Antisocial personality disorder

INTRODUCTION

Clinicians often consider patients manifesting Antisocial Personality Disorder (ASPD) as not responding well to treatment for Substance Use Disorder (SUD)--a viewpoint supported by considerable empirical research (1-6). The SUD patients with ASPD engage in more use of illicit drugs (7), a factor favoring chronicity (8). However, recent studies have demonstrated the efficacy of particular interventions for the SUD-ASPD patient, including drug courts, jail diversion, closely supervised parole, outpatient commitment, cognitive-behavioral therapy, and one mode of pharmacotherapy (9-12). Moreover, these treatments--when successful--greatly reduce criminal behavior in those with comorbid SUD-ASPD (13, 14). These optimistic findings indicate the need for greater understanding of SUD patients with ASPD. The current study was undertaken in order to assess SUD severity in a group of SUD patients; a separate evaluation for Antisocial Personality Disorder (ASPD) was conducted with the same group as well. Research questions were as follows:

* Do SUD patients with ASPD report more substance-related symptoms and problems, a different course of SUD, and more family history of SUD?

* Would addiction psychiatrists assessing SUD patients make more or different SUD diagnoses in patients with ASPD?

* Do SUD patients with ASPD report more SUD treatment in association?

METHOD

Patients

From a clinical sample of 642 patients, 34 patients were excluded because they were under the age of 18 and two patients did not meet criteria for a Substance Use Disorder (SUD). The remaining 606 voluntary patients, who had an alcohol and/or drug related problem, were referred to two programs located within Departments of Psychiatry at two university medical centers. Referrals came from primary medical clinicians, mental health clinicians, and substance abuse clinicians. About 90% were initially assessed as outpatients. Patients were sober and not manifesting withdrawal signs or symptoms at the time of evaluation. They represented a broad socioeconomic group, with recompense including private fee-for-service, referrals from Health Maintenance Organizations, Medicare-Medicaid, and Medical Assistance; each source of finance representing about 20% to 30% of the sample. Informed consent was obtained to analyze and report these findings in an anonymous fashion.

Demographic comparison of the two groups showed that the ASPD group tended to be less educated and younger, but gender, marital status, and employment status did not differ. These data are as follows:

Data Collection

Patients were categorized as having Antisocial Personality Disorder if they met the DSM criteria for Antisocial Personality Disorder (ASPD), a method that has shown good validity and reliability over time as compared to other instruments (15). These criteria required a childhood diagnosis of Conduct Disorder plus later antisocial behavior. Antisocial behavior associated with subsequent SUD, by itself, would not qualify the patient for the diagnosis of ASPD. A research associate (J.N.), blinded to other data, obtained data from patients using a scheduled questionnaire of ASPD diagnostic criteria. The "remorse" item was dropped from the DSM-IV criteria, due its common presence early in abstinence; this modification changed the ASPD criteria to DSM-III-R.

The patients completed the Michigan Assessment-Screening Test/ Alcohol-Drug. This scale, adapted from Seltzer's original Michigan Alcoholism Screening Test (16), was assessed in an SUD sample (17).

A trained interviewer, blind to the ASPD category, used scheduled interview formats to obtain data on substance abuse problems and history. All interviewers were trained at the master's level and were experienced in working with SUD patients (MSW, CNS, MS psychologist). They obtained the following data:

* A 57-item, interview-based scale, the Minnesota Substance Abuse Problem Scale or M-SAPS (18), which includes a total scale score (in which all items are equally rated) and six subscales as follows: Psychological Problems, Pharmacologial Problems (behaviors and experiences related to dependence), Family Problems, Interpersonal Problems (outside the family), Occupational Problems (including academic problems for those in school or training), Financial Problems, and Legal Problems; all items were ranked for only those problems associated with substance use;

* Family history, asking specifically about substance abuse in mother, father, and in any sibling, grandparent, or aunt/uncle (related by blood); the total number of relatives who had died of a substance-related death, had been treated for SUD, or clearly met DSM criteria for SUD were tabulated as having SUD;

