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CanJPsychiatry 2015;60(7):309314

In Review

The Natural History of Antisocial Personality Disorder

Donald W Black, MD1


1
Professor of Psychiatry, Department of Psychiatry, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa.
Correspondence: 2126b MEB/Psychiatry Research, University of Iowa Carver College of Medicine, Iowa City, IA 52242; donald-black@uiowa.edu.

Antisocial personality disorder (ASPD) is characterized by a pattern of socially irresponsible,


Key Words: antisocial exploitative, and guiltless behaviour. ASPD is associated with co-occurring mental health
personality disorder, and addictive disorders and medical comorbidity. Rates of natural and unnatural death
sociopathy, natural history,
(suicide, homicide, and accidents) are excessive. ASPD is a predictor of poor treatment
psychopathy, review
response. ASPD begins early in life, usually by age 8 years. Diagnosed as conduct
disorder in childhood, the diagnosis converts to ASPD at age 18 if antisocial behaviours
Received and accepted March
2015.
have persisted. While chronic and lifelong for most people with ASPD, the disorder tends
to improve with advancing age. Earlier onset is associated with a poorer prognosis. Other
moderating factors include marriage, employment, early incarceration (or adjudication
during childhood), and degree of socialization.

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Lhistoire naturelle du trouble de la personnalit antisociale


Le trouble de la personnalit antisociale (TPAS) est caractris par un modle de
comportement socialement irresponsable, exploiteur et sans remords. Le TPAS est
associ des troubles de sant mentale et de dpendance co-occurrents et une
comorbidit mdicale. Les taux de dcs naturels et non naturels (suicide, homicide,
accidents) sont excessifs. Le TPAS est prdicteur dune mauvaise rponse au traitement.
Le TPAS dbute tt dans la vie, habituellement vers lge de 8 ans. Diagnostiqu comme
trouble des conduites dans lenfance, le diagnostic devient celui du TPAS 18 ans si
les comportements antisociaux ont persist. Bien que le trouble soit chronique et durant
toute la de vie pour la plupart des personnes souffrant du TPAS, il tend samliorer en
vieillissant. Un dbut plus prcoce est associ un moins bon pronostic. Dautres facteurs
modrateurs sont notamment le mariage, lemploi, lincarcration prcoce (ou une dcision
judiciaire dans lenfance), et un degr de socialisation.

A ntisocial personality disorder is defined by a pattern


of socially irresponsible, exploitative, and guiltless
behaviour.1 Symptoms include failure to conform to law,
C infections, and the human immunodeficiency virus.1012
People with ASPD use a disproportionate share of medical
and mental health services.9,13 ASPD has been identified
failure to sustain consistent employment, manipulation of as a predictor of poor treatment response in certain
others for personal gain, deception of others, and failure populations.1416
to develop stable interpersonal relationships.2 Lifetime People with ASPD have high mortality rates owing to
prevalence for ASPD is reported to range from 2% to 4% accidents, suicide, and homicide.17,18 One study18 showed
in men and from 0.5% to 1% in women.3,4 Prevalence peaks elevated death rates from diabetes mellitus, suggesting
in people age 24 to 44 years and drops off in people 45 to that some people with ASPD may neglect their medical
64 years.5 The male-to-female ratio is estimated at between problems or fail to comply with medical regimens.
2:1 and 6:1, depending on assessment method and sample
characteristics.6 The prevalence of ASPD varies with the
Early Course
setting but can reach 80% in correctional settings.7,8
Antisocial behaviours typically have their onset before age
ASPD is associated with co-occurring mental health and 8 years.6 Nearly 80% of people with ASPD developed their
addictive disorders, including major depressive disorder, first symptom by age 11 years.6 Boys develop symptoms
bipolar disorder, anxiety disorders, somatic symptom earlier than girls, who may not develop symptoms until
disorders, substance use disorders, gambling disorder, puberty.6 Robins19 has observed that a child who makes it
and sexual disorders.9,10 People with ASPD are at risk for to age 15 without exhibiting antisocial behaviours (that is,
traumatic injuries, accidents, suicide attempts, hepatitis CD) will not develop ASPD. Other investigators have also

