Abstract
The prevalence of antisocial traits was investigated in a group of veterans who were in treatment at an out-patient psychiatric clinic and who did not meet diagnostic criteria for an antisocial personality disorder. Standardized DSM-III-R interviews were used to diagnose Axis I disorders and antisocial personality disorders and traits. Frequencies of antisocial traits were compared between patients and controls as well as between diagnostic subgroups in the clinical population. Odds ratios were used to assess the effect of antisocial traits on several standardized measures of functioning. There was no overall difference in the dimensional measure of antisocial traits between the clinical and normal groups. There were trends for the frequency of individual traits to vary by Axis I diagnosis. The amount of antisocial traits (measured dimensionally) negatively affected measures of functioning for the overall clinical population. Different specific antisocial traits were associated with trends towards poorer functioning in the alcohol, major depression and post-traumatic stress syndrome subgroups. It is recommended that future research in the area of antisocial traits pay careful attention to the possible negative effects on functioning of subthreshold antisocial traits and also to Axis I comorbidity. © 1997 Elsevier Science Ireland Ltd.
Keywords: Personality disorder; Alcohol abuse; Major depression; Post-traumatic stress disorder; Comorbidity;
Diagnosis
1. Introduction
The concept of antisocial personality has been approached from many different perspectives. In DSM-III-R (American Psychiatric Association, 1987), it is conceptualized as a syndrome with definite familial and probable genetic components (Robins, 1966; Crowe, 1974). Eysenck (1977) considered antisocial personality to have definite genetic components, while Hare (1968) focused on the concept of a biological deficit in the limbic system. Millon (1981) and many other dimensional theorists viewed sociopathy as a personality trait which exists to a greater or lesser extent throughout most of the population and which may be normally distributed. Although a complete review of the concept of antisocial personality is beyond the scope of this article, it appears that many theorists believe that antisocial traits that do not reach the threshold necessary to qualify for a formal diagnosis may, nonetheless, have negative effects on behavior and functioning (the dimensional concept of sociopathy). The term ‘antisocial’ is used in this article because it best describes the DSM measures used in this study. The behavioral/descriptive approach of DSM should be distinguished from the more theoretical orientation of researchers such as Hare (1968), whose concept posits an emotional deficit — lovelessness and lack of guilt — combined with an impulse disorder that has its roots in a deficit in the central nervous system.
This report focuses on veterans in an out-patient psychiatric clinic and examines the prevalence of modest levels of antisocial traits in this population and the effects of these traits, if present, on general functioning. The study’s goals were: (a) to determine if veterans in a psychiatric out-patient clinic who do not meet criteria for antisocial personality disorder have more antisocial traits than screened control veterans; (b) to explore whether the presence of antisocial traits differs by Axis I diagnosis; and (c) to examine how the presence of antisocial traits affects functioning in this population.
2. Methods
Subjects for this study were drawn from a free-standing Veterans Administration out-patient clinic in a city in the Northeast United States with a population of 300000. The population was 100% male. Two subpopulations were sampled. The first was a random sample of psychiatric out-patients who did not meet criteria for antisocial personality disorder. The second group consisted of veterans who presented to the medical clinic for acute, minor medical problems and who had no history of psychiatric illness.
The information used in this report was gathered by direct interview. The evaluation consisted of an established measure of Axis I disorders, the Structured Clinical Interview for DSM-III-R (SCID) (Spitzer et al., 1988), and an established measure of DSM-III-R personality disorders, the Personality Disorder Examination, version 2 (PDE) (Loranger et al., 1987; Loranger, 1988). The computerized dimensional scoring on the PDE was used to determine overall antisocial dimensions; veterans scored positive on a given antisocial dimension if they had a score of ‘2’. The interview also included the Hollingshead scale of socioeconomic status, the Global Assessment Scale (GAS) (Spitzer et al., 1973; Endicott et al., 1976), the percentage of VA disability, and several dimensional self-report scales measuring various aspects of functioning. The self-report scales include a measure of work functioning (WORK), a combined measure of family and home functioning (FAMILY/HOME), and a combined measure of work and social functioning (WORK and SOCIAL). These self-report functioning scales are Likert scales, have face validity, and have been extensively used in pharmacological treatment trials.
