Antisocial Personality Antisocial Personality Disorder and Substance Disorder and Substance

AbuseAbuse

November 18, 2003November 18, 2003

By:By:Ms. K. MeetzeMs. K. MeetzeMs. R. MeltonMs. R. MeltonMr. M. MelvinMr. M. MelvinMs. B. MoozaMs. B. Mooza

Antisocial Personality Disorder Antisocial Personality Disorder DSM-IV CriteriaDSM-IV Criteria

A. There is a pervasive pattern of disregard for A. There is a pervasive pattern of disregard for and violation of the rights of others occurring and violation of the rights of others occurring since age 15 years, as indicated by three (or since age 15 years, as indicated by three (or more) of the following:more) of the following:

1)1) failure to conform to social norms with respect to lawful behaviors as failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrestindicated by repeatedly performing acts that are grounds for arrest

2)2) deceitfulness, as indicated by repeated lying, use of aliases, or conning deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasureothers for personal profit or pleasure

3)3) impulsivity or failure to plan aheadimpulsivity or failure to plan ahead4)4) Irritability and aggressiveness, as indicated by repeated physical fights Irritability and aggressiveness, as indicated by repeated physical fights

or assaultsor assaults5)5) reckless disregard for safety of self or othersreckless disregard for safety of self or others6)6) consistent irresponsibility, as indicated by repeated failure to sustain consistent irresponsibility, as indicated by repeated failure to sustain

consistent work behavior or honor financial obligationsconsistent work behavior or honor financial obligations7)7) lack of remorse, as indicated by being indifferent to or rationalizing lack of remorse, as indicated by being indifferent to or rationalizing

having hurt, mistreated, or stolen from anotherhaving hurt, mistreated, or stolen from another

Antisocial Personality DisorderAntisocial Personality Disorder DSM-IV Criteria (continued)DSM-IV Criteria (continued)

B. The individual is at least age 18 years.B. The individual is at least age 18 years.

C. There is evidence of Conduct Disorder with C. There is evidence of Conduct Disorder with onset before age 15 years.onset before age 15 years.

D. The occurrence of antisocial behavior is not D. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or exclusively during the course of Schizophrenia or a Manic Episode.a Manic Episode.

Substance Abuse Substance Abuse DSM-IV CriteriaDSM-IV Criteria

A. A maladaptive pattern of substance use A. A maladaptive pattern of substance use leading to clinically significant impairment or leading to clinically significant impairment or distress, as manifested by one (or more) of the distress, as manifested by one (or more) of the following, occurring within a 12 month period:following, occurring within a 12 month period:

1)1) recurrent substance use resulting in a failure to fulfill recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., major role obligations at work, school, or home (e.g., repeated absences or poor work performance related repeated absences or poor work performance related to substance; substance related absences, suspensions, to substance; substance related absences, suspensions, or expulsions from school; neglect of children or or expulsions from school; neglect of children or household)household)

2)2) recurrent substance use in situations in which it is recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)operating a machine when impaired by substance use)

Substance Abuse Substance Abuse DSM-IV Criteria (continued)DSM-IV Criteria (continued)

3) recurrent substance-related legal problems (e.g., arrests 3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)for substance-related disorderly conduct)

4) continued substance use despite having persistent or 4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical with spouse about consequences of intoxication, physical fights)fights)

B. The symptoms have never met the criteria for B. The symptoms have never met the criteria for Substance Dependence for this class of substance. Substance Dependence for this class of substance.

Antisocial Personality Disorder Antisocial Personality Disorder StatisticsStatistics

• Overall, approximately 3% of men and 1% of women Overall, approximately 3% of men and 1% of women in the general population meet the criteria for ASPD.in the general population meet the criteria for ASPD.

• Data from the Epidemiological Catchment Area Data from the Epidemiological Catchment Area (ECA) Study (NIMH, 1991) indicate that of the (ECA) Study (NIMH, 1991) indicate that of the 22.5% of the U.S. population who have a mental 22.5% of the U.S. population who have a mental illness (83.6% being diagnosed with antisocial illness (83.6% being diagnosed with antisocial personality disorder), approximately 29% also have a personality disorder), approximately 29% also have a substance abuse disorder.substance abuse disorder.