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In Review

reported that the presence of CD in childhood is a robust


predictor of ASPD in adulthood.2022 Clinical Implications
ASPD is important to diagnose because of its
The DSM-5 definition of ASPD requires a history of
2
prognostic implications.
childhood CD, the diagnosis used for persistent and serious
ASPD shows the continuity between childhood and
childhood behaviour problems. Once the child passes age adult behavioural problems.
18 years, if the behavioural problems have persisted the
ASPD is chronic and lifelong for most people, but tends
diagnosis changes to ASPD. An estimated 25% of girls and to moderate with advancing age.
40% of boys with CD will later meet criteria for ASPD.6 A
Limitations
subset of antisocial adults have no history of childhood CD,
but appear to meet adult criteria for ASPD; these people Many prospective studies have involved
nonrepresentative samples, such as those who have
tend to have milder syndromes.23,24 been hospitalized or adjudicated.
The definition of ASPD has evolved, complicating the
Early Studies: The Gluecks and Robins interpretation of findings in early studies.
Research conducted in the 1940s and 1950s by Robins19 at Many prospective studies have used a limited number
Washington University in St Louis, and by the Gluecks (see of predictive variables.
Glueck and Glueck25) at Harvard, independently showed
the continuity between adult and childhood behavioural
problems. The work of these researchers later influenced
the diagnostic criteria for ASPD in DSM-III.26 concluded that 12% had remitted (that is, no evidence of
The Gluecks followed 500 boys between age 10 and 17
25 antisocial behaviour), while another 27% had improved
years judged officially delinquent by the Massachusetts but not remitted, and 61% were unimproved or worse. The
correctional system. The boys were contacted for interviews median age for improvement was 35 years, but Robins
at ages 25, 32, and 45 years. In the 1990s, Sampson and noted that there was no age beyond which improvement
Laub27 reanalyzed the Gluecks data, originally published seemed impossible.19, p 222 That a subject had improved did
in Unraveling Juvenile Delinquency,25 and were able to not mean the disorder was no longer a problem. She writes
confirm their findings. Severe antisocial behaviour in the following:
childhood (that is, problems serious enough to constitute The finding that more than one-third of the
delinquency in the eyes of the law) was strongly linked to sociopathic group had given up much of the antisocial
adult criminality and deviant behaviour. Arrests between behavior ... does not mean that at present they are
age 17 and 32 years were 3 to 4 times more likely to occur strikingly well-adjusted and agreeable persons. Many
in men with a history of delinquent behaviour than in of them report interpersonal difficulties, irritability,
their nondelinquent peers. Childhood antisocial behaviour hostility toward wives, neighbors, and organized
also predicted educational achievement, economic status, religion. They are in many cases no longer either a
employment, and family life in adulthood. Sampson and threat to the life and property of others nor a financial
Laub27 concluded that the varied outcomes correlated drain on society.19, p 236
with childhood behaviour are all expressions of the same
underlying trait.
The Iowa Antisocial Follow-Up
More influential was the work of Robins,19 who studied 524 Black et al28 followed-up 71 men who had been
subjects seen in a child guidance clinic between 1922 and psychiatrically hospitalized at the University of Iowa
1932 and followed up in the 1950s. She described the study between 1945 and 1970 and met DSM-III criteria for
in Deviant Children Grown Up.19 The children were, on ASPD, which were applied retrospectively to the case
average, 13 years old when seen at the clinic; nearly three- notes. The researchers were able to trace over 90% of the
quarters were boys, most of whom had been referred from men and had sufficient information to rate outcome in 45
juvenile court. Robins concluded that ASPD is a chronic, who had been hospitalized an average of 29 years earlier.
persistent disorder that seldom remits. The men were a mean age of 56 years at the follow-up.
Among the 524 subjects, 94 qualified for an ASPD With ratings similar to those used by Robins,19 Black
diagnosis in adulthood, 82 of whom were interviewed an et al28 concluded that 27% of the subjects had remitted, 31%
average of 30 years later. Now in their 30s and 40s, Robins had improved but not remitted, and 42% were unimproved
or worse. Subjects most likely to have improved were the
least symptomatic at baseline and had achieved an older
age by the time of the follow-up. Black et al28 concluded
Abbreviations that many of the antisocial behaviours present at index
ASPD antisocial personality disorder evaluation were still present at follow-up:
CD conduct disorder Although most of our subjects were no longer
DSM Diagnostic and Statistical Manual of Mental Disorders having frequent confrontations with the police, they
continued to have enduring problems with poor

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The Natural History of Antisocial Personality Disorder

