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Medical Treatment For Antisocial Personality Disorder?

JackD

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    I was brushing up on antisocial personality disorder today; why not right? When i was reading about treatment for it, it said that one approach is to create a sense of hopelessness, remorse, and anxiety in the client. So i was wondering, have they ever tried to give people with antisocial personality disorder drugs would cause depression or anxiety? I have heard about medications that dramatically lower serotonin levels, like reserpine, wouldn't that help with treatment?

    Don't worry, i do recognize this may make no sense. I obviously wouldn't have an intimate knowledge of psychopharmacology.
     

    erg923

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      Hmmm. never heard of such a thing. While low serotonin levels are associated with depression, there is nothing in the literature that suggests this a sufficient mechanism, by itself, for inducing or causing clinical depression. Resperine has been shown to induce depressive symptoms as a side effect of its use, but according to the literature, this only occurs in approximately 15% of patients using the drug. Regardless, I cant imagine the ethical justification for inducing depression in someone pharmacologically. Don't know if that's even possible. However, transient mood induction paradigms (i.e.,velton procedure, and hypnotic mood induction) are often used in experimental psychopathology research. Especially by those in cognitive research examining the depressogenic schematas that are theorized to exist in depressed individuals. Ethically, you would violating many principles by imploring pharmacological treatment to induce a depression, if thats even possible. In experimental psychopathology research, the closest you are going to see is mood priming using transient mood induction paradigms and empathy induction procedures.
       

      whopper

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        Antisocial PD has shown some distinct markers on certain tests but no "medical" treatment as far as I know have shown any significant results in its treatment. ITs not like you can give an SSRI to someone with Antisocial PD & all of a sudden they'll want to lead productive lives as law biding citizens.

        have they ever tried to give people with antisocial personality disorder drugs would cause depression or anxiety?

        Problem here is as physicians who have taken an Oath to "Do no Harm", its hard to do a study that suggests what you ask. I can see several IRB at several institutions denying a request for a study to do this & with good reason. Most people diagnosed with Antisocial PD are in jail or have a criminal history. To do an experiment on such a population where meds are given that causes anxiety or depression is morally/ethically questionable.
         
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        erg923

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          "Antisocial PD has shown some distinct markers on certain tests but no "medical" treatment as far as I know

          Just curious to what distinct markers ASP shows? ASP is far from my area of study, so I'm lacking on research knowledge here. I do know, from a neuropsychological perspective, perseverative errors on the Wisconsin Card Sorting are a consistent finding, but that about all I know and its certianly far from pathonemonic. Is there consistent findings in imaging research maybe? Hypometabolism of the frontal regions or limbic structures maybe? Curious to get a physician opinion here, as I have never discussed ASP with psychiatrists, just psychologists.
           

          billypilgrim37

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            ...and its certianly far from pathonemonic...

            The Greek, it BURNS!!!

            pathoGNOMONIC

            pathos + gnomikos (like gnosis... knowledge, like the diagnosis ("through" knowledge) or the prognosis (future knowlege))

            so, disease + (discerning) knowledge.

            -From your loving classical languages nerd.
             

            OldPsychDoc

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              The Greek, it BURNS!!!

              pathoGNOMONIC

              pathos + gnomikos (like gnosis... knowledge, like the diagnosis ("through" knowledge) or the prognosis (future knowlege))

              so, disease + (discerning) knowledge.

              -From your loving classical languages nerd.


              Gee I thought it was PNEUmonic, you know, like those memory things...:D
               

              whopper

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                Just curious to what distinct markers ASP shows?

                Nuts, don't have the lecture handout on me but from memory, some personality inventory tests show different results for those with ASPD.


                Also certain forms of psychometric testing showed ASPD people processed certain forms of data differently. I'll have to look it up again from my notes because they're not on me now.

