Is antisocial personality disorder really NPD on crack?

I have to admit I’ve been confused by the distinctions between the Cluster B personality disorders, especially those of NPD and ASPD. There seems to be little distinction in most literature between NPD and ASPD (antisocial personality disorder) with most experts saying the difference is just a matter of degree, with ASPD (psychopathy or sociopathy) being higher on the spectrum than NPD.

Let’s turn to the Bible of mental disorders for some clarification. These are from the DSM IV-TR, but have apparently been updated, because these descriptions are all labeled obsolete. But for our purposes, I’ll stick with these criteria.

Diagnostic criteria for 301.81 Narcissistic Personality Disorder

Handsome narcissistic young man looking in a mirror

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

(3) believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)

(4) requires excessive admiration

(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

(8) is often envious of others or believes that others are envious of him or her

(9) shows arrogant, haughty behaviors or attitudes

Diagnostic criteria for 301.7 Antisocial Personality Disorder

antisocial_personality

A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:

(1) failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
(2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
(3) impulsivity or failure to plan ahead
(4) irritability and aggressiveness, as indicated by repeated physical fights or assaults
(5) reckless disregard for safety of self or others
(6) consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
(7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

B. The individual is at least age 18 years.

C. There is evidence of Conduct Disorder with onset before age 15 years.

D. The occurrence of antisocial behavior is not exclusively during the course ofSchizophrenia or a Manic Episode.

Just for comparison’s sake, let’s include the (obsolete) criteria for the other two Cluster B disorders: BPD (Borderline Personality Disorder) and HPD (Histrionic Personality Disorder):

Diagnostic criteria for 301.83 Borderline Personality Disorder

borderline

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) frantic efforts to avoid real or imagined abandonment.
Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

(3) identity disturbance: markedly and persistently unstable self-image or sense of self

(4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, Substance Abuse, reckless driving, binge eating).
Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

(6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

(7) chronic feelings of emptiness

(8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

(9) transient, stress-related paranoid ideation or severe dissociative symptoms

Diagnostic criteria for 301.50 Histrionic Personality Disorder

histrionic_personality

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) is uncomfortable in situations in which he or she is not the center of attention

(2) interaction with others is often characterized by inappropriate sexually seductive or provocative behavior

(3) displays rapidly shifting and shallow expression of emotions

(4) consistently uses physical appearance to draw attention to self

(5) has a style of speech that is excessively impressionistic and lacking in detail

(6) shows self-dramatization, theatricality, and exaggerated expression of emotion

(7) is suggestible, i.e., easily influenced by others or circumstances

(8) considers relationships to be more intimate than they actually are

It does seem that ASPD is more linked to criminality than NPD, most likely due to poor impulse control, which isn’t a problem in people with NPD. People with ASPD are more willing to break the law and are more likely to be in prison. They are less likely to be concerned with image or consequences of their actions (most people with NPD want to maintain their sqeaky clean image which means staying out of prison). Antisocials also seem more prone to violent behavior.

The DSM criteria for ASPD seem to describe psychopathy/sociopathy. Most narcissists are probably not psychopaths, but are on the same spectrum. Does this mean that ASPD and NPD should really be considered the same disorder, with ASPD higher on the psychopathy spectrum?

BPD is more clearly distinguishable from ASPD and NPD because a person suffering from this disorder does have a conscience and can feel empathy and remorse, but like someone with ASPD they have problems with impulse control. Also, their motives for doing what they do are different: they fear abandonment, while people with ASPD and NPD fear their true self being exposed.

HPD seems very similar to the somatic form of narcissism and includes many narcissistic traits. However, it seems that someone with HPD would be more prone to drama, neediness and tantrum throwing (although these traits aren’t unknown in narcissists). Like BPD, the motives for the sufferer’s behavior seem based on insecurity and fear of abandonment rather than the need to maintain a false front.

NPD and ASPD are more common in males than females, and HPD and BPD are more common in females than males. Does gender determine what disorder a child is more likely to develop later in life? Are BPD and HPD really the “female” forms of the other two disorders?

ASPD almost seems like an exaggeration of typically male traits–aggressiveness, lack of emotion (except rage), and risk taking; whilst HPD seems like an exaggeration of typically female traits — excessive emotionality, preoccupation with beauty/sexiness, and excessive neediness. BPD and NPD are somewhere in between these two and can include elements of both: ASPD –> NPD –> BPD –> HPD

The fact that the American Psychiatric Association keeps changing their criteria just makes things even more confusing.

Advertisements