the misuse of alcohol, in the genesis of life-course-persistent antisociality. Two possible developmental pathways are described, one predominantly male, the other predominantly female, through which adult antisociality results from adverse circumstances in childhood and adolescence.
Using recently published general population studies, this chapter updates an earlier Moran review on the epidemiology of ASPD. It examines the prevalence, comorbidity, psychosocial functioning, impact on health services and cultural differences of those with ASPD and, to a lesser extent, of those with psychopathy and on prisoners. It finds that the prevalence of ASPD ranges between 0.6% and 4.3% in men (which is significantly higher than in women). It has multiple comorbidities – both with other mental disorders (especially with substance misuse and affective disorder) together with other Cluster B PDs. Despite significant mental health and psychosocial impairment, those with ASPD rarely seek treatment for their disorder. There are marked cultural differences in the prevalence of ASPD with studies in the United States showing significantly higher rates than in Europe or in Asia. The prevalence of ASPD among prisoners is c. 55% among men and 31% among women with community prevalence rates for psychopathy ranging from 0.6% in the United Kingdom and 1.0% in the United States. Both ASPD and psychopathy have a positive association with both increased mortality and suicidality, suggesting that, together with their other impairments, they are a group that require mental health interventions.
Starting with a discussion of antisocial personality disorder as a diagnostic construct, this chapter argues that models of mental disorders should focus on symptoms (and individual traits) rather than on flawed diagnostic syndromes. It is argued that interpersonal antagonism, callousness and hostility lie at the core of antisocial personality, which is broader than the constructs – ASPD and psychopathy – with which it is traditionally associated. Paranoia and boredom proneness are considered as key elements of antisocial personality. Assessment of antisocial individuals should consider the three aspects of self: self as social actor, self as motivated agent, and self as autobiographical author, as well as their location on the prosocial-antisocial continuum. Arising from the assessment, a case formulation should seek to articulate the central mechanisms that cause and maintain the individual's main problems and to explain how they are related. When an individual shows violent behaviour it is important that the case formulation identifies the type of violence that is shown and the functions it serves. Consistent with the Good Lives Model (GLM), it is important that positive aspects are included in a strength-based case formulation, covering areas such as work, relationships, accommodation, health and leisure activities.
This chapter examines the evidence of efficacy in the pharmacological and psychological treatment of those with ASPD in good-quality trials for those with ASPD and finds that such evidence is lacking. Given the range of impairments in those with ASPD cited in the previous chapter, here we propose a pragmatic approach that relies on the non-specific effects of psychotherapy, together with the judicious use of medication as required. The former focuses on (1) engagement through an explanation of the disorder, (2) the creation of expectations and (3) identifying relevant treatment options. Judicious use of medication, when necessary, is also recommended. This process is organised by a case conceptualisation of the individual which seeks to integrate the nomothetic (i.e., general principles) with the idiographic (i.e., individual) aspects of the case. For those with ASPD, particular attention needs to be paid to managing therapeutic ruptures as the impulsive and paranoid traits in those with ASPD are likely to lead to premature termination. We believe that these principles offer the practitioner not only a sensible and defensible procedure, but one which is within the ambit of most community mental health teams so it has wide applicability.
This introduces some major concerns and themes covered in the book. It is suggested assessment of antisocial personality should combine a nomothetic (trait-based) approach with an idiographic (person-centred) approach. The latter aims to capture, first, the particular motives, values and goals that drive the individual’s antisocial behaviour, and second, the feeling of continuity, coherence and sense of agency expressed in the individual’s life story. The reader is warned against an uncritical acceptance of ASPD as a ‘disorder’.
This chapter reviews what is known about the interpersonal style of people with antisocial personality and psychopathy, concluding that antisocial individuals have a cold, vindictive and hostile interpersonal style and that they lack the motivation to engage in an empathic way with others. The triarchic view of human selfhood– the self as social actor, as motivated agent and as autobiographical author – is introduced as a framework within which the antisocial individual might be understood from a first-person perspective. So-called dark traits are considered, particularly their role in sexual offending and sexual sadism. It is suggested the ‘dark traits’ construct might be expanded to include paranoia, moral disengagement, spitefulness and greed. The concept of ‘emotion goals’ is introduced and considered in relation to a quadripartite typology of violence that sees violence as reflecting appetitive versus aversive motivation interacting with an impulsive versus controlled dimension.
Here, we explore the thorny issue of the involuntary detention of those with ASPD (and those with psychopathic traits) for treatment. We use, as a frame, the recent history in the United Kingdom of attitudes using the changes in the legal designation of ‘psychopathic disorder’ whereby such individuals might be so detained. As there is undeniable evidence that those with the legal designation of psychopathic disorder are at higher risk of re-offending after discharge, psychiatrists were reluctant to admit them for treatment. This filtered down to the community so that those with a PD label were denied treatment. Faced with this dilemma, the government introduced the DSPD programme, whose rationale was underpinned by a defensible notion of both risk and treatability. We believe that, given the wide margin of error associated with both risk estimation and the efficacy of treatment (especially if the latter is imposed rather than consented to), this was unlikely to have a good outcome, and so it proved. We propose an alternative whereby sentencing and treatment of those with PD if convicted are uncoupled, thereby preserving a cordon sanitaire between the custodial and therapeutic realms.
It remains something of a mystery why some individuals behave in persistently malevolent and destructive ways towards their fellows, causing untold harm both to themselves and their victims. This book argues that to understand the roots of antisocial behaviour, one first has to understand what motivates the majority of people to behave prosocially - to think, feel and act in non-malevolent ways. All people are motivated to seek emotion goals - to feel thrilled and excited, to feel safe from the threats of others, to feel a sense of justice, and to feel gratified. However some individuals seek these emotion goals in antisocial ways due to an excess of emotions such as distrust, boredom, greed, vengeance and insecurity. The authors outline interpersonal and neurobiological correlates of antisocial personality, its developmental antecedents, its frequency and pattern across different societies and cultures, and different approaches to its treatment and rehabilitation.