                The data while interesting never made that permanent mark in my brain because it unfortunately had very little clinical relevance. Kinda like the new findings that PTSD requires certain genes for that disorder to be expressed. Great--but I'm never going to order a gene test for PTSD (At least at this time, maybe 10 years down the road...), so I don't got the names of those genes memorized.
                 

                erg923

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                  The pathognomic thing was an automatic spell check correction, but thanks for pointing it out.
                  Well I do know about psychometric test patterns. A couple of MMPI-2 scales can tap it, and the Psychopathy Checklist taps Cleckly's criteria quite a bit. The problem with ASP, as its currently defined, is that all the criteria are totally behavioral manifestations. Personality tests only tap into the attitudes presumed to underly the manifested behavior, which obviously presents a construct validity issue with the assessment using personality tests. I mentioned the perseverative error rate on the Wisconsin Card Sort, and I know they also tend to have have a suppressed stroop effect. I would imagine they might have problems with "go-no go" and other tasks of dominant response inhibition, but don't know if that's a consistent finding or not. Other than the frontal type stuff, im not sure their is anything else in the neuropsych lit. I was inquiring more from a medical perspective though, that I might not be aware of (neuroimaging, behavioral genetics, or endocrinology). Anything in that literature base? I would doubt it, but was just curious.
                   

                  whopper

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                    JackD

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                      but according to the literature, this only occurs in approximately 15% of patients using the drug.
                      I heard it had a 50% suicide attempt rate. If true, the depression rate is probably more than 15%.

                      Ok, ok, it may be unethical (don't you miss the days when researches could do whatever they wanted?) but still, if these people don't feel depression or anxiety but can through a lot work, and that is the goal of treatment, then why wouldn't inducing it pharmacologically work? Even if reserpine wouldn't work, certainly there is something out there that would cause the symptoms needed for treating the disorder.
                       

                      Floyd78

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                        I heard it had a 50% suicide attempt rate. If true, the depression rate is probably more than 15%.

                        Ok, ok, it may be unethical (don't you miss the days when researches could do whatever they wanted?) but still, if these people don't feel depression or anxiety but can through a lot work, and that is the goal of treatment, then why wouldn't inducing it pharmacologically work? Even if reserpine wouldn't work, certainly there is something out there that would cause the symptoms needed for treating the disorder.


                        I think that, so far, purely pharmacological approaches have proven to be at best only mildly effective in the treatment of personality disorders (the pharmacological treatment of borderline personality disorder comes to mind) which I guess is something to expect, since this kind of approach doesn't really take into account the complexity and mutifactorial nature of these disorders. In my opinion, the treatment you have suggested is perhaps too reductionistic and most likely all you would achieve would be to add depressive and anxious symptomatology to the character disorder without significantly modifying it.
                         
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                        erg923

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                          I heard it had a 50% suicide attempt rate. If true, the depression rate is probably more than 15%.

                          Ok, ok, it may be unethical (don't you miss the days when researches could do whatever they wanted?) but still, if these people don't feel depression or anxiety but can through a lot work, and that is the goal of treatment, then why wouldn't inducing it pharmacologically work? Even if reserpine wouldn't work, certainly there is something out there that would cause the symptoms needed for treating the disorder.

                          So do you think that the 50% suicide rate (if correct) is solely due to the drug? Or could it be a function of the types of patients who received it? I think the later is more parsimonious until research suggests otherwise. Keep in mind that resperine was formerly used to treat patients with psychosis and sever mania who happen to have a base rate suicide occurrence of almost 30%.

                          A couple of things: One, I don't think it's correct to say that these people "don't feel depression or anxiety." I think this is somewhat of a stretch. Several methods, including Galvanic skin response, and other psychophysiological methods have demonstrated decreased autonomic arousal. Decreased is the key word here, meaning that the threshold for these responses maybe maybe lower, on average. I don't think this translates into an inability to experience depression or anxiety. Empathy, especially in those who qualify for psychopathy, maybe be a different story however. In fact, the only time you are likely to see a person with ASP voluntarily walk into your clinic is when they are experiencing other axis I conditions (depression or anxiety) that are troubling them.

                          Second, keep in mind that mood induction is just one of many proposed treatments for ASP, and none of these have been shown to be particularly effective. Inducing a second problematic issue (ie., depression) into patients that are already notoriously difficult to treat would only complicate matters significantly. I think inducing transient mood states through experimental paradigms such as priming would accomplish the state necessary for this proposed therapy, without subjecting patients to prolonged depressed mood, or the risks associated with pharmacological therapy. As I mentioned before, techniques aimed at empathy induction are common place in therapy with ASP patients, but I am not sure how artificially inducing depressed mood states would increase insight, because they often have difficulty with empathy, which is necessary for insight into how others experience emotion. I'd like to know the efficacy and treatment size effects of this therapy when compared to other methods.

