Psychobiological aspects of antisocial personality disorder, psychopathy, and violence

Antisocial personality disorder (ASPD) and the related condition of psychopathy (psychopathic personality) hold strong interest for researchers and practitioners because of their chronic nature and costly impact on society. Individuals who exhibit symptoms of these clinical conditions account for a disproportionate number of crimes, including violent offenses, and are more likely to reoffend than other adjudicated individuals. (1) A clear understanding of psychological and biological processes underlying these conditions and their predictive relations with violence is essential for developing effective treatment and prevention programs for curtailing violent victimization.

The key focus of this article is on understanding violent offending (eg, reactive, proactive, firearm violence) tied to ASPD and psychopathy using a psychobiological lens to aid in characterizing pathological processes that give rise to acts of violence.

In reviewing the literature on ASPD and psychopathy and the biological bases of their overlap and relations with violent offending, we argue that most forms of ASPD-related violence reflect disturbances in the functioning of negative valence and cognitive control systems, and in the normal adaptive interplay between the two. This is in contrast to affective-interpersonal features specific to psychopathy that entail disturbances in emotional processing (deficient fear and empathy) and social relations (domination, exploitativeness) that give rise to more proactive forms of violence.

After reviewing relevant existing work, we extend from the general case to discuss the rare but highly impactful phenomenon of mass shootings. In these cases, hostile-alienated tendencies commonly seen in ASPD take an unusually dark turn, toward fantasy-fueled acts of violent vengeance.

Definitions and distinctions

Contemporary diagnostic nosology defines ASPD primarily in terms of observable norm-violating behaviors, rather than more internal affective states or personality traits (conceived in DSM-III). DSM-5 contains 2 definitions of ASPD-one in "Diagnostic Criteria and Codes," the other in "Emerging Measures and Models." The first is a traditional criterion-based, categorical diagnosis carried over without revision from DSM-IV. The diagnosis is assigned to individuals aged 18 or older if 3 or more of 7 adult symptoms are exhibited together with symptoms of conduct disorder earlier in life (ie, before age 15). With the exception of items pertaining to remorse and deceptiveness, the diagnostic criteria for ASPD largely reflect behavioral tendencies associated with a highly reckless, impulsive (ie, disinhibited) disposition.

The second definition contains a new dimensional system for characterizing personality pathology that includes trait-based definitions of 6 distinct personality disorders, including ASPD. ASPD is characterized in this system by elevations on personality disorder-related traits from 2 categories: antagonism and dis-inhibition--a combination supported by structural and biometric analysis of adult symptoms of ASPD. (2)

While ASPD is defined primarily in terms of impulsive, aggressive, and illicit behaviors, psychopathy is defined by impulsive-antisocial behavior occurring together with distinct affective-interpersonal features that entail a dominant and forceful social style, manipulativeness, callousness/cruelty, and emotional insensitivity. The assessment instrument that has dominated contemporary research on psychopathy is the Psychopathy Checklist-Revised (PCL-R), developed to identify the condition in incarcerated offenders. (1) While the PCL-R is devised to assess psychopathy as a unitary condition, factor...