* A history of substance use, using a format that included any lifetime use, age at first use, years of use, and days of use in the last year (19); it was obtained for licit drugs (alcohol, tobacco, caffeine), illegal use of licit drugs (e.g., amphetamines, anxiolytics-sediatives, inhalants), and illicit drugs (e.g., heroin, cocaine, hallucinogens, phencyclidine or PCP) (20); longest periods of abstinence were ascertained for the last year, last five years, and last decade; a 7-item self-help inventory was also administered (21);

* Treatment history, using a scheduled format including types of treatment (i.e., detoxification, general hospital, state hospital, therapeutic community, halfway house residence, other residential treatment, and outpatient care including either outpatient clinic visits or day program), quantified by number of admissions to each modality, days of care in each modality (one outpatient visit=one day), and imputed costs for each modality to produce a lifetime cost of care: none of these data applied to the current treatment episode.

An addiction psychiatrist blind to the ASPD category made a lifetime diagnosis of SUD, using DSM criteria.

Consent

Each patient provided informed consent following orientation. Copies of signed consent were provided to the patient, inserted in the medical record, and kept in our research files.

Data Analysis

Nonparametric categorical data (e.g., presence vs. absence of a variable vs. ASPD) were compared using the Chi Square test, with a correction for continuity. For instances in which the expected numbers in any one cell were five or less, a Fisher Exact Test was employed. Parametric data (e.g., age, education) were compared between the two groups using the Student t test. Continuous nonparametric data (e.g., symptom scales, treatment measures) were compared using the Mann-Whitney U test. A probability level of .01 was chosen as being significant due to the large number of comparisons and the large sample size. Probability levels between .02 and .05 were reported as trends that might be tested in other samples with a larger proportion of patients with ASPD.

Logistic regression analyses were conducted, using a conditional forward entry model. The first regression was to assess the effect of significant demographic characteristics on ASPD (using p<.05 as a cut-off), since these demographic factors could confound the data if they showed an interactive effect. The second regression involved entering the two significant univariate demographic factors (lower age and less education) along with the significant M-SAPS scores and treatment variables, since these bore the strongest consistent univariate association with ASPD (using p<.01 as a cut-off).

FINDINGS

Self-Rated Michigan Assessment-Screening Test/Alcohol-Drug (MAST/AD)

Patients with ASPD had higher (i.e., more morbid) scores on the MAST/AD, averaging four more symptom/problem reports. However, as shown in Table 1, this scale failed to show a significant difference between the two groups but did show a trend at p=.04.

Interviewer-Rated Minnesota Substance Abuse Problem Scale (M-SAPS)

Patients with ASPD had significantly more SUD problems and symptoms on this 57-item scale, averaging 6.2 more symptoms than did those without ASPD (p<.001, see Table 1). Among the subscales, those showing the greatest difference between the two groups were Family Problems, Interpersonal Problems (outside of the family), and Legal Problems. Psychological, Pharmacological, and Financial Problems were also significantly different. Only one scale, Occupational Problems, failed to show a difference.

Among the 57 items reported in association with substance use, nine items showed a significant difference at .01. Beginning with the most significant, these included the following: divorce and/or permanent alienation from family, physical fights, verbal arguments, property felony conviction, loss of boyfriend/girlfriend, harassing others via the telephone, poor credit rating, and using substances on the job. Those with ASPD reported more of all of these nine items. (See Appendix 1 for a list of all 57 items.)

Family History of SUD

As shown in Table 1, none of the family categories (i.e., father, mother, any sibling, grandparents, any aunt/uncle) showed a significant difference, although all of them were slightly higher in the ASPD group. When all of the five categories were combined, the ASPD group reported, on average, 0.5 more relatives with SUD (see Table 1). Despite the small difference, it was significant at p<.005.