Substance Abuse StatisticsSubstance Abuse Statistics

• According to the 2002 National Survey of Substance According to the 2002 National Survey of Substance Abuse Treatment Services (N-SSATS) released by Abuse Treatment Services (N-SSATS) released by the Substance Abuse and Mental Health Services the Substance Abuse and Mental Health Services Administration (SAMHSA) this month, nearly half of Administration (SAMHSA) this month, nearly half of the 1.1 million people receiving treatment services on the 1.1 million people receiving treatment services on a given day had both drug and alcohol problems.a given day had both drug and alcohol problems.

• 21 % were in treatment for alcohol alone21 % were in treatment for alcohol alone• 31% for only drug abuse31% for only drug abuse• 48% for both48% for both• 8% were under the age of 18 yrs.8% were under the age of 18 yrs.

Diagnosing ASPD Among Diagnosing ASPD Among Substance Abusers Substance Abusers

(Messina, 2001)(Messina, 2001)There is a lot of debate among social scientists and clinicians over the There is a lot of debate among social scientists and clinicians over the accurate measurement of ASPD.accurate measurement of ASPD.Social scientists mostly use DSM criteria to assess ASPD, but many of Social scientists mostly use DSM criteria to assess ASPD, but many of them have raised concerns about possible limitations. Some argue that them have raised concerns about possible limitations. Some argue that the DSM overemphasizes observable behavioral criteria instead of the DSM overemphasizes observable behavioral criteria instead of underlying personality traits. underlying personality traits. Structured and semistructured interviews and self-report inventories Structured and semistructured interviews and self-report inventories were created in the late 1980s and widely used to increase the were created in the late 1980s and widely used to increase the reliability and validity of DSM diagnoses. reliability and validity of DSM diagnoses. Structured and semistructured interviews decrease the information Structured and semistructured interviews decrease the information variance because they require clinicians to ask the same questions. variance because they require clinicians to ask the same questions. Self-inventories were brought about by a need for diagnostic Self-inventories were brought about by a need for diagnostic procedures that took less time, were not as expensive, and that could procedures that took less time, were not as expensive, and that could properly diagnose psychiatric disorders. properly diagnose psychiatric disorders. Two of the most used diagnostic scales for assessing personality Two of the most used diagnostic scales for assessing personality disorders, also used with substance-abusing populations, are the disorders, also used with substance-abusing populations, are the Structured Clinical Interview for the DSM-III-R, Axis and theStructured Clinical Interview for the DSM-III-R, Axis and theMillon Clinical Multiaxial Inventory, 2nd edition.Millon Clinical Multiaxial Inventory, 2nd edition.

SCID SCID (Messina, 2001)(Messina, 2001)

The SCID is a semistructured clinical interview developed in 1985 for making The SCID is a semistructured clinical interview developed in 1985 for making Axis I and Axis II diagnoses using the DSM-III-R classifications. Axis I and Axis II diagnoses using the DSM-III-R classifications.

The scaled questions and the questionnaire focus primarily on antisocial The scaled questions and the questionnaire focus primarily on antisocial behavior in childhood that has continued into adulthood. behavior in childhood that has continued into adulthood.

It is used to diagnose past and current mental disorders in a study population It is used to diagnose past and current mental disorders in a study population including psychiatric patients, medical patients, subjects in the community, including psychiatric patients, medical patients, subjects in the community, and substance abusers. and substance abusers.

The reliability of the SCID has been tested in several clinical and nonclinical The reliability of the SCID has been tested in several clinical and nonclinical population. The reliability can vary according to the circumstances in which it population. The reliability can vary according to the circumstances in which it is being used.is being used.

Studies have shown good to excellent test-retest reliability of the SCID in Studies have shown good to excellent test-retest reliability of the SCID in psychiatric and substance-abusing populations. psychiatric and substance-abusing populations.