occupational performance, social isolation, marital public schools, 1517 were screened, and the 30% most
discord, poor family relations, and substance antisocial were selected for follow-up, along with 30%
abuse.p 138 of the remainder as a comparator. The boys ranged in age
Black et al29 compared the course of the antisocial men to from 7 to 13 years at intake. In this study, the researchers
that of people with schizophrenia or depression, as well were able to show that problem behaviours occurred along
as to healthy control subjects, data previously published a developmental trajectory from childhood to adolescence.
in the Iowa 500 study. All subjects had been hospitalized The onset of minor covert acts, such as lying and shoplifting,
at the same facility. In this comparison, antisocial men tended to occur before the onset of property damage, which,
fared less well than depressed subjects and healthy control in turn, occurred before the onset of moderate-to-serious
subjects in their marital, occupational, and psychiatric forms of delinquency.
adjustment. Antisocial men functioned better than people
with schizophrenia in their marital status and housing, but The Jack Rollers Story
not in their occupational status or aggregate psychiatric The natural history of ASPD is illustrated in a more
symptoms. In other words, they were more likely than personal way by examining the true life of Stanley (the
people with schizophrenia to be married and to have their Jack Roller), as portrayed in the books The Jack Roller:
own housing, but they were as likely to perform poorly in A Delinquent Boys Own Story by Clifford Shaw36 and The
the workplace and to have disabling psychiatric symptoms Jack Roller at 70 by the Jack Roller and Jon Snodgrass.37
though the specific symptoms differed. Stanley was a chronic runaway at age 6, truant by age 8,
Both Black et al28,30 and Robins19 found that a sizable in custody 26 times before age 10, and 38 times by age
percentage of people with ASPD improve or remit with 17, including 3 terms at a home for incorrigible boys, and
advancing age. This finding is consistent with crime statistics, 1 year each in 2 reformatories. Through a great deal of
which show that arrests peak among people in their late teens ingenuity, Snodgrass found and re-interviewed Stanley
and then decline. Few arrests occur in older adults; when when he was 70 years old. No longer involved in any
arrests occur they are due to conduct offences, such as public significant criminal activity, Stanley continued to have
drunkenness, rather than with violent crime.31 While the trouble keeping jobs, was constantly on guard against
aging antisocial person is less troublesome to the community, assault by others, and took little responsibility for his
many remain troublesome to their families, neighbours, and own problems. He clearly had all the earmarks of ASPD,
coworkers. Many of these people will need to draw on public despite his advanced age.
resources for survival; and many of those who improve are Shaw later edited Brothers in Crime, published in 1938.38
unable to regain lost opportunities in education, employment, The book describes the 5 Martin boys and their progression
and domestic life. For some people, improvement still means from juvenile delinquents to adult criminals, who, together,
living on societys margins.32 spent a total of 55 years in prison. At the time of publication,
the brothers ranged in age from 25 to 35 years, 4 of the 5 were
Youth Follow-up Studies considered improved and were engaged in self-supporting
The Developmental Trends Study21,33,34 began in 1987 activities, although the oldest, John, was actively alcoholic,
and involved 177 boys in Pennsylvania and Georgia, age while the youngest, Carl, was incarcerated. The stories of
7 to 12 years, who were followed up at regular intervals their misbehaviour intertwine, but also display the familial
into early adulthood. The purpose of the study was to nature of ASPD.
document the course of disruptive behaviour over time
and its interaction with co-occurring disorders. The boys Different Trajectories
were recruited from university clinics to which they had Moffitt and colleagues (see Moffitt39 and Odgers et al40)
been referred because of disruptive behaviour disorders, have suggested that ASPD is highly stable in a small
such as attention-deficit hyperactivity disorder or CD. percentage of men and women whose behavioural problems
The investigators showed the following: boys with an are extreme (categorized as life-course-persistent). As part
early onset of symptoms had a faster progression to more of the Dunedin longitudinal study in New Zealand, Moffitt
serious problems than boys whose problems emerged at and colleagues traced the outcome of 1037 children from
a later age; physical fighting predicted the onset of CD age 3 to 32 years. Conversely, most antisocial youth with
more than any other symptoms; oppositional defiant behavioural problems were categorized as having an
disorder appeared to be a developmental precursor to CD adolescence-limited form of antisocial behaviour, described
in some boys; and CD was predictive of the later diagnosis as less severe and typically arising in the context of teenage
of ASPD. peer group pressure. These teens typically have little or no
The Pittsburgh Youth Study33,35 was a longitudinal study history of earlier antisocial behaviour and will improve
of inner-city boys that also began in 1987, and whose aim on their own, as most children diagnosed with CD do not
was to trace the development of antisocial and delinquent develop adult ASPD. For both men and women, the life-
behaviour from childhood to early adulthood. Among boys course-persistent group showed an early onset of antisocial
in the first, fourth, and seventh years in the Pittsburgh behaviour, developed more severe behavioural problems,