Lifetime Use of Substances

As shown in Table 1, lifetime use of the licit substances alcohol and caffeine were virtually universal and identical in the two groups. However, the ASPD group reported a significantly higher rate of lifetime tobacco use at .01. In order to simplify data presentation, only four of the eight illicit drug categories are shown: i.e., cannabis, amphetamine, cocaine, and opioids (hallucinogens, PCP, solvents, and sedatives). As shown in Table l, the ASPD group reported lifetime use significantly more often for three of these drugs; there was a lifetime trend for more cocaine use in the ASPD group at .05.

Of the possible 11 substances included in our interview schedule, ASPD patients reported a lifetime average of 8.1 substances, as compared to 6.6 substances for other patients. Although this difference amounts to only 1.5 drugs on average, it was significantly different at .001 (see Table 1).

Age at first use for all substances was younger in the ASPD group (see Table 1). However, the difference was significant for only two substances, both of them licit: alcohol and tobacco. There was a trend for earlier cannabis use by ASPD patients (p=.05). Patients tended to begin these drugs during later childhood to later adolescence, with average start-ups in early adolescence by ASPD patients and middle adolescence by non-ASPD patients. Caffeine use began early in both groups and did not show a difference. Amphetamine, cocaine, and opioid use began after age 18 (on average) in both groups and did not show a difference.

Years of use did not differ for any substance between the ASPD and non-ASPD patients. Likewise, daily use in the last year did not differ for any substance across the two groups. In Table 1, only alcohol and cannabis data are presented to exemplify the similarities for these variables.

Longest periods of abstinence from substances being abused were ascertained for three time frames: the last year, the last five years, and the last decade (see Table 1). As indicated, abstinence duration did not vary in association with ASPD.

The number of self-help efforts, with a possible score ranging from 0 to 7, showed no difference between the two groups.

Psychiatrist SUD Diagnoses

None of the lifetime SUD diagnoses showed a difference between the two groups (see Table 1). In addition, the number of lifetime SUD diagnoses did not show a difference.

SUD Treatment History

None of the seven modalities of treatment showed a significant difference across the two groups, although a few of them (detoxification, halfway house, residential treatment) showed trends. Combining all seven modalities, the ASPD group reported more treatment use. Despite the absence of a difference by modality, the differences for the combined data were highly significant. The ASPD patients also were admitted more frequently to SUD treatment, had more days of SUD treatment, and had a higher lifetime cost of SUD treatment (see Table 1).

Logistic Regression Analysis

The first logistic regression entered age and education with ASPD in order to discern whether in conjunction age and education bore a stronger relationship to ASPD than they did separately. Neither demographic characteristic was retained in the analysis (for age, Odds Ratio (OR)=0.97, 95% Confidence Interval (C.I.)=0.92 to 1.01 ; for education, OR=0.90, 95% C.I. =0.78 to 1.04).

The second logistic regression included the two demographic characteristics (age and education), the M-SAPS subscales, and the SUD treatment variables. In the forward conditional logistic regression, the following variables were retained in association with ASPD:

* Higher M-SAPS Legal Problems subscale score: OR of 1.40 and a 95% C.I. of 1.08 to 1.81 (Wald statistic=6.280, p=.012);

* Higher M-SAPS Family Problems subscale score: OR of 1.23 and a 95% C.I. of 1.05 to 1.45 (Wald statistic=6.184, p=.013).

The other M-SAPS subscales and all of the treatment variables were dropped from the analysis.

DISCUSSION

Severity of Substance-Related Problems

On dyadic comparisons, the M-SAPS subscales indicating legal offenses, family conflicts, and interpersonal problems with nonfamily (friends, coworkers, neighbors) showed the most difference between ASPD and non-ASPD patients. Pharmacological symptoms suggested that the ASPD group's dependence or substances was high. More financial problems revealed greater irresponsibility in managing finances and using funds to purchase drugs among the ASPD patients. An equal level of occupational problems between the two groups was consistent with the absence of a difference in current employment between the two groups.