The validity of the SCID may vary according to the scale, the specific disorder, The validity of the SCID may vary according to the scale, the specific disorder, and the criterion measure, but it often generates the highest agreement with and the criterion measure, but it often generates the highest agreement with the criterion diagnosis.the criterion diagnosis.

MCMI MCMI (Messina, 2001)(Messina, 2001)

The MCMI was one of the first diagnostic scales measuring The MCMI was one of the first diagnostic scales measuring ASPD with a drug abuse scale embodied in it. ASPD with a drug abuse scale embodied in it.

It is a self-report inventory consisting of 175 true-false It is a self-report inventory consisting of 175 true-false items designed to assess basic personality styles, severe items designed to assess basic personality styles, severe personality disorders, and clinical syndromes. It also personality disorders, and clinical syndromes. It also measures personality characteristics associated with measures personality characteristics associated with substance abuse. substance abuse.

The MCMI has been recently used with substance-abusing The MCMI has been recently used with substance-abusing populations to identify a substance abuse problem, to populations to identify a substance abuse problem, to assess the personality of the known abuser, or to predict assess the personality of the known abuser, or to predict treatment response. treatment response.

The reliability and validity of this test have been the The reliability and validity of this test have been the subject of several reviews.subject of several reviews.

SCID vs. MCMI SCID vs. MCMI (Messina, 2001)(Messina, 2001)

Studies show that there is a small degree of agreement between the Studies show that there is a small degree of agreement between the SCID and the MCMI, making it clear that these two diagnostic scales SCID and the MCMI, making it clear that these two diagnostic scales are very different. are very different.

The low diagnostic agreement between the two scales may be due to The low diagnostic agreement between the two scales may be due to the different types of information collected by the two scales.the different types of information collected by the two scales.

It has been suggested that the SCID-II overstresses observable It has been suggested that the SCID-II overstresses observable behavioral characteristics, giving too large a role to criminality in the behavioral characteristics, giving too large a role to criminality in the diagnosis of ASPD.diagnosis of ASPD.

Conversely, the MCMI-II focuses on capturing pathological Conversely, the MCMI-II focuses on capturing pathological personality traits, as well as antisocial behaviors.personality traits, as well as antisocial behaviors.

Researchers asking similar questions about the association of ASPD to Researchers asking similar questions about the association of ASPD to treatment outcomes, but using different diagnostic scales, may obtain treatment outcomes, but using different diagnostic scales, may obtain inconsistent answers. It is difficult to draw definite conclusions inconsistent answers. It is difficult to draw definite conclusions regarding the proper measurement of ASPD in substance-abusing regarding the proper measurement of ASPD in substance-abusing samples without additional empirical evidence.samples without additional empirical evidence.

History of MisdiagnosisHistory of Misdiagnosis

• Historically, far too many clients have been misdiagnosed Historically, far too many clients have been misdiagnosed as mentally ill—depressed, schizophrenia, bipolar, or as mentally ill—depressed, schizophrenia, bipolar, or personality disordered—when their symptoms were clearly personality disordered—when their symptoms were clearly attributable to drug or alcohol use.attributable to drug or alcohol use.

• Conversely, countless mentally ill clients have had Conversely, countless mentally ill clients have had psychiatric symptoms falsely attributed to substance psychiatric symptoms falsely attributed to substance abuse.abuse.

• In both cases, the misdiagnosis leads to negative outcomes, In both cases, the misdiagnosis leads to negative outcomes, with either the substance abuse disorder or the mental with either the substance abuse disorder or the mental illness left untreated.illness left untreated.

It has been shown that people with substance abuse disorders have It has been shown that people with substance abuse disorders have unusually high rates of additional psychiatric disorders.unusually high rates of additional psychiatric disorders.

For example, in drug-dependent patients participating in drug For example, in drug-dependent patients participating in drug treatment programs, the lifetime prevalence rate for ASPD is 44%.treatment programs, the lifetime prevalence rate for ASPD is 44%.

Comorbid disorders complicate treatment and have been associated Comorbid disorders complicate treatment and have been associated with higher rates of relapse after treatment.with higher rates of relapse after treatment.