                          Third, yes, certain drugs, like resperine can cause depressive symptoms as a side effect. However, assuming that this mimics true clinical depression is a reductionist view of the multifactorial causes of depression and how it is truly experienced in depressed patients. There is no way to mimic the negative cognitive schematas (which are widely accepted and supported by experimental research) that contribute to, and exacerbate, the experience of negative emotions in depressed patients There is also no way to mimic the psychosocial environments/situations and stresses that are often part of the depressed patient's world. So basically, i don't think there is a way to reliably induce a true depressive state pharmacologically, and even if you could, there are other experimental methods that can that serve as less dangerous alternatives for this proposed therapy.
                           

                          JackD

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                            Keep in mind that resperine was formerly used to treat patients with psychosis and sever mania

                            I never heard of that. I know it was used to treat hypertension but not psychosis.

                            ASP voluntarily walk into your clinic is when they are experiencing other axis I conditions

                            True but from what i hear, it is mostly substance abuse, not depression or anxiety.
                             

                            Anasazi23

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                              In fact, the only time you are likely to see a person with ASP voluntarily walk into your clinic is when they are experiencing other axis I conditions (depression or anxiety) that are troubling them.

                              This isn't necessarily true. Oftentimes, antisocials seek psychiatric services after a multitude of personal failures that are likely related to their maladaptive personalities. They've been fired from a job, lost a loved-one, been threatened with divorce, etc. which has caused them to seek help at the urging of a frustrated and concerned relative or family member. Rarely do they present with overt depressive symptoms. In my experience, they are much more likely to deny any overt problems with themselves but rather, blame their circumstances on external factors. Also commonly, they do not present with DSM criteria for depression or an anxiety disorder, since their dealings are almost always ego-syntonic.
                               

                              erg923

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                                Yes, resperine can be used to treat hypertension. It was its antihypertensive proproperties that made it effective in sedating severely agitated manic or psychotic patients. I would highly doubt the suicide rate was 50% in a psychiatrically normal hypertensive population, but it would be more believable if it was in manic and psychotic populations.

                                And yes, I was trying to get at the ego-syntonic nature of ASP by explaining that they seek treatment for issues that have come to trouble them, not the PD itself. Often times, trouble with work or interpersonal relationships. Dysphoric mood can certainly be a result of these stresses. And I cant believe I left out substance abuse which is the number reason.
                                 

                                whopper

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                                  they are much more likely to deny any overt problems with themselves but rather, blame their circumstances on external factors.

                                  I've seen the same. Especially when they've been "institutionalized". Its easier for them to simply go back to prison than to try a new life. In their defense, its hard to start a new life with a prison sentence on their record.

                                  In terms of using resperine as a treatment: if the goal is to create a sense of depression, anxiety & remorse, I don't think reserpine is necessarily going to create remorse. Yes it can cause depression, but I'm not sure about remorse.

                                  There's a difference between trying to get a patient to see the error of their ways (which induces depression, anxiety & remorse). Sometimes it happens, sometimes you get a breakthrough where someone really wants to turn their life around when they realize the harm caused to others & loss of potential in their own lives.

                                  But doing it pharmacologically? Ouch. That's a very different approach. If someone saw the harm they caused & felt remorseful, they're going to have low mood. That's way different than a doctor inducing depression via medication.

                                  I can think of a lot of pharmacological approaches that can make prison stays very difficult for prisoners & create a "disincentive" for them to come back. However they're pretty much unconstituional & violate medical ethics. Someone could very well just as much argue to torture prisoners to make sure they wouldn't want to come back to prison.

                                  Only way I can see the reserpine approach approved by an IRB board is if it was completely voluntary & the prisoner had the right to pull out whenever he/she wanted out, or done in a 3rd world country where human rights are not respected. Even then at least for myself I wouldn't approve it if I was on that board.