The logistic regression analysis revealed that two M-SAPS subscale scores, Legal Problems and Family Problems, remained highly associated with ASPD, even when age, education, other M-SAPS scores, and treatment variables were taken into account. This analysis demonstrated a strong independent association of legal and family problems with ASPD in these patients.

The greater association of the interview-based M-SAPS with ASPD, as compared to the self-rated MAST/AD scores, was unexpected. The unpredicted difference between the self-rated MAST/AD and the interview-based M-SAPS scales could be due to one or more of the following:

* the M-SAPS has twice as many items as the MAST/AD;

* the M-SAPS items reflect greater severity of addiction than to the MAST/ AD;

* the interviewer format, with skilled clinicians conducting the interviews and making the ratings, may have elicited symptoms, behaviors, and problems indicative of greater severity.

We are not sure whether one or all of these possible explanations are likely.

Course of Substance Use in SUD

ASPD and non-ASPD patients manifested considerable similarity in their courses of substance use. They began use of illicit drugs at about the same age. In addition, their years of use, days of use in the last year, and longest periods of abstinence did not differ. Their lifetime diagnoses, made by addiction psychiatrists, showed no difference. These findings suggest that, in the main, the course of substance use itself did not differ greatly in association with SUD.

A few more minor differences in the course of substance use were suggested by the data, however. Patients with ASPD showed greater risk-taking behavior in starting alcohol and tobacco use earlier and in being more apt to ever use illicit drugs. Their younger current age and similar duration of use suggested an earlier onset of substance abuse (as contrasted with substance use). However, these differences were relatively few in comparison to the overwhelming majority of similarities.

SUD Treatment

Although the SUD + ASPD group was several years younger on average, they had experienced about 50% more SUD treatment modalities, more admissions to SUD treatment+ more days in SUD treatment, and greater lifetime cost of SUD treatment. These SUD treatment data confirmed the findings of more severe problems in association with comorbid SUD and ASPD discussed earlier. Although the diversity of treatment experience was wide (as reflected in the large standard deviations for each of these variables), the statistical significance between the ASPD and non-ASPD groups was, nonetheless, large. These findings suggest both a propensity to seek or require treatment among patients with ASPD, as well as perhaps a shorter-lived response to the treatment received.

The fact that these treatment variables dropped out of our regression analysis suggested that the associated psychological, pharmacological, legal, family, interpersonal, and financial problems interacted with ASPD, so that ASPD did not come through the analysis as an independent factor contributing to more treatment. We believe the greater levels of treatment in ASPD probably act through the many SUD-associated problems that are reflected in the M-SAPS instrument.

Why Do Severity and Course Differ So Greatly?

One might expect that a similar temporal course of substance use and abstinence would lead to similar severity of substance-related symptoms, behaviors, and problems. Factors in the ASPD patients that might have accounted for this difference in severity and course included the following:

* earlier age of alcohol and tobacco use, fostering a more morbid course over the same period of time as those who start alcohol and tobacco use later;

* greater use of illicit substances, associated with more legal problems;

* ASPD itself, with its adverse influences on decisions, behavior, and relationships, perhaps rendering those so afflicted more impaired despite comparable chronology and SUD diagnoses.

Still, these data on course suggest, but do not demonstrate, the cause for the greater severity of substance-related problems among patients with combined SUD-ASPD. From the standpoint of treatment, etiology may not make much difference. From the standpoint of prevention, however, further identifying etiology could be important. For example, delaying onset of alcohol and tobacco use or reducing availability of illicit drugs could theoretically reduce the severity of SUD among those patients with SUD. On the other hand, if severity is inherently related to the behavior and psychology associated with ASPD, these environmental interventions may not be effective.