The comorbidity rates of substance abuse and ASPD are broken down The comorbidity rates of substance abuse and ASPD are broken down as follows:as follows:African-American men 49%African-American men 49%African-American women 26%African-American women 26%Caucasian men 52%Caucasian men 52%Caucasian women 39%Caucasian women 39%

This information is important because it helps professionals design This information is important because it helps professionals design effective treatments for their patients (Compton, 2000).effective treatments for their patients (Compton, 2000).

Studies have shown….Studies have shown….

There have been many studies conducted that show There have been many studies conducted that show alcoholism is positively correlated with ASPD.alcoholism is positively correlated with ASPD.

The results of one such study show that serious antisocial The results of one such study show that serious antisocial behavior (including conduct disorder and ASPD), gender, behavior (including conduct disorder and ASPD), gender, and a family history of problem drinking are all and a family history of problem drinking are all significantly associated with alcoholism.significantly associated with alcoholism.

However, having either antisocial personality or a family However, having either antisocial personality or a family drinking problem identified only 49% of male alcoholics drinking problem identified only 49% of male alcoholics and only 14% of female alcoholics.and only 14% of female alcoholics.

This shows that these criteria are inefficient screeners for This shows that these criteria are inefficient screeners for primary prevention of alcoholism.primary prevention of alcoholism.

Thus, more data is needed to better understand the Thus, more data is needed to better understand the development of alcoholism, as well as the lack of development of alcoholism, as well as the lack of development of this disorder in people with major risk development of this disorder in people with major risk factors, such as ASPD (Lewis, 1991).factors, such as ASPD (Lewis, 1991).

Narcotic addiction has also been studied in ASPD patients.Narcotic addiction has also been studied in ASPD patients.

One interesting study by Lewis et al. showed that ASPD One interesting study by Lewis et al. showed that ASPD men with narcotic addiction had a lower prevalence rate of men with narcotic addiction had a lower prevalence rate of alcoholism, compared to ASPD men without an addiction.alcoholism, compared to ASPD men without an addiction.

The authors of that study theorized that narcotic use and The authors of that study theorized that narcotic use and addiction might impede the development of alcoholism.addiction might impede the development of alcoholism.

Opiates may give stronger positive reinforcement because Opiates may give stronger positive reinforcement because they bind directly to opiate receptors, versus the more they bind directly to opiate receptors, versus the more indirect pathway that alcohol takes to produce an effect. indirect pathway that alcohol takes to produce an effect.

This could cause a delay in the development of problematic This could cause a delay in the development of problematic drinking if narcotics are preferred by addicts (Lewis, drinking if narcotics are preferred by addicts (Lewis, 1987).1987).

Common personality factors observed in individuals with Common personality factors observed in individuals with ASPD, alcoholism, and drug abuse are “impulsivity, a ASPD, alcoholism, and drug abuse are “impulsivity, a failure to inhibit behavior which had previously led to failure to inhibit behavior which had previously led to negative consequences, and valuing immediate euphoria or negative consequences, and valuing immediate euphoria or gain over long-term consequences.”gain over long-term consequences.”

Cloninger proposed a tridimensional model to explain the Cloninger proposed a tridimensional model to explain the deviance found in people with ASPD.deviance found in people with ASPD.

He proposed that they are “high in novelty seeking, low in He proposed that they are “high in novelty seeking, low in reward dependence, and low in harm avoidance” (Lewis, reward dependence, and low in harm avoidance” (Lewis, 1991).1991).

These factors could help explain why there is a connection These factors could help explain why there is a connection between ASPD and alcoholism, but more research is between ASPD and alcoholism, but more research is warranted in this field to be able to better help future warranted in this field to be able to better help future patients.patients.

There is a growing realization among researchers that There is a growing realization among researchers that ASPD is highly correlated with substance abuse (Messina, ASPD is highly correlated with substance abuse (Messina, 2001).2001).

It has been found that those with ASPD are high It has been found that those with ASPD are high consumers of alcohol and there is an association between consumers of alcohol and there is an association between cognitive impairment and high alcohol consumption.cognitive impairment and high alcohol consumption.