                                  Personally I'd favor this approach...pink clothes for prisoners.
                                  http://youtube.com/watch?v=llXPtNGEKn4
                                  I'd further add flower symbols, smiley faces, maybe a hello kitty or telly tubby face added to the suit for the worse prisoners. Maybe even make them wear a pink bikini & start playing Cher music.
                                   

                                  submit

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                                    Jack, I thought antisocial was the result of low serotonin. But I feel there is something to that theory so much, so, that I added your question to something I wrote on wiki, but if you want your link removed please let me know. http://wiki.answers.com/Q/Who_gave_antisocial_personality_disorder_its_name

                                    I would like to know more of your opinions.

                                    If antisocial is a chemical imbalance caused by genetics, then genes are not typically able to turn on and off, easily, right, so if someone experiences antisocial, but it leaves them for a while, then returns, that would not signify the ability for genes to turn neurotransmitters off an on, eazsily. Right?
                                     
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                                    BobA

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                                      This guy Dr. Kiehl is doing some cool fMRI work on antisocial personality. Of course, it's more mapping the brain structures involved and not so much focusing on neurotransmitters. But cool to see the structural aspects of personality disorders elucidated.
                                       
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                                        somebody is finally getting it right. The info about caffeine and the other stuff, and looking at this from the appropriate vantage point, is all on the right track, from my perspective. you got it.
                                         
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                                          stimulants alone are not the answer, because some antisocials self medicate with stimulants, and it only serves to make them worse, so what if there was something to enhance the serotonin and lower the dopamine. Enhancing the serotonin may serve to bring the balance of serotonin and dopamine. Their symptoms seem worse in the evening, and include agitation, anger, criticism, and bad moods, and this is probably because their adrenaline is wearing down, so rather than feeling tired, with too little adrenaline, they are tiired and mean and moody because of too little adrenaline in comparison to dopamine, but I am only guessing. I also wonder if digestive enzymes play a role. There is something called beano, which has enzymes which help digest sugar, and sugar creates adrenaline. I have anxiety and it makes me worse, but it also helped me lose 20 lbs with just one small drop out of the dropper that came with the bottle, and digesting sugar faster may be helpful in losing weight. When I took digestive enzymes, I took beano, as well, and I think all the enzymes helped me lose weight, which may be because you are digesting food faster, but I am not sure which digestive enzyme is the most beneficial for losing weight, or which is the only one that caused me to lose weight. Caffeine, or something similar, would have to be used in conjunction with something that would give them the loving feelings you get with serotonin. Maybe small amounts of 5- htp, like a milligram a day. It would have to be under a doctor's guidance.
                                           
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                                            thyroid imbalance, even minor, can be involved, as well as digestive enzymes, in causing less neurotransmitters and transmitter imbalances.

                                            These are simply suggestions to give to your doctor.
                                             
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                                            kugel

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                                              stimulants alone are not the answer, because some antisocials self medicate with stimulants, meth, being one of them, and it only serves to make them worse, so there must be something to enhance the serotonin and lower the dopamine, but enhancing the serotonin may also serve to bring the balance of serotonin and dopamine. I also know that their symptoms are worse in the evening, and include agitation, anger, criticism, hanging up on others, and general bad attitudes, and this is probably because their adrenaline is wearing down. I also wonder if digestive enzymes play a role. There is something called beano, which has enzymes which help digest sugar, and sugar creates adrenaline. I have anxiety and it makes me worse, but it also helped me lose 20 lbs with just one small tip of the syringe, so the stuff works. It would have to be used in conjunction with something that would give them the loving feeling like serotonin. Maybe small amounts of 5- htp, like a milligram a day. It is worth a shot, and they could try it for a few days, and judge how they feel, .

                                              And the evidence for any of this in regards to treating ASPD (other than "some antisocials self medicate with stimulants") is what?
                                              And what do you mean by "it also helped me lose 20 lbs with just one small tip of the syringe?"
                                               

                                              OldPsychDoc

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                                                There are case reports of a new Italian medication called Goldschlaeger being effective for this condition.

