Comorbidity in Antisocial Personality Disorder

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Comorbidity is the accompaniment of another disease with the original disease in someone. This can create some problems, especially in the diagnosis of Antisocial Personality Disorder, as there are multiple symptoms that are quite common in multiple disorders. [1] Due to this, the lack of proper differentiation between what is pure Antisocial Personality Disorder and that of comorbid disease is predictable. One of the most common co-occurrences that are seen in individuals is Attention Deficit Hyperactivity Disorder (ADHD), and can account for a large percent of the population with ASPD.[3] Aggressive behavior, which is already quite eminent in ASPD individuals, leads to increased substance dependence. [1] According to Witchen et. al. (2000), another very commonly occurring disorder are anxiety disorders that tend to lead to certain heightened symptoms. Due to this, those with ASPD of different comorbidities require treatments that are specifically designed for them, so that the treatment would have maximum effect. [2]

Anxiety Disorder

Almost half of the male population with ASPD displays comorbidity with an anxiety disorder. It has been speculated that in combination with an anxiety disorder it would result in a reduction in criminal activity and overall decline in ASPD development. [26] That being said there has been new evidence that proposes, that due to the escalated response to threat, it would prompt increased violent actions in the individuals. [26] According to a survey, it seemed that individuals with ASPD and anxiety disorder presented with an elevated possibility of major depression, use of substance, and be more suicidal. [27] If left untreated, as the person increases their use of substance due to anxiety, the prospect of recurrent violence will also be elevated. [28]

A fairly recent study intended to study the relationship between ASPD and anxiety disorders and its link to violent behavior. The study was carried out in a state penitentiary, the inmates were interviewed that exclusively had comorbid ASPD and anxiety disorder, and just ASPD. [1]The results revealed an elevated frequency of suicide, substance abuse than when ASPD manifested alone. [2] Those with the comorbidity were anticipated to participate in physical fights and assaults more than those with just ASPD. [1] It was also noted that the individuals with comorbidity also presented with a wider array of symptoms than those without. [1] They also displayed higher rates of crime before the age of 15. [2] The study also yielded a positive relationship between the number of ASPD symptoms and the sum of anxiety symptoms present. [1] Based on these results, the study concluded that the comorbidity led to an early outset and increased severity of ASPD and delinquency. [1]


In many studies, the monoamine oxidase A (MAOA) has been associated with the development of antisocial behavior. [4] Especially the promoter region of MAOA played an important role, the low activity allele of MAOA leads to antisocial behavior and increased delinquency. [4] Usually, the MAOA, breaks down many neurotransmitters such as serotonin, norepinephrine, and dopamine after reuptake. Due to this, MAOA is significant in adjusting behavior. [5] In males, this allele is especially correlated to an increased response in “the left amgydala, cingulate cortex, left insular cortex and lateral orbitofrontal cortex ,” thus leading to an elevation in antisocial behavior and anxiety. [4] This low activity allele is associated with making a connection between the amygdala and orbitofrontal cortex. [4] Due to the MAOA variant, a significant decrease in the capabilities of the orbitofrontal cortex can be seen, which leads to the decline in the ability to control feedback to unsympathetic stimuli. [6] Individuals with ASPD and anxiety must possess this low activity allele, which would explain their uncontrollable reaction to threats and taking part in violence. [4]

Attention Deficit Hyperactivity Disorder

Attention-deficit-hyperactivity disorder, also known as ADHD is a commonly occurring disorder in which individuals display problems with attention, impulse, and hyperactivity. [7] ADHD frequently occurs in people with Antisocial Personality Disorder (ASPD). As a significant number of those with ADHD continue to have it into adulthood, it is important to realize the damage that might arise with comorbidity [7] The number of symptoms present is indicative of how severe ADHD can be and of also indicate the psychosocial consequence in adulthood. [8] The category of the symptom also indicates whether the person will be antisocial, [8] According to, Thapar (2006), impulsivity and hyperactivity are better antisocial symptoms than others. [8] Individuals with comorbid ASPD and ADHD tend to be neglected in childhood, have separated parents, decreased maternal care, and suicidal tendencies. [7]. Those with such symptoms tended to have an earlier onset of antisocial behaviors. [7] Thus, it is best if it is detected early on by having an assessment done to determine whether the ADHD is comorbid or not. (umit). If caught early, it can serve as a warning of how severe it will be. [7]