It has been found that among men and women ASPD and It has been found that among men and women ASPD and other substance use disorders are associated with more other substance use disorders are associated with more alcohol consumption in the year following treatment.alcohol consumption in the year following treatment.

ASPD among men and social phobia among women ASPD among men and social phobia among women predict higher frequency of loss of control (Tomasson, predict higher frequency of loss of control (Tomasson, 1996).1996).

Schuckit et al. (1985)Schuckit et al. (1985)

• Schuckit assessed the relationship between ASPD and Schuckit assessed the relationship between ASPD and drinking behaviors in 577 people who entered an drinking behaviors in 577 people who entered an alcoholism treatment program.alcoholism treatment program.

• The study found that those people who had ASPD before The study found that those people who had ASPD before they developed drinking problems consumed significantly they developed drinking problems consumed significantly more drinks per day and experienced significantly more more drinks per day and experienced significantly more alcohol-related problems alcohol-related problems (e.g., being fired or demoted or (e.g., being fired or demoted or spending time in jail) spending time in jail) compared with people who did not compared with people who did not meet the criteria for ASPD.meet the criteria for ASPD.

Schuckit et al. (cont.)Schuckit et al. (cont.)

• When analyzed together, these findings When analyzed together, these findings suggest that:suggest that:

1. 1. people with ASPD experience higher people with ASPD experience higher rates of rates of alcohol abuse and dependence than alcohol abuse and dependence than the general population, andthe general population, and

2. 2. people who drink to excess are more people who drink to excess are more likely to likely to experience alcohol-related experience alcohol-related problems than other alcoholics. problems than other alcoholics.

According to Bucholz et al.According to Bucholz et al.ASPD and alcohol dependence have been found to be ASPD and alcohol dependence have been found to be related in both clinical and general population samples.related in both clinical and general population samples.

The comorbidity of ASPD and alcohol abuse is both The comorbidity of ASPD and alcohol abuse is both clinical and etiological…clinical and etiological…clinical: poorer prognosis of antisocial alcoholics in treatmentclinical: poorer prognosis of antisocial alcoholics in treatmentetiological: types II and B, they tend to be more familial than their etiological: types II and B, they tend to be more familial than their non-ASPD partnersnon-ASPD partners

There have been reported increased rates of ASPD in the There have been reported increased rates of ASPD in the alcoholic population.alcoholic population.

Recent data suggests a strong genetic relation between Recent data suggests a strong genetic relation between alcohol dependence and ASPD.alcohol dependence and ASPD.

In a study done by Goldstein et al.In a study done by Goldstein et al.

ASPD patients have a poorer agreement between self-ASPD patients have a poorer agreement between self-reported post treatment drug behavior and hair data. reported post treatment drug behavior and hair data. This adds to evidence that the DSM-IV requirement of This adds to evidence that the DSM-IV requirement of childhood onset of ASPD is very important to look at in childhood onset of ASPD is very important to look at in substance abusers. This will also help identify this substance abusers. This will also help identify this chronically antisocial and drug addicted group, to be at chronically antisocial and drug addicted group, to be at much higher risk for early post treatment failure.much higher risk for early post treatment failure.ASPD is one of the most frequently diagnosed disorders ASPD is one of the most frequently diagnosed disorders with a comorbidity of substance abuse on a study of with a comorbidity of substance abuse on a study of outpatient alcoholism treatment. Clients with ASPD were outpatient alcoholism treatment. Clients with ASPD were assigned cognitive behavior therapy and others were assigned cognitive behavior therapy and others were assigned interpersonal focused treatments. They found assigned interpersonal focused treatments. They found that the clients with ASPD who participated in cognitive that the clients with ASPD who participated in cognitive behavior therapy were less likely to become involved with behavior therapy were less likely to become involved with alcohol 2 years post treatment. alcohol 2 years post treatment.

In a study done by Gerra et al.In a study done by Gerra et al.

Early aggressive behavior predicts substance abuse later Early aggressive behavior predicts substance abuse later on and early onset alcohol abuse. Therefore, children with on and early onset alcohol abuse. Therefore, children with Conduct Disorder are more likely to abuse drugs in the Conduct Disorder are more likely to abuse drugs in the future.future.