Other studies have suggested alternative possible causes or mechanisms for the severity of SUD in those with ASPD. For example, a study of drug users in the National Household Survey on Drug Abuse (22) revealed that the frequency of drug use bore a linear relationship to the extent of criminal activity, suggesting that severity of substance-related behaviors or problems may co-vary with frequency of use, perhaps independent of duration of use. Finn and colleagues showed that, among alcoholics with early onset, those with Conduct Disorder manifested an increased sensitivity to reward, greater novelty seeking and impulsivity, and low harm avoidance (23); these psychological characteristics could favor a more rapid course of SUD. In our study of SUD patients from a few decades ago, young patients with antisocial behaviors eroded their social resources more than did other patients, showing among others less employment, family support, and network of friends (24); these losses could hasten the adverse consequences of SUD.

Laboratory findings suggest neurophysiologic mechanisms that could favor rapid deterioration of SUD patients with ASPD. A decade ago Bauer and colleagues demonstrated low P300 amplitudes in the frontal lobes of young, nonalcoholic men with ASPD (25). In a later study using P300 amplitudes, the number of childhood Conduct Disorder behaviors, and adult ASPD symptoms were associated with lower amplitudes in the frontal region in subjects aged 30 or younger (26). Combined neuroimaging and autonomic testing in ASPD shows a peculiar combination of frontal lobe deficits, increased heart rate, and decreased skin conductance (27). Low arousal, as indicated by low skin conductance, may foster insensitivity to aversive consequences, thereby producing continued self-destructive acts (28). Greater body lead burden also has been associated with antisocial and delinquent behavior in grade school boys, suggesting mild organic brain damage as a contributing factor (29).

Schubiner and coworkers also found a high comorbidity of childhood Conduct Disorder and Attention Deficit Hyperactivity among adults with SUD (30). The ADHD comorbidity (which we did not study) could also contribute to a more rapid deterioration. Tremblay and colleagues observed the precursors of antisocial behavior as early as kindergarten (i.e., high impulsivity, low anxiety, low reward dependence), suggesting an onset of significant psychosocial morbidity even before substance use begins (31). This early onset could undermine the social and other adaptive skills needed to cope with life and. in the event of SUD, to cope with the difficult tasks required during recovery.

Family History

Paternal factors were studied extensively as a potential cause for ASPD in patients with SUD. However, the data are conflicting. In one study, paternal substance disorder did not affect the prevalence of ASPD among SUD patients (32). In another study by the same investigative team, paternal alcoholism was associated with increased rates of Conduct Disorder in preadolescent offspring (33). Our data failed to show any link of ASPD specifically to paternal SUD. However, the sum total of all SUD relatives was slightly, but significantly, greater among the APSD patients.

Caveat

One team of investigators studying veterans with SUD did not find that ASPD affected the course or morbidity of SUD (8, 34, 35). Thus, our findings may not extend to all subgroups of patients with SUD. The discrepancy between our data and these veteran-based data could be due to military enlistment procedures, which might eliminate individuals with Conduct Disorder (or at least those with more severe forms of Conduct Disorder). Individuals with Conduct Disorder may choose not to join the military (due to the highly regimented lifestyle and authoritarian organization), may be turned away if trying to join the military (due to legal problems, school drop out), may fail to complete basic training (since antisocial behavior may undermine unit cohesion), and/or may receive a dishonorable discharge due to antisocial behavior. In any of these events, they would not appear in a sample of veterans receiving VA treatment.

APPENDIX 1

Minnesota Substance Abuse Problem Scale: 57 Items

Instructions: Rate Only Those Items That Have Been Associated with Any Alcohol and Drug Use, Including Items That Lead Up to Use, Items That Occur During Use, and Items That Occur During Withdrawal from Use or During Attempts to Remain Abstinent

Pharmacological items

1. Morning use.

2. Use of the job or at school.

3. Use associated with memory loss (blackout).

4. Increased tolerance (same dose produces less effect than previously).

5. Decreased tolerance (same dose produces greater effect than previously).

6. Occasional loss of control over use (less than half of the time, uses more of the substance or for longer than intended).