                                                Pffft. Obviously you're being influenced by those fancy lunches those smooth talking Goldschlaeger reps have been buying you lately.
                                                First of all, head-to-head studies clearly demonstrate the superior efficacy of Jagermeister in these situations. But furthermore, neither of these "atypical" agents have ever been shown to work any faster or more reliably than Smirnoff, SoCo, Jack Daniels, or even (albeit requiring somewhat higher doses) Coors Light. In my practice, we have even realized considerable cost savings in the treatment of this condition with generic tequila.
                                                 

                                                OldPsychDoc

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                                                  Antisocial personality disorder? Since when do you need medication for being shy? :laugh: Wow

                                                  All kidding aside, as you get a bit further along in your education, you'll learn that what is meant by "antisocial personality" is not synonymous with shyness or social phobia, but sociopathy--a serious problem in psychiatry and society as a whole.
                                                   

                                                  silas2642

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                                                    - only the ones who got caught.

                                                    Seem to be plenty in politics.

                                                    I remember the psychiatrist who was giving us a lecture on personality d/o's-- he was saying that with the antisocials, "it's really not THEM with the problem, it's everyone else." So they really don't tend to show up at the doorsteps of clinician's very often without a court order in hand; which is good, he stated, because "we have no idea what to do for them."
                                                     

                                                    whopper

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                                                      "we have no idea what to do for them."

                                                      I love it. We don't have a treatment for them, but we as psychiatrists are somehow supposed to solve the problem.

                                                      You see some patients learn how to manipulate this. You got a schizoaffective DO person with ASPD who is fully stable on his meds, and is compliant, but whenever he's a arrested (for things like shoplifting, drug dealing etc), he raises him arms up and tells the police he's a psychatric patient, they drop him off at the emergency psyche center, and he's off to the psyche unit for a few weeks, then discharged. Then he does the same thing again & again & again & again & again.

                                                      HE's basically figured out how to obtain a get out of a jail free card, and he didn't mind going to inpatient either, because he viewed it as a vacation and a place to meet new women.
                                                       

                                                      nitemagi

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                                                        There's some interesting working going internationally with sociopathy/psychopathy. I was at the AAPL meeting this year and heard some fascinating discussions about work in Denmark (maybe it was Holland) where after committing a crime and found to have a mental illness including ASPD, will first make them serve jail time THEN hospitalize them indefinitely, or until a psychiatrist says they're ready for release. The idea being that if they're faced with indefinite imprisonment or engagement in therapy authentically, they will choose to engage in therapy. They had a recidivism rate decrease from something like 84% to 7%. Of course that's skewed for those they actually released.

                                                        Now in the UK they're trying to follow this practice, except it's a program designed by the government (not psychiatrists), and per the presentation is much less successful. I'll try to dig out my conference packet to find some publication references. In the UK they even designed a new personality type -- DSPD (Dangerous and Severe Personality Disorder), an illness named and created by the government/civil servants. Their work is going on mainly at Broadmoore hospital (link below). Interesting stuff.

                                                        http://www.dspdprogramme.gov.uk/
                                                         

                                                        kugel

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                                                          I have to admit, I get nervous when people start talking about extending a criminal sentence on the basis of "mental illness." This gets dangerously close to times/places where psychiatry has been used to lock up "wrong thinkers" for the convenience of the government. If "serving your time" now means that you might get indefinitely hospitalized after you have served your sentence, and on the word of government doctors, then something basic has changed about he philosophy of the criminal justice system.

                                                          I can currently hold people for a maximum of 72 hrs (before going in front of a judge to prove continued immediate need) when they are an imminent danger to self/others - NOT on the basis of the fact that their illness makes them likely to eventually hurt/kill someone.

                                                          I urge great caution before physicians get involved in this kind of effort. Such things are already beginning in the US, and I don't like it. I don't like doctors having the authority to indefinitely hospitalize anyone - for any reason. We are either engaging in treatment, or we are incarcerating people. I don't believe we can do both. I don't like doctors getting involved in deciding who is "fit" to be in society. I don't like doctors hospitalizing people on the basis of the fact that a court states a particular person committed a particular act - years ago before the person was incarcerated. I have a friend who practiced psychiatry under the soviet system in Ukraine before coming here. He was forced to "hospitalize" dissidents - and these things make him very, very nervous.
                                                           
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