Their study showed increased rates of irritability, Their study showed increased rates of irritability, impulsivity, and ASPD when paired with substance abuse impulsivity, and ASPD when paired with substance abuse regardless of the individuals’ drug use history.regardless of the individuals’ drug use history.

New studies suggest a comorbidity between biological New studies suggest a comorbidity between biological changes underlying proneness to substance abuse and changes underlying proneness to substance abuse and

aggressive or violent traits.aggressive or violent traits.

Gender Differences Gender Differences (Ross, 1988)(Ross, 1988)

Many more men than women are affected by substance abuse in Many more men than women are affected by substance abuse in treatment and general populations. treatment and general populations.

Most studies of the prevalence of mental disorders in patients with Most studies of the prevalence of mental disorders in patients with alcohol and drug problems have ignored, or only examined in passing, alcohol and drug problems have ignored, or only examined in passing, gender differences.gender differences.

Many professionals believe that women with alcohol problems are Many professionals believe that women with alcohol problems are more pathological and show more maladjustment and abnormality more pathological and show more maladjustment and abnormality than their male counterparts. This is based on the assumption that, than their male counterparts. This is based on the assumption that, since there is a stronger social taboo against excessive drinking among since there is a stronger social taboo against excessive drinking among women than men, to the extent that women exhibit alcoholism they are women than men, to the extent that women exhibit alcoholism they are also indicating greater pathology by its expression. also indicating greater pathology by its expression.

Studies have shown that there is a greater amount of psychiatric Studies have shown that there is a greater amount of psychiatric treatment among women with alcohol problems. Studies have also treatment among women with alcohol problems. Studies have also shown more frequent reports by these women than alcoholic men of shown more frequent reports by these women than alcoholic men of depressed or sad mood, feelings of inadequacy, low self-esteem, and depressed or sad mood, feelings of inadequacy, low self-esteem, and anxious affect. An elevated rate of suicide attempts relative to men has anxious affect. An elevated rate of suicide attempts relative to men has also been revealed.also been revealed.

Gender Differences Gender Differences (continued)(continued)

(Ross, 1988)(Ross, 1988)Women consistently report more physical and emotional Women consistently report more physical and emotional symptoms than men, that they more frequently seek help symptoms than men, that they more frequently seek help for these discomforts, and that physicians perceive for these discomforts, and that physicians perceive women’s complaints as more often related to some form of women’s complaints as more often related to some form of mental disorder as compared to men.mental disorder as compared to men.

Overall, studies show no significant differences between Overall, studies show no significant differences between the sexes in the prevalence of alcohol or drug disorders as the sexes in the prevalence of alcohol or drug disorders as a whole. a whole.

However, several other differences were shown:However, several other differences were shown:Women are more likely to receive a lifetime or current diagnosis of Women are more likely to receive a lifetime or current diagnosis of

barbiturate/sedative/hypnotic abuse or dependence; more likely to have an barbiturate/sedative/hypnotic abuse or dependence; more likely to have an anxiety disorder or psychosexual dysfunctions and bulimia.anxiety disorder or psychosexual dysfunctions and bulimia.

Men are more likely given lifetime and current diagnoses of cannabis Men are more likely given lifetime and current diagnoses of cannabis abuse/dependence and tobacco dependence significantly more often than abuse/dependence and tobacco dependence significantly more often than female patients and more likely to receive the diagnosis of ASPD.female patients and more likely to receive the diagnosis of ASPD.

BibliographyBibliographyAmerican Psychiatric Association. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Diagnostic and Statistical Manual of Mental Disorders,

Fourth EditionFourth Edition. Washington, DC: 1994.. Washington, DC: 1994.

Bucholz, K.K., V.M. Hesselbrock, A.C. Health, J.R. Kramer, and M.A. Schuckit (2000). Bucholz, K.K., V.M. Hesselbrock, A.C. Health, J.R. Kramer, and M.A. Schuckit (2000). Research report. A latent class analysis of antisocial personality disorder symptom data Research report. A latent class analysis of antisocial personality disorder symptom data from a multi-centre family study of alcoholism. Retrieved November 10, 2003, from from a multi-centre family study of alcoholism. Retrieved November 10, 2003, from EBSCOhost Research Databases.EBSCOhost Research Databases.