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In Review

and had a greater variety of problems than the adolescent- Another factor that may moderate eventual outcome is
limited group. degree of childhood socialization, which is the childs
tendency to form relationships and internalize social norms.
Outcome Predictors in ASPD Jenkins and Glickman42 identified 2 types of children with
Robins19 found that most of the children improved as they CD: the socialized and the undersocialized. They observed
grew older and did not become adults with ASPD. She that the ability to develop group loyalty is crucial and marks
concluded that variety and severity of childhood behaviour a fundamental division among children with CD. Socialized
problems were the single best predictors of adult antisocial children, regardless of their behaviour, form strong ties to a
behaviour. Robins writes as follows: familiar group of friends, whereas undersocialized children
tend to be loners. In a 10-year, follow-up study, Henn
No patient without moderately severe antisocial et al43 found that socialized delinquents were less likely to
behavior, as measured by having six or more kinds have been convicted of crimes or imprisoned as adults than
of antisocial behavior, four or more episodes of undersocialized delinquents.
antisocial behavior, or an episode of such behavior
serious enough that it might have led to a court
Other Studies
appearance, was diagnosed sociopathic personality
Three additional studies are relevant to any review of the
as adult.19, p 157
natural history of ASPD. These are the follow-up studies
Among the few variables predictive of long-term of Maddocks,44 Gibbens et al,45 and Tong,46 all conducted in
adjustment, Robins19 observed that greater improvement the United Kingdom in the 1950s and 1960s. The subjects
occurred in people over 40 years at the time of follow-up. in each study were considered psychopaths, a rough
These findings are consistent with data reported by Black equivalent of ASPD.
et al,28,30 in which improvement in men with ASPD was Maddocks44 reported a 5-year, follow-up study of patients
positively associated with increasing age. Another variable seen in an outpatient department between 1961 and 1963. The
is incarceration. Robins found that men incarcerated less men were considered psychopaths, and the inclusion criteria
than a year had a higher rate of remission than those who included impulsivity, trouble with the law, several spouses or
were never incarcerated, or those who were incarcerated sexual partners, trouble at school, and unreliability. Maddocks
for longer periods of time. This latter finding suggests traced 52 of 59 men; 10 (19%) had settled down, 39 (75%)
that a brief incarceration could act as a deterrent to further had not settled, and 3 (6%) had died by suicide. He defined
antisocial behaviour. settled down as having shown a reduction of impulsiveness
enabling the patient to stay in the same job, stay with the
Relationships same partner, and generally a reduction in symptoms that
Marriage is another moderating variable. In Robins study,19 placed him in the category in the first place.44, p 511 While
over one-half of married people with ASPD improved, but there was no clear distinction between men who had settled
few unmarried people improved. Spouses, partners, and and those who had not, 15 (38%) of those who had not settled
others close to the person with ASPD can play an important drank excessively or were frank alcoholics.
role in urging therapy, and improvement often comes Gibbens et al45 reported on a 8-year, follow-up of 72
when one has a source of personal support and motivation. incarcerated criminal psychopaths whose courses were
People with ASPD who remitted had stronger family compared with those of 59 ordinary criminals. The
ties, were more involved in their communities, and were psychopaths were considered as having severe cases, and
more likely to live with their spouses. These findings are were selected with the assistance of experienced prison
largely consistent with the Gluecks findings that linked job medical officers. The psychopaths had a greater number of
stability and marital attachment with improvement.25 Each subsequent convictions than the control subjects, yet 24%
of these situationsfrom brief incarceration to relative had only 1 or no conviction. Of note, the psychopaths were
success with marriage and family lifecould easily be the more likely than the control subjects to have an abnormal
result of improvement rather than its cause. electroencephalograph. Gibbens et al45 concluded that
One might expect that people with ASPD who stay psychopathic personality does not inevitably portend
happily married, or who have not faced lengthy periods of as hopeless a prognosis as is usually implied.p 109
incarceration, simply have milder cases of ASPD to begin Psychopaths considered aggressive had a worse prognosis,
with or are otherwise predisposed to getting better. There compared with the inadequate psychopaths. They had
is some evidence for this, at least regarding marriage. In more reconvictions and were committed for aggressive
a study of male twins followed from 17 to 29 years, the offences, such as willful damage and drunken assault.
researchers discovered that men with less severe forms Gibbens et al45 write as follows:
of antisocial behaviour were more likely to marry than It seems probable that the aggressive psychopath
their more antisocial twin.41 Possibly, severe antisocial is so crippled in all his social relations that he is
symptoms hinder marriage because they interfere with only able to live by crime and his record therefore
forming intimate relationships. consists very largely of acquisitive offences.p 112

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The Natural History of Antisocial Personality Disorder

Tong46 reported on the outcome of criminal psychopaths. Acknowledgements


They had been legally classified as psychopaths in the Dr Black has received royalties from the American
United Kingdom, and incarcerated between 1954 and 1961 Psychiatric Publishing, Oxford University Press, and
at Rampton Hospital, a special close security psychiatric UpToDate, Inc, and he has received research support from
hospital that catered to offenders considered dangerous or AstraZeneca, the National Institute on Aging, and the Nellie
to have violent propensities. Tong defined psychopathic Ball Trust.
behaviour as The Canadian Psychiatric Association proudly supports the
criminal behavior charcterised by extreme In Review series by providing an honorarium to the authors.
callousness, brutality, disregard for others, on the
one hand, and or criminal behavior which is not References
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