7. Regular or complete loss of control over use (half or more of the time, uses more of the substance or for longer than intended).

8. Uses to feel normal.

9. Has attempted to reduce or control use (by limiting dose, frequency of use, duration of use, changing type of substance).

10. Has used substitute, emergency, or inexpensive intoxicants (e.g., hair tonic, rubbing alcohol, cough medicines, solvents, mouthwash).

11. Uses to relieve physical symptoms (e.g., headache, pain, insomnia).

12. Uses to relieve psychological symptoms (e.g., anger, sadness, boredom).

Psychological-Behavioral items

1. Panic attacks.

2. Nightmares (recall of frightening or horrific dreams).

3. Night terrors (crying out in sleep).

4. Abuse of telephone (e.g., calling others in the middle of the night, repetitive long distance phone calls, hassling or teasing others by phone, threatening or harassing phone calls).

5. Ashamed or guilty about behavior while using, or about use itself.

6. Self-pity.

7. Suicidal ideas.

8. Unreasonable resentments.

9. Keeping a hidden supply of alcohol and/or drugs.

10. Suspicious or mistrustful of others.

11. Preoccupied with using alcohol and/or drugs.

12. Secretive about alcohol and/or drug use.

13. Needing alcohol and/or drugs to relax.

14. Using drugs and/or alcohol alone.

15. Rapid or "priming" use (e.g., after work. before a party).

16. Anticipates, plans, or "craves" next use.

17. Late to appointments, fails appointments.

Occupation (work, homemaking, and/or school) items

1. Decreased productivity or grades.

2. Decreased time spent at work, studies, or homemaking (e.g., Monday morning absenteeism).

3. Confronted by supervisor, boss, partner, teacher, counselor, etc.

4. Quit or changed jobs or school because of use.

5. Did not get promoted or graduate because of use.

Family items (either family-of-origin or family-of-marriage)

1. Arguments (verbal) with family members.

2. Fights (physical) with family members.

3. Took money from family for alcohol and/or drugs.

4. Left home because of conflict related to alcohol and/or drugs.

5. Alienated from family for one or more periods due to alcohol and/or drugs.

6. Confronted by family member regarding use.

7. Permanent separation or divorce.

Interpersonal items

1. Verbal arguments (outside family).

2. Physical fights (outside family).

3. Loss of friends.

4. Loss of girlfriend/boyfriend.

5. Loss of sexual interest or enjoyment.

6. Most current friends of acquaintances have alcohol and/or drug problems.

Financial items

1. Unable to pay bills.

2. Poor credit rating.

3. Repossession (e.g., appliance, TV, car, home).

4. Selling personal belongings to buy alcohol and/or drugs.

5. Bankruptcy.

Legal items

1. Driving while intoxicated conviction.

2. Conviction related to liquor or drug laws (e.g., open bottle in car, possession of illicit drugs).

3. Property offenses.

4. Personal offenses.

5. Incarcerated as a result of such convictions.

ACKNOWLEDGMENTS

Acknowledgment is expressed to Dr. James Halikas, Dr. Sheila Specker, Mr. John Neider, and Mr. Greg Carlson for their respective roles in evaluating these patients as well as tabulating and analyzing these data. The Laureate Foundation of Tulsa also provided support to tabulate and analyze these data.

REFERENCES

(1.) Nurco DN, Shaffer JW, Cisin IH. An ecological analysis of the interrelationships among drug abuse and other indices of social pathology. Int J Addict 1984; 19(4):441-451.

(2.) Arndt IO, McLellan AT, Dorozynsky L, Woody GE, O'Brien CP. Desipramine treatment for cocaine dependence; role of antisocial personality disorder. J Nerv Ment Dis 1994; 182(3):151-156.

(3.) Favrat B, Rao S, O'Conner PG, Schottenfeld R. A staging system to predict prognosis among methadone maintenance patients, based on admission characteristics. Subst Abuse 2002; 23(4):233-244.