Importance of Serotonin

The relationship between decreased serotonergic function and increased impulse and aggression has been previously been established. [17] Children with ADHD often exhibit aggressive behaviours. [18] Despite the fact that people with ASPD do not always display aggression, there have been studies conducted that link this disorder to impairment in serotonin function. [19] In a long-term study by Flory (2007), children with ADHD underwent a fenfluramine challenge to determine their prolactin response. After 7-11 years, the same children underwent evaluations to determine whether they developed ASPD, [18] Fenfluarmine is a drug that releases serotonin, [18] If there was a decreased prolactin response to fenfluarmine, it indicated an impaired serotonin system in the individual, which indicated the potential of development of ASPD in the individuals once they were older. [18] This study was especially important in this subject, as it is one of the only studies that encompassed a number of years, following people from childhood to adult.

Importance of Sleep

Disruptions in sleep are commonplace in those with ADHD regardless of age. [10] This is very common in children; they tend to have increased reaction times and be drowsier throughout the day, [11] There seem to be many discrepancies found in children with ADHD. In fact in a recent study, [12] these children showed increased slow wave sleep percentage than those without ADHD. In another study by Lindberg (2003), they discovered that individuals with ASPD, also displayed a similar pattern in their slow wave sleep, especially in stage 4 sleep. It is interesting that only ASPD and ADHD manifest this increase. A study determined there was a possible relationship between those with childhood ADHD, who grew up to display ASPD symptoms, and abnormal sleeping patterns. [14] In many EEG studies, ADHD children tended to have elevated theta and delta activity and reduced alpha and beta activity. [15] Theta activity usually occurs in frontal vicinities while delta, alpha and beta in posterior vicinities. [15] As a normal person ages, there is usually a reduction of theta function and elevation in beta function. [16] This is not seen in those with ADHD, which might suggest a delayed maturation. [16] When one ages, usually there is a decrease in delta and theta potentials, as well as in slow wave sleep. [13] In individuals with ASPD and ADHD, the opposite is seen, and this further suggests a lag in the maturity of their sleep patterns. [13]

Substance Abuse

Antisocial Personality Disorder and Substance Abuse are immensely comorbid. In fact, in those who are diagnosed with substance abuse, about 14% of alcohol abusers and 18% of drug abusers showed symptoms for ASPD. [2] Looking at the reverse causation, about 84% of people with ASPD, display substance abuse. [2]Both disorders tend to have underlying genetic factors associated with them. [21] Substance Abuse and ASPD are also linked with aggression and delinquency. [22] Those with the comorbidity displayed higher number of symptoms and earlier outset. [22]

Understanding the difference between the different types of substance abuse is important, as there are many types of substances that fall under the category. By doing so it allows the ability to further research in the field to properly diagnose individuals and thus that proper treatment can be administered to the patients. Often, it is easier to diagnose those who manifest ASPD alone, but when comorbidity, especially substance abuse in involved, the diagnosis becomes difficult. [20] It is difficult as it is hard to differentiate whether the substance abuse is due to ASPD manifestation or if it was an early offset. [20] This is hard to tell because there is much overlap between the disorders. [20]


Individuals with a comorbidity of ASPD and substance abuse tend to have increased loss of the frontal part of their brain than if they had the disorders separately. [23] In fact, boys with the comorbidity displayed a decline in neuronal activity when confronted with decisions and rewards and increase when presented with loss. [24] A 2012 study was conducted that determined a single nucleotide polymorphism (SNP) that seemed to have established a strong link with ASPD. [25] The gene, COL25A1, codes for protein that manifests itself in neurons that specifically are near the amyloid-β which tend to be found in people with Alzheimer’s disease. [25] This suggests there is involvement of COL25A1 in the growth and decay of the brain. [25]

The study genotyped more than 4000 individuals and they were additionally interviewed to gather more information about their substance dependence. [25] The study revealed a link between ASPD and COL25A1. [25] It was the only SNP significant in the two samples of the experiment (African American and European American). [25] Not only is the SNP predicted to be a possible agent that might instigate ASPD, it might also explain the significance of the substance abuse comorbidity.

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