Patients were approached, either by mail or in person at the time of a visit to the out-patient clinic, to take part in the study. Approximately 65% of eligible subjects participated in the interviews. To evaluate possible differences between respondents (those who were interviewed) and non-respondents (those who declined to participate in the research), the two groups were compared by chart review on the variables of diagnosis, age, and percentage of VA disability. (Chart diagnoses had to be used for comparison as there were no research diagnoses for the non-respondents.) No differences at the P < 0.10 level between respondents and non-respondents were found on any of these variables. Thus, there did not appear to be any major demographic or diagnostic differences between the two groups that would bias extrapolation of findings to the entire population of veterans. There were no major differences in length and type of treatment among the subgroups.
The screened control group was identified by chart review of an out-patient medical clinic located on the same site as the psychiatric clinic. A random sample of those without significant medical problems were contacted and interviewed. Those who had an Axis I diagnosis were excluded from the screened control group.
Interviews were performed by bachelor’s level research assistants who had undergone extensive training on all of the instruments involved. This training included reading, videotapes, didactic sessions and supervised practice interviews. Training materials and consultation were supplied by the Biometric Unit of the New York State Psychiatric Institute. Interviews were performed in person and not over the telephone. Research assistants were unaware of the purpose of the study and did not know in which group a given subject would be placed. The developer of the PDE participated in the training of some of the research assistants on the PDE.
All out-patients who met criteria for antisocial personality disorder were eliminated. The remaining group was compared to the screened controls and examined according to the presence of Axis I disorders(where the sample size was large enough to do so). Diagnoses used to distribute subjects into different subgroups were determined according to the SCID interview (described above) which used DSM-III-R criteria.
Patients from the clinical group were compared with the control group on mean number of antisocial traits and individual traits. Where there were enough subjects to do so, subsamples consisting of a specific diagnostic group from the patient group were compared with the rest of the clinical population. Both control and patient groups, as well as diagnostic subgroups within the patient group, were examined to determine the effect of antisocial traits on measures of functioning.
Statistical analyses were performed with SAS version 6.08 for personal computers (SAS Institute, 1993). Individual comparisons used Fisher’s exact test for categorical variables and analysis of variance for continuous variables. Odds ratios were calculated using Proc Logist in the SAS program.
The use of multiple statistical tests increases the risk of finding significant differences on the basis of chance alone. Because 85 tests were performed, only those statistical values at or above 0.0005 were considered significant for the purposes of this report. Values between 0.02 and 0.0005 were considered trends and are reported for reader interest.
3. Results
There were 134 subjects in the clinical group and 28 subjects in the control group. All subjects were male. The two groups did not differ significantly in mean age: clinical group = 56.6 years (S.D. 12.8), control group = 55.5 years (S.D. 11.7). As would be expected, the control group had higher socioeconomic status (Hollingshead score = 4.5, S.D.= 0.9), control group (Hollingshead score = 3.6, S.D. = 1.2; Ft = 19.8, P = 0.0001). Similarly, the mean GAS score in the control group (84.8, S.D. = 6.3) was in the direction of higher functioning than that in the clinical group (65.7, S.D. = 12.2; Fj = 67.6, P = 0.0001).
There were no significant differences in mean dimensional antisocial traits as measured by the PDE between the clinical group (3.9, S.D.= 3.5) and the control group (4.7, S.D. = 3.0; Fx = 1.23, P = 0.27). There were three trends toward differences between controls and patients when individual traits were examined. The clinical group more often scored positive on the trait ‘is irritable or aggressive’ (22.3% vs. 3.3%, Fisher’s exact P = 0.02) while the control group had higher scores in two traits, ‘lack of remorse’ (23.8% vs. 3.5%, Fisher’s exact P = 0.001) and also ‘deliberately destroyed others’ property’ (13.3% vs. 2.9%, Fisher’s exact P = 0.02) (see Table 1)...
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James H. Reich, MD, MPH, is a board-certified Forensic Psychiatrist with extensive civil psychiatry experience who has done hundreds of evaluations. His services are available for civil and some criminal law cases. Clients are assured of his personal dedication to each case. He does high quality research, expert evaluations, writes a solid report, and will testify well. Dr. Reich has been deposed over 50 times.
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