(4.) Carroll KM, Ball SA, Rounsaville BJ. A comparison of alternate systems for diagnosing antisocial personality disorder in cocaine abusers. J Nerv Ment Dis 1993; 181(7):436-443.

(5.) Crowley TJ, Mikulich SK, MacDonald M, Young SE, Zerbe GO. Substance-dependent, conduct-disordered adolescent males: severity of diagnosis predicts 2-year outcome. Drug Alcohol Depend 1998; 49:225-237.

(6.) Brochu S, Bergeron J, Landry M, Germain M, Schneeberger P. The impact of treatment on criminalized substance addicts. J Addict Disord 2002; 21(3):23-41.

(7.) King VL, Kiforf MS, Stoller KB, Carter JA, Brooner RK. Influence of antisocial personality subtypes on drug abuse treatment response. J Nerv Ment Dis 2001; 189(9):593-601.

(8.) McKay JR, Alterman AI, Cacciola JS, Mulvaney FD, O'Brien CP. Prognostic significance of antisocial personality disorder entering continuing care. J Nerv Ment Dis 2000; 188(5):287-296.

(9.) Miller NS, Sheppard LM. Addiction treatment and continuing care in forensic populations. Psychiatr Ann 2000; 30(9):589-596.

(10.) Steadman HJ, Deane MW, Morrissey JP, Westcott ML, Salasin S, Shapiro S. A SAMHSA research initiative assessing the effectiveness of jail diversion programs for mentally ill persons. Psychiatr Res 1999; 50(12): 1620- 1623.

(11.) Longabaugh R, Rubin A, Malloy P, Beattie M, Clifford PR, Noel N. Drinking outcomes of alcohol abusers diagnosed as antisocial personality disorder. Alcohol, Clin Exp Res 1994; 18(4):778-785.

(12.) Powell BJ, Campbell JL, Landon JF, Liskow BI, Thomas HM, Nickel EJ, Dale RM, Penick EC, Samuelson SD, Lacoursiere RB. A doubleblind, placebo-controlled study of nortriptyline and bromocriptine in male alcoholics subtyped by comorbid psychiatric disorders. Alcohol, Clin Exp Res 1995: 19(2):452-468.

(13.) Verheul R, VanDenBrink W, Koeter MWJ, Hartgers C. Antisocial alcoholic patients show as much improvement at 14-month follow-up as non-antisocial alcoholic patients. Am J Addict 1999; 8:24-33.

(14.) Hernandex-Avilia C, Burleson JA, Poling J, et al. Personality and substance use disorders as predictors of criminality. Compr Psychiatry 2000; 41(4):276-283.

(15.) Messina N, Wish E, Hoffinan J, Nemes S. Diagnosing antisocial personality disorder among substance abusers: the SCID versus the MCMI-II. Am J Drug Alcohol Abuse 2001; 27(4):699-717.

(16.) Selzer M. The Michigan Alcoholism Screening Test (MAST): the quest for a new diagnostic instrument. Am J Psychiatr 1971 ; 127:1653-1658.

(17.) Westermeyer J, Yargic I, Thuras P. Michigan Assessment-Screening Test for Alcohol and Drugs (MAST/AD): evaluation in a clinical sample. Am J Addict 2004; 13:1-12.

(18.) Westermeyer J, Nugent S, Crosby R. The Minnesota Substance Abuse Problem Scale: psychometric analysis and validation in two clinical samples. Am J Addict 1998; 7:24-34.

(19.) Westermeyer J, Kopka S, Nugent S. Course and severity of substance abuse among patients with comorbid major depression. Am J Addict 1997; 6(4):284-292.

(20.) Westermeyer J, Eames S, Nugent S. Comorbid dysthymia and substance disorder: treatment history and cost. Am J Psychiatr 1998; 15(11): 1556-1560.