Studying phenotypic and genetic characteristics of age at onset (AAO) and polarity at onset (PAO) in bipolar disorder can provide new insights into disease pathology and facilitate the development of screening tools.
To examine the genetic architecture of AAO and PAO and their association with bipolar disorder disease characteristics.
Genome-wide association studies (GWASs) and polygenic score (PGS) analyses of AAO (n = 12 977) and PAO (n = 6773) were conducted in patients with bipolar disorder from 34 cohorts and a replication sample (n = 2237). The association of onset with disease characteristics was investigated in two of these cohorts.
Earlier AAO was associated with a higher probability of psychotic symptoms, suicidality, lower educational attainment, not living together and fewer episodes. Depressive onset correlated with suicidality and manic onset correlated with delusions and manic episodes. Systematic differences in AAO between cohorts and continents of origin were observed. This was also reflected in single-nucleotide variant-based heritability estimates, with higher heritabilities for stricter onset definitions. Increased PGS for autism spectrum disorder (β = −0.34 years, s.e. = 0.08), major depression (β = −0.34 years, s.e. = 0.08), schizophrenia (β = −0.39 years, s.e. = 0.08), and educational attainment (β = −0.31 years, s.e. = 0.08) were associated with an earlier AAO. The AAO GWAS identified one significant locus, but this finding did not replicate. Neither GWAS nor PGS analyses yielded significant associations with PAO.
AAO and PAO are associated with indicators of bipolar disorder severity. Individuals with an earlier onset show an increased polygenic liability for a broad spectrum of psychiatric traits. Systematic differences in AAO across cohorts, continents and phenotype definitions introduce significant heterogeneity, affecting analyses.
The state of California, in the United States of America, has a population of nearly 40 million people and is the 5th largest economy in the world. During the coronavirus disease 2019 (COVID-19) pandemic in 2020-2021, the state experienced a medical surge that stressed its sophisticated health-care and public health system. During this period, ventilators, oxygen, and other equipment necessary for providing ventilatory support became a scarce resource in many health-care settings. When demand overwhelms supply, creative solutions are required at all levels of disaster management and health care. This study describes the disaster response by the state of California to mitigate the emergency demands for oxygen delivery resources.
Self-reported activity restriction is an established correlate of depression in dementia caregivers (dCGs). It is plausible that the daily distribution of objectively measured activity is also altered in dCGs with depression symptoms; if so, such activity characteristics could provide a passively measurable marker of depression or specific times to target preventive interventions. We therefore investigated how levels of activity throughout the day differed in dCGs with and without depression symptoms, then tested whether any such differences predicted changes in symptoms 6 months later.
Design, setting, participants, and measurements:
We examined 56 dCGs (mean age = 71, standard deviation (SD) = 6.7; 68% female) and used clustering to identify subgroups which had distinct depression symptom levels, leveraging baseline Center for Epidemiologic Studies of Depression Scale–Revised Edition and Patient Health Questionnaire-9 (PHQ-9) measures, as well as a PHQ-9 score from 6 months later. Using wrist activity (mean recording length = 12.9 days, minimum = 6 days), we calculated average hourly activity levels and then assessed when activity levels relate to depression symptoms and changes in symptoms 6 months later.
Clustering identified subgroups characterized by: (1) no/minimal symptoms (36%) and (2) depression symptoms (64%). After multiple comparison correction, the group of dCGs with depression symptoms was less active from 8 to 10 AM (Cohen’s d ≤ −0.9). These morning activity levels predicted the degree of symptom change on the PHQ-9 6 months later (per SD unit β = −0.8, 95% confidence interval: −1.6, −0.1, p = 0.03) independent of self-reported activity restriction and other key factors.
These novel findings suggest that morning activity may protect dCGs from depression symptoms. Future studies should test whether helping dCGs get active in the morning influences the other features of depression in this population (i.e. insomnia, intrusive thoughts, and perceived activity restriction).
The Comprehensive Assessment of Neurodegeneration and Dementia (COMPASS-ND) cohort study of the Canadian Consortium on Neurodegeneration in Aging (CCNA) is a national initiative to catalyze research on dementia, set up to support the research agendas of CCNA teams. This cross-country longitudinal cohort of 2310 deeply phenotyped subjects with various forms of dementia and mild memory loss or concerns, along with cognitively intact elderly subjects, will test hypotheses generated by these teams.
The COMPASS-ND protocol, initial grant proposal for funding, fifth semi-annual CCNA Progress Report submitted to the Canadian Institutes of Health Research December 2017, and other documents supplemented by modifications made and lessons learned after implementation were used by the authors to create the description of the study provided here.
The CCNA COMPASS-ND cohort includes participants from across Canada with various cognitive conditions associated with or at risk of neurodegenerative diseases. They will undergo a wide range of experimental, clinical, imaging, and genetic investigation to specifically address the causes, diagnosis, treatment, and prevention of these conditions in the aging population. Data derived from clinical and cognitive assessments, biospecimens, brain imaging, genetics, and brain donations will be used to test hypotheses generated by CCNA research teams and other Canadian researchers. The study is the most comprehensive and ambitious Canadian study of dementia. Initial data posting occurred in 2018, with the full cohort to be accrued by 2020.
Availability of data from the COMPASS-ND study will provide a major stimulus for dementia research in Canada in the coming years.