Compton, III, W.M., Cottler, L.B., Abdallah, A.B., et al. “Substance Compton, III, W.M., Cottler, L.B., Abdallah, A.B., et al. “Substance Dependence and Other Psychiatric Disorders Among Drug Dependent Dependence and Other Psychiatric Disorders Among Drug Dependent Subjects: Race and Gender Correlates.” Subjects: Race and Gender Correlates.” The American Journal on AddictionsThe American Journal on Addictions 9 (2000): 9 (2000): 113-125.113-125.

Goldstein, Rice B., Carol Bigelow, Jane McCusker, Benjamin F. Lewis, Kenneth A. Mundt, Goldstein, Rice B., Carol Bigelow, Jane McCusker, Benjamin F. Lewis, Kenneth A. Mundt, and Sally I. Powers (2001). Research article. Antisocial Behavioral Syndromes and and Sally I. Powers (2001). Research article. Antisocial Behavioral Syndromes and Return to Drug Use Following Residential Relapse Prevention/Health Education Return to Drug Use Following Residential Relapse Prevention/Health Education Treatment. Retrieved November 10, 2003, from EBSCOhost Research Databases. Treatment. Retrieved November 10, 2003, from EBSCOhost Research Databases.

Gerra, G., A. Zaimovic, G. Moi, M. Bussandri, R. Delsignore, R. Caccavari, & F. Brambilla Gerra, G., A. Zaimovic, G. Moi, M. Bussandri, R. Delsignore, R. Caccavari, & F. Brambilla (2003). Research article. Neuroendocrine correlates of antisocial personality disorder in (2003). Research article. Neuroendocrine correlates of antisocial personality disorder in abstinent heroin-dependent subjects. Retrieved November 10, 2003, from EBSCOhost abstinent heroin-dependent subjects. Retrieved November 10, 2003, from EBSCOhost Research Databases. Research Databases.

BibliographyBibliography (continued) (continued)Lewis, C.E. & Bucholz, K.K. “Alcoholism, Antisocial Behavior and Family History.” Lewis, C.E. & Bucholz, K.K. “Alcoholism, Antisocial Behavior and Family History.” British British

Journal of AddictionJournal of Addiction 86 (1991): 177-194. 86 (1991): 177-194.

Lewis, C.E., Halikas, J.A., Morse, C., et al. “Alcoholism in Narcotic Addicts with Antisocial Lewis, C.E., Halikas, J.A., Morse, C., et al. “Alcoholism in Narcotic Addicts with Antisocial Personality. Personality. British Journal of AddictionBritish Journal of Addiction 82 (1987): 305-311. 82 (1987): 305-311.

Messina, Nena, et al. “Diagnosing Antisocial Personality Disorder Among Substance Messina, Nena, et al. “Diagnosing Antisocial Personality Disorder Among Substance Abusers: The SCID versus The MCMI-II” Abusers: The SCID versus The MCMI-II” The American Journal of Drug Alcohol The American Journal of Drug Alcohol AbuseAbuse 27 (2001): 699-717. 27 (2001): 699-717.

Ross, Helen E., Ph.D., et al. “Sex Differences in the Prevalence of Psychiatric Disorders in Ross, Helen E., Ph.D., et al. “Sex Differences in the Prevalence of Psychiatric Disorders in Patients With Alcohol and Drug Problems” Patients With Alcohol and Drug Problems” British Journal of AddictionBritish Journal of Addiction 83 (1988):1179- 83 (1988):1179-1192.1192.

Tomasson, Kristinn & Vaglum, Per. “Psychopathology and alcohol consumption among Tomasson, Kristinn & Vaglum, Per. “Psychopathology and alcohol consumption among treatment-seeking alcoholics: a prospective study” treatment-seeking alcoholics: a prospective study” AddictionAddiction 91 (1996): 1019-1030. 91 (1996): 1019-1030.