(21.) Westermeyer J, Myott S, Aarts R, Thuras P. Self-help strategies among substance abusers. Am J Addict 2001; 10:249-257.

(22.) French MT, McGreary KA, Chitwood DD, McCoy CB, Inciardi JA, McBride D. Chronic drug use and crime. Subst Abuse 2000; 21(2):95-109.

(23.) Finn PR, Mazas CA, Justus AN, Steinmetz J. Early-onset alcoholism with conduct disorder: go/no go learning deficits, working memory capacity, and personality. Alcohol, Clin Exp Res 2002; 26(2):186-206.

(24.) Westermeyer J, Walzer V. Sociopathy and drug use in a young psychiatric population. Dis Nerv Syst 1975; 36(12):673-677.

(25.) Bauer LO, O'Conner S, Hesselbrock VM. Frontal P300 decrements in antisocial personality disorder. Alcohol, Clin Exp Res 1994; 18(6): 1300-1305.

(26.) Costa L, Bauer L, Kuperman S, Projesz B, O'Conner S, Hesselbrock V, Rohrbaugh J, Beglieter H. Frontal 300 decrements, alcohol dependence, and antisocial personality disorder. Biol Psychiatry 2000; 47:1064-1071.

(27.) Raine A, Lencz T, Bihrle S, Lacasse L, Colletti P. Reduced prefrontal gray matter volume and reduced autonomic activity in antisocial personality disorder. Arch Gen Psychiatry 2000; 57:119-127.

(28.) Herpertz SC, Werth U, Lukas G, Qunabi H, Schuerkens A, Kunert HJ, Freese R, Flesch M, Mueller-Isberner R, Osterheider M, Saas H. Emotion in criminal offenders with psychopathy and borderline personality disorder. Arch Gen Psychiatry 2001; 58:737-745.

(29.) Needleman HL, Riess JA, Tobin MJ, Biesecker GE, Greenhouse JB. Bone lead levels and delinquent behavior. J Am Med Assoc 1996; 275(5):363-369.

(30.) Schubiner H, Rzelepis A, Milberger S, Lockhart N, Kruger M, Kelly BJ, Schoener EP. Prevalence of attention deficit/hyperactivity disorder and conduct disorder among substance abusers. J Clin Psychiatry 2000; 61(4):244-251.

(31.) Tremblay RE, Pihl RO, Vitaro F, Dobkin PL. Predicting early onset of male antisocial behavior behavior from preschool behavior. Arch Gen Psychiatry 1994; 51:732-739.

(32.) Moss HB, Lynch KG, Hardie TL, Baron DA. Family functioning and peer affiliation in children of fathers with antisocial personality disorder and substance dependence: associations with problem behaviors. Am J Psychiatr 2002; 159(4):607-614.

(33.) Moss HB, Baron DA, Hardie TL, Vanyukov MM. Preadolescent children of substance-dependent fathers with antisocial personality disorder: psychiatric disorders and problem behaviors. Am J Addict 2001; 10:269-278.

(34.) Cacciola JS, Rutherford MJ, Alterman AI, Snider EC. An examination of the diagnostic criteria for antisocial personality disorder in substance abusers. J Nerv Ment Dis 1994; 182(9):517-523.

(35.) Cacciola JS, Alterman AI, Rutherford MJ, Snider EC. Treatment response of antisocial substance abusers. J Nerv Ment Dis 1995; 183(3):166-171.

Address correspondence to Joseph Westermeyer, M.D., M.P.H., Ph.D., Chief of Psychiatry and Director of Mental Health, Minneapolis VAMC, University of Minnesota, Minneapolis, MN, USA.

Joseph Westermeyer, M.D., M.P.H., Ph.D. and Paul Thuras, Ph.D. Minneapolis VAMC, University of Minnesota, Minneapolis, Minnesota, USA

COPYRIGHT 2005 Taylor & Francis Ltd.
COPYRIGHT 2